| Prostate and Colorectal Cancer Screening |
| Covered services include medically necessary prostate and
colorectal cancer screenings. Please refer to your contract for
how cancer screenings are covered. |
| These Pharmacy Benefits Are Limited |
- The maximum quantity for pharmacy purchased medications is a
30-day supply.
- Compound medications are only covered when one ingredient is
a federal legend or state restricted medication.
|
| These Benefits Are Limited |
- Outpatient mental illness is limited to 12 visits per calendar
year
- Inpatient mental illness is limited to 8 days per calendar
year.
- We provide transplant coverage only to those who have been covered
by us, or another insurer with similar transplant coverage, for
a total of at least 12 months (or since birth), providing there
is no lapse between the two coverages. Benefits are based on the
recipient’s eligibility, not the donor’s. Our payment
for certain covered transplant services and supplies is limited
to a lifetime maximum of $250,000 per enrollee
- Emergency care covered services include the medical
examination and ancillary tests required in determining the
extent of an emergency medical condition. Examples
include but are not limited to: Suspected heart attack,
serious burn, loss of consciousness, poisoning, bleeding
that does not stop and severe pain.
- Acupuncture is limited to 12 treatments per calendar year
- Spinal manipulation is limited to 10 treatments per calendar
year
- Inpatient rehabilitation care is limited to $15,000 per calendar
year
- Outpatient rehabilitation care is limited to $1,500 per calendar
year
- Neurodevelopmental therapy is limited to $1,500 per
calendar year for children age 6 and under.
- Home health care is limited to 130 days per calendar year
- Skilled nursing facility care is limited to 100 days per calendar
year
- Durable medical equipment is limited to $2,500 per calendar
year
- Ground and air ambulance combined is limited to $5,000 per calendar
year (does not apply to emergent use)
- Dental care is limited to the treatment of an accidental injury
to natural teeth or fractured jaw and limited to $1,000 per
calendar year. Diagnosis must be made within 6 months
and treatment within 12 months of injury.
- Hospitalization for medically necessary dental care is limited
to $1,000 per calendar year.
- Growth hormone benefit, when eligible according to the
contract, is limited to $20,000 per calendar year.
- The following will be covered only after nine months of
enrollment: preexisting conditions, allergies, otitis media
(ear infections), removal of tonsils and adenoids and
sterilization procedures. You may receive credit from prior
creditable medical coverage, providing there is a less than
63-day lapse between the two coverages.
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|
| These Pharmacy Benefits Are Not Covered |
- Impotence and infertility medications
- Experimental/investigational medications
- Medications prescribed for cosmetic purposes
- Smoking cessation products
|
| Services And Supplies Not Covered |
- Immunizations for the sole purpose of travel or passport
purposes.
- Services provided by a member of your immediate family.
- Services or supplies that are not medically necessary.
- Chemical dependency
- Services related to or supporting infertility and reversal of
sterilization procedures.
- Orthognathic surgery
- Temporomandibular joint disorder.
- Custodial care, personal hygiene, and other forms of
supervised self-care.
- Services and supplies provided for obesity or weight reduction, lncluding complications arising from such
treatment.
- Chronic or long-term psychotherapy (services provided in
excess of crisis intervention or short-term therapy).
- Services or supplies for the treatment of personality and
gender identity disorders.
- Cosmetic/reconstructive services and supplies, including
complications arising from such services.
- Experimental and investigational treatment, procedures,
equipment, devices, and supplies.
- Treatment for addiction to tobacco, tobacco products, nicotine
substitutes, or foods.
- Appliances or equipment primarily for personal comfort or
convenience, and therapeutic devices including eyeglasses
and hearing aids.
- Routine physical, mental, eye, hearing examinations, or eye
exercises (except where specifically listed).
- Surgery to alter the refractive character of the eye.
- Self-help training, instructional programs, and physical
exercise programs (except where specifically listed).
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Asuris NW Health 
