Summary Plan Description

Orthotics

90% Network and 80% Non-Network
The Orthotics Benefit Is Not Available Under Retiree Coverage

Benefits are provided for services and supplies prescribed by a physician for custom-made foot orthotics constructed of acrylic, plastic or metal, with a maximum of $400 paid in any two-consecutive-year period. Covered services include the custom-made device which must be worn at all times that shoes are worn and not just for specific activities. Physician services, including impression casting, are paid under a separate benefit.