Summary Plan Description

Medical Supplies

90% Network and 80% Non-Network

Benefits are provided for the following items prescribed by a physician if the patient has an immediate medical need: sterile surgical dressings; casts; splints; surgical and orthopedic appliances; compression support stockings (e.g., Jobst) up to four pair per calendar year; catheters; syringes; and formulas for the treatment of phenylketonuria. The plan may elect to provide benefits for a less costly alternative item.

Benefits are not provided for:

  1. Supplies purchased or dispensed when a plan benefit is not in effect or when the patient is not covered under this plan.
  2. Items purchased or used more frequently than considered reasonable by the plan.
  3. Incontinence supplies, ear plugs, enemas, alcohol swabs, cotton balls, or like supplies.
  4. Freight, postage or delivery charges.
  5. Compression support stockings (e.g., Jobst) in excess of four pair per calendar year.