Summary Plan Description

Prosthetic Devices and Artificial Limbs

90% Network and 80% Non-Network

Prosthetic Devices

Benefits are provided for prosthetic devices that replace all or part of an internal body organ (including contiguous tissue) or that replace all or part of the function of a permanently inoperative or malfunctioning internal body organ. Examples of items and equipment that are considered prosthetic devices are:

  • Cardiac pacemakers.
  • Devices that replace all or part of the ear or nose.
  • Colostomy bags and other ostomy equipment.
  • Urinary collection systems with or without a tube for cases of permanent incontinence, and Foley catheters.
  • Joint implants.

Replacements, repairs and adjustments are not covered until five years have elapsed, unless medical necessity is proven as described below:

  • The prosthesis must be replaced because of changing fit or poor function.
  • It costs less to buy a new prosthesis than to repair the old one.

Prosthetic Lenses

The term "internal body organ" includes the lens of an eye. Prostheses replacing the lens of an eye include postsurgical lenses customarily used during convalescence from eye surgery in which the lens of the eye was removed. Permanent lenses are also covered when required by a patient lacking the organic lens of the eye because of surgical removal or congenital absence.

When intraocular surgery is performed and the natural lens is removed, this plan covers, as a medical benefit, the reasonable cost of the initial contact lens or pair of eyeglasses when used to replace the natural lens. The "reasonable cost" means the cost of the new lens and any necessary services incident to the placement of the contact lens. "Initial" means only the first contact lens or eyeglasses that replaces the natural lens, and not any other that might be required at a later date because of a change in visual acuity. This benefit may apply to treatment of the following medical conditions:

  • An injury to intraocular structures of the eye which requires the removal of the lens of the eye.
  • Keratoconus.
  • Keratitis sicca or bullous keratopathy (dry eye).
  • Sightless and shrunken by inflammatory disease by the use of a shell (or shield).

For patients who are aphakic who do not have an intraocular lens (IOL), the following lenses or combination of lenses are covered when determined to be medically necessary: bifocal lenses in frames; lenses in frames for far vision and lenses in frames for near vision; or when a contact lens(es) for far vision is prescribed (including cases of binocular and monocular aphakia), benefits will be paid for the contact lens(es) and lenses in frames for near vision to be worn at the same time as the contact lens(es), and lenses in frames to be worn when the contacts have been removed.

Lenses which have ultraviolet absorbing or reflecting properties are covered in lieu of regular (untinted) lenses if it is determined that such lenses are medically necessary for the patient.

Benefits are not provided for:

  1. Cataract sunglasses obtained in addition to the regular (untinted) lenses.
  2. Anti-reflective coating and oversize lenses.
  3. Scratch resistant coating.
  4. Charges for deluxe frames.
  5. Contact lens cleaning solution.
  6. Normal saline for contact lenses.
  7. Low vision aids.
  8. Progressive lenses.
  9. Presbyopia-correcting intraocular lenses.

Braces

Services and Supplies Must Be Precertified Unless the Patient Is A Medicare-Eligible Retiree

Legs, arms, back, and neck braces, and trusses are covered expenses when prescribed by a physician. A "brace" includes rigid and semi-rigid devices used for the purpose of supporting a weak or deformed body part or for restricting or eliminating motion in an injured or diseased part of the body. Back braces include, but are not limited to, special corsets (sacroiliac, sacrolumbar, and dorsolumbar corsets), and belts. Orthopedic shoes are covered if an integral part of a leg brace.

Benefits are not provided for:

  1. Elastic stockings (excluding compression support stockings), garter belts or similar devices.
  2. Freight, postage or delivery charges.
  3. Routine upkeep.

Artificial Limbs

Services and Supplies Must Be Precertified Unless the Patient Is A Medicare-Eligible Retiree

Artificial legs, arms, and eyes are a covered benefit when prescribed by a physician. A terminal device is also covered regardless of whether an artificial arm is required by the patient. Stump stockings (up to four per calendar year) and harnesses (including replacements) are also covered when these appliances are essential to the effective use of the artificial limb. Adjustments to an artificial limb or other appliance required by wear or by a change in the patient's condition are covered when ordered by a physician. Replacements and repairs are not covered until five years have elapsed, unless medical necessity is proven.

Benefits are not provided for:

  1. A prosthesis or artificial limb ordered when a plan benefit is not in effect or when the patient is not covered under the plan.
  2. Freight, postage or delivery charges.
  3. Routine upkeep.

Wigs and Hairpieces

One wig or hairpiece for a patient who has lost hair as a result of chemotherapy or radiation therapy. The maximum the plan will pay for a wig or hairpiece is $450. Benefits are not provided for hair weaves or hair implants.