WIXLIB

Our Benefit GuidelinesIn providing benefits for Covered Services, thebenefit guidelines listed below apply as well asany other applicable payment rules specific toparticular categories of Services:1. Payment for certain Health Care Services isincluded within the Allowed Amount for theprimary procedure, and therefore noadditional amount is payable for any suchServices.2. Payment is based on the Allowed Amountfor the actual Service rendered (i.e.,payment is not based on the AllowedAmount for a Service which is more complexthan that actually rendered), and is notbased on the method utilized to perform theService or the day of the week or the time ofday the procedure is performed.3. Payment for a Service includes allcomponents of the Health Care Servicewhen the Service can be described by asingle procedure code, or when the Serviceis an essential or integral part of theassociated therapeutic/diagnostic Servicerendered.Covered Services CategoriesAccident CareHealth Care Services to treat an injury or illnessresulting from an Accident not related to your jobor employment are covered.Exclusion:Health Care Services to treat an injury or illnessresulting from an Accident related to your job oremployment are excluded.Allergy Testing and TreatmentsTesting and desensitization therapy (e.g.,injections) and the cost of hyposensitizationserum are covered. The Allowed Amount forallergy testing is based upon the type andWhat Is Covered?number of tests performed by the Physician.The Allowed Amount for allergy immunotherapytreatment is based upon the type and number ofdoses.Ambulance ServicesGround AmbulanceGround Ambulance Services for EmergencyMedical Conditions and limited non-emergencyground transport may be covered only when:1. For Emergency Medical Conditions – it isMedically Necessary to transport you fromthe place an Emergency Medical Conditionoccurs to the nearest Hospital that canprovide the Medically Necessary level ofcare. If it is determined that the nearestHospital is unable to provide the MedicallyNecessary level of care for the EmergencyMedical Condition, then coverage forAmbulance Services shall extend to the nextnearest Hospital that can provide MedicallyNecessary care; or2. For limited non-emergency groundAmbulance transport – it is MedicallyNecessary to transport you by ground:a. from an Out-of-Network Hospital to thenearest In-Network Hospital that canprovide care;b. to the nearest In-Network or Out-ofNetwork Hospital for a Condition thatrequires a higher level of care that wasnot available at the original Hospital;c.to the nearest more cost-effective acutecare facility as determined solely by us;ord. from an acute facility to the nearestcost-effective sub-acute setting.Note: Non-emergency Ambulance transportationmeets the definition of Medical Necessity onlywhen the patient's Condition requires treatmentat another facility and when another mode of2-2

transportation, whether by Ambulance orotherwise (regardless of whether covered by usor not) would endanger the patient’s medicalCondition. If another mode of transportationcould be used safely and effectively, regardlessof time, or mode (e.g. air, ground, water) thenAmbulance transportation is not MedicallyNecessary.Air and Water AmbulanceAir and water Ambulance coverage isspecifically limited to transport due to anEmergency Medical Condition when thepatient’s destination is an acute care Hospital,and:1. the pick-up point is not accessible by groundAmbulance, or2. speed in excess of the ground vehicle iscritical for your health or safety.Air and water Ambulance transport for nonemergency transport is excluded unless it isspecifically approved by us in advance of thetransport.ExclusionGround, air and water Ambulance Services forsituations that are not Medically Necessarybecause they do not require Ambulancetransportation including but not limited to:1. Ambulance Services for a patient who islegally pronounced dead before theAmbulance is summoned.2. Aid rendered by an Ambulance crew withouttransport. Examples include, but are notlimited to situations when an Ambulance isdispatched and:3. Non-emergency transport to or from apatient’s home or a residential, domiciliary orcustodial facility.4. Transfers by medical vans or commercialtransportation (such as Physician ownedlimousines, public transportation, cab, etc.).5. Ambulance transport for patientconvenience or patient and/or familypreference. Examples include but are notlimited to:a. patient wants to be at a certain Hospitalor facility for personal/preferencereasons;b. patient is in a foreign country, or out-ofstate, and wants to return home for asurgical procedure or treatment (or forcontinued treatment), or after beingdischarged from inpatient care; orc.patient is going for a routine Service andis medically able to use another mode oftransportation but can’t pay for, findand/or prefers not to use suchtransportation.6. Air or water Ambulance Services in theabsence of an Emergency MedicalCondition, unless such Services areauthorized by us in advance.Ambulatory Surgical CentersHealth Care Services rendered at an AmbulatorySurgical Center are covered and include:1. use of operating and recovery rooms;2. respiratory, or inhalation therapy (e.g.,oxygen);a. the crew renders aid until a helicoptercan be sent;3. drugs and medicines administered (exceptfor take home drugs) at the AmbulatorySurgical Center;b. the patient refuses care or transport; or4. intravenous solutions;c.5. dressings, including ordinary casts;only basic first aid is rendered.6. anesthetics and their administration;What Is Covered?2-3

7. administration of, including the cost of,whole blood or blood products (except asoutlined in the Drugs exclusion of the “WhatIs Not Covered?” section);8. transfusion supplies and equipment;9. diagnostic Services, including radiology,ultrasound, laboratory, pathology andapproved machine testing (e.g., EKG); and10. chemotherapy treatment for provenmalignant disease.3. Physical Therapy by a Physical Therapist,Occupational Therapy by an OccupationalTherapist, and Speech Therapy by aSpeech Therapist. Covered therapiesprovided in the treatment of AutismSpectrum Disorder are covered even thoughthey may be habilitative in nature (providedto teach a function) and are not necessarilylimited to restoration of a function or skill thathas been lost.Payment Guidelines for Autism SpectrumDisorderAnesthesia Administration ServicesAdministration of anesthesia by a Physician orCertified Registered Nurse Anesthetist (“CRNA”)may be covered. In those instances where theCRNA is actively directed by a Physician otherthan the Physician who performed the surgicalprocedure, payment for Covered Services, ifany, will be made for both the CRNA and thePhysician Health Care Services at the lowerdirected-services Allowed Amount in accordancewith BCBSF’s payment program then in effectfor such Covered Services.Exclusion:Coverage does not include anesthesia Servicesby an operating Physician, his or her partner orassociate.Autism Spectrum DisorderAutism Spectrum Disorder Services provided toa Covered Dependent who is under the age of18, or if 18 years of age or older, is attendinghigh school and was diagnosed with AutismthSpectrum Disorder prior to his or her 9 birthdayconsisting of:1. well-baby and well-child screening for thepresence of Autism Spectrum Disorder;2. Applied Behavior Analysis, when renderedby an individual certified pursuant to Section393.17 of the Florida Statutes or licensedunder Chapters 490 or 491 of the FloridaStatutes; andWhat Is Covered?Applied Behavior Analysis Services for AutismSpectrum Disorder must be authorized inaccordance with criteria established by us,before such Services are rendered. Servicesperformed without authorization will bedenied. Authorization for coverage is notrequired when Covered Services are providedfor the treatment of an Emergency MedicalCondition.Exclusion:Any Services for the treatment of AutismSpectrum Disorder other than as specificallyidentified as covered in this section.Note: In order to determine whether suchServices are covered under this Benefit Booklet,we reserve the right to request a formal writtentreatment plan signed by the treating physicianto include the diagnosis, the proposed treatmenttype, the frequency and duration of treatment,the anticipated outcomes stated as goals, andthe frequency with which the treatment plan willbe updated, but no less than every 6 months.Behavioral Health ServicesMental Health ServicesDiagnostic evaluation, psychiatric treatment,individual therapy, and group therapy renderedto you by a Physician, Psychologist or MentalHealth Professional for the treatment of a Mentaland Nervous Disorder may be covered.Covered Services may include:2-4

1. Physician office visits;Substance Dependency Treatment Services2. Intensive Outpatient Treatment (rendered ina facility), as defined in this Booklet;When there is a sudden drop in consumptionafter prolonged heavy use of a substance aperson may experience withdrawal, oftencausing both physiologic and cognitivesymptoms. The symptoms of withdrawal varygreatly, ranging from minimal changes topotentially life threatening states. DetoxificationServices can be rendered in different types oflocations, depending on the severity of thewithdrawal symptoms.3. Partial Hospitalization, as defined in thisBooklet, when provided under the directionof a Physician; and4. Residential Treatment Services, as definedin this Booklet.Exclusion:1. Services rendered for a Condition that is nota Mental and Nervous Disorder as defined inthis Booklet, regardless of the underlyingcause, or effect, of the disorder;2. Services for psychological testingassociated with the evaluation and diagnosisof learning disabilities or intellectualdisability;3. Services beyond the period necessary forevaluation and diagnosis of learningdisabilities or intellectual disability;4. Services for educational purposes;5. Services for marriage counseling unlessrelated to a Mental and Nervous Disorder asdefined in this Booklet, regardless of theunderlying cause, or effect, of the disorder;6. Services for pre-marital counseling;7. Services for court-ordered care or testing, orrequired as a condition of parole orprobation;Care and treatment for Substance Dependencyincludes the following:1. Inpatient and outpatient Health CareServices rendered by a Physician,Psychologist or Mental Health Professionalin a program accredited by The JointCommission or approved by the state ofFlorida for Detoxification or SubstanceDependency.2. Physician, Psychologist and Mental HealthProfessional outpatient visits for the careand treatment of Substance Dependency.We may provide you with information onresources available to you for non-medicalancillary services like vocational rehabilitation oremployment counseling, when we are able to.We don’t pay for any services that are providedto you by any of these resources; they are to beprovided solely at your expense. Youacknowledge that we do not have anyContractual or other formal arrangements withthe Provider of such services.Exclusion:8. Services to test aptitude, ability, intelligenceor interest [except as covered under theAutism Spectrum Disorder subsection];9. Services required to maintain employment;Long term Services for alcoholism or drugaddiction, including specialized inpatient units orinpatient stays that are primarily intended as achange of environment.10. Services for cognitive remediation; andBreast Reconstructive Surgery11. inpatient stays that are primarily intended asa change of environment.Surgery to reestablish symmetry between twobreasts and implanted prostheses incident toMastectomy is covered. In order to be covered,such surgery must be provided in a mannerWhat Is Covered?2-5

chosen by your Physician, consistent withprevailing medical standards, and in consultationwith you.Child Cleft Lip and Cleft Palate TreatmentTreatment and Services for Child Cleft Lip andCleft Palate, including medical, dental, SpeechTherapy, audiology, and nutrition Services fortreatment of a child under the age of 18 who hascleft lip or cleft palate are covered. In order forsuch Services to be covered, your CoveredDependent’s Physician must specificallyprescribe such Services and such Services mustbe consequent to treatment of the cleft lip orcleft palate.Clinical TrialsClinical trials are research studies in whichPhysicians and other researchers work to findways to improve care. Each study tries toanswer scientific questions and to find betterways to prevent, diagnose, or treat patients.Each trial has a protocol which explains thepurpose of the trial, how the trial will beperformed, who may participate in the trial, andthe beginning and end points of the trial.If you are eligible to participate in an ApprovedClinical Trial, routine patient care for Servicesfurnished in connection with your participation inthe Approved Clinical Trial may be coveredwhen:Even though benefits may be available underthis Booklet for routine patient care related to anApproved Clinical Trial you may not be eligiblefor inclusion in these trials or there may not beany trials available to treat your Condition at thetime you want to be included in a clinical trial.Exclusion:1. Costs that are generally covered by theclinical trial, including, but not limited to:a. Research costs related to conductingthe clinical trial such as researchPhysician and nurse time, analysis ofresults, and clinical tests performed onlyfor research purposes.b. The investigational item, device orService itself.c.Services inconsistent with widelyaccepted and established standards ofcare for a particular diagnosis.2. Services related to an Approved ClinicalTrial received outside of the United States.Concurrent Physician CareConcurrent Physician care Services arecovered, provided: (a) the additional Physicianactively participates in your treatment; (b) theCondition involves more than one body systemor is so severe or complex that one Physiciancannot provide the care unassisted; and (c) thePhysicians have different specialties or have thesame specialty with different sub-specialties.1. an In-Network Provider has indicated suchtrial is appropriate for you; orConsultations2. you provide us with medical and scientificinformation establishing that yourparticipation in such trial is appropriate.Consultations provided by a Physician arecovered if your attending Physician requests theconsultation and the consulting Physicianprepares a written report.Routine patient care includes all MedicallyNecessary Services that would otherwise becovered under this Booklet, such as doctorvisits, lab tests, x-rays and scans and hospitalstays related to treatment of your Condition andis subject to the applicable Cost Share(s) on theSchedule of Benefits.What Is Covered?Contraceptive InjectionsMedication by injection is covered whenprovided and administered by a Physician,for the purpose of contraception, and islimited to the medication and administration.2-6

Dental ServicesDiabetes Outpatient Self-ManagementDental Services are limited to the following:Diabetes outpatient self-management trainingand educational Services and nutritioncounseling (including all Medically Necessaryequipment and supplies) to treat diabetes, ifyour treating Physician or a Physician whospecializes in the treatment of diabetes certifiesthat such Services are Medically Necessary, arecovered. In order to be covered, diabetesoutpatient self-management training andeducational Services must be provided underthe direct supervision of a certified DiabetesEducator or a board-certified Physicianspecializing in endocrinology. Additionally, inorder to be covered, nutrition counseling mustbe provided by a licensed Dietitian. CoveredServices may also include the trimming oftoenails, corns, calluses, and therapeutic shoes(including inserts and/or modifications) for thetreatment of severe diabetic foot disease.1. Care and stabilization treatment renderedwithin 62 days of an Accidental Dental Injuryto Sound Natural Teeth.2. Extraction of teeth required prior to radiationtherapy when you have a diagnosis ofcancer of the head and/or neck.3. Anesthesia Services for dental careincluding general anesthesia andhospitalization Services necessary to assurethe safe delivery of necessary dental careprovided to you or your Covered Dependentin a Hospital or Ambulatory Surgical Centerif:a) the Covered Dependent is under 8years of age and it is determined by adentist and the Covered Dependent’sPhysician that:i.dental treatment is necessary due toa dental Condition that issignificantly complex; orii.the Covered Dependent has adevelopmental disability in whichpatient management in the dentaloffice has proven to be ineffective;orb) you or your Covered Dependent hasone or more medical Conditions thatwould create significant or unduemedical risk for you in the course ofdelivery of any necessary dentaltreatment or surgery if not rendered in aHospital or Ambulatory Surgical Center.Exclusion:1. Dental Services provided more than 62 daysafter the date of an Accidental Dental Injuryregardless of whether or not such servicescould have been rendered within 62 days;andNotwithstanding the above, if your BenefitBooklet was amended by a Pharmacy ProgramEndorsement which covers diabetes equipmentand supplies, then diabetes equipment andsupplies will be covered in accordance with theterms and conditions of such PharmacyProgram Endorsement.Diagnostic ServicesDiagnostic Services when ordered by aPhysician are limited to the following:1. radiology, ultrasound and nuclear medicine,Magnetic Resonance Imaging (MRI);2. laboratory and pathology Services;3. Services involving bones or joints of the jaw(e.g., Services to treat temporomandibularjoint [TMJ] dysfunction) or facial region if,under accepted medical standards, suchdiagnostic Services are necessary to treatConditions caused by congenital ordevelopmental deformity, disease, or injury;2. Dental Implant.What Is Covered?2-7

4. approved machine testing (e.g.,electrocardiogram [EKG],electroencephalograph [EEG], and otherelectronic diagnostic medical procedures);and5. genetic testing for the purposes ofexplaining current signs and symptoms of apossible hereditary disease.Dialysis ServicesDialysis Services including equipment, training,and medical supplies, when provided at anylocation by a Provider licensed to performdialysis including a Dialysis Center are covered.Down SyndromeDown syndrome Services provided to a CoveredDependent who is under the age of 18, or if 18years of age or older is attending highschool, consisting of:1. Applied Behavior Analysis, when renderedby an individual certified per Section 393.17of the Florida Statutes; and2. Physical Therapy by a Physical Therapist,Occupational Therapy by an OccupationalTherapist, and Speech Therapy by aSpeech Therapist. Covered therapiesprovided in the treatment of Down syndromeare covered even though they may behabilitative in nature (provided to teach afunction) and are not necessarily limited torestoration of a function or skill that hasbeen lost.Payment Guidelines for Down SyndromeApplied Behavior Analysis Services for Downsyndrome must be authorized in accordancewith criteria established by us, before suchServices are rendered. Services performedwithout authorization will bedenied. Authorization for coverage is notrequired for Emergency Services provided forthe treatment of an Emergency MedicalCondition.What Is Covered?Note: In order to determine whether suchServices are covered under this Booklet, wereserve the right to request a formal writtentreatment plan signed by the treating Physicianto include the diagnosis,

mother's or newborn's attending Provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 as applicable). In any case, under Federal law, your Group Plan can only require that a provider obtain authorization for prescribing an inpatient hospital stay that exceeds 48 hours (or 96 hours).