Outpatient Infusion Therapy Services. Services must be arranged by a PCP and approved through Prior Authorization by HMO. Some outpatient Infusion Therapy services for routine maintenance drugs have been identified as capable of being safely administered, outside of a Hospital. Your out-of-pocket expenses may be lower when these Covered Services are provided in an Infusion Suite, a home or an office instead of an Outpatient Hospital setting. Non-maintenance outpatient Infusion Therapy services will be covered the same as any other illness. The Schedule of Copayments and Benefit Limits describes payment for Infusion Therapy services. Outpatient Laboratory and X-Ray Services Laboratory and radiographic procedures, services and materials, including (but not limited to) diagnostic x-rays, x- ray therapy, chemotherapy, fluoroscopy, electrocardiograms, laboratory tests and therapeutic radiology services must be ordered, authorized or arranged by the PCP and provided through a Participating facility. Prior Authorization may be required. Rehabilitation Services and Habilitation Services Rehabilitation Services and physical, speech and occupational therapies that in the opinion of a Physician are Medically Necessary and meet or exceed Your treatment goals are provided when Prior Authorization is obtained or prescribed by Your PCP or Specialist. For a physically disabled person, treatment goals may include maintenance of functioning or prevention or slowing of further deterioration. Rehabilitation Services and Habilitation Services may be provided in the Provider’s office, in a Hospital as an inpatient, in an outpatient facility, or as home health care visits. Rehabilitation Services and Habilitation Services, including coverage for chiropractic services, are available from a Participating Provider when Prior Authorization is obtained or prescribed by Your PCP. Benefits are provided for Habilitation Services provided for a Member with a disabling condition when both of the following conditions are met: • the treatment is administered by one of the following Participating Providers: a licensed speech language pathologist, licensed audiologist, licensed occupational therapist, licensed physical therapist, Physician, licensed nutritionist, licensed social worker or licensed psychologist. • the initial or continued treatment must be proven and not Experimental/Investigational. Benefits for Habilitation Services do not apply to those services that are solely educational in nature or otherwise paid under stat...
