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. 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 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 state or federal law for purely educational services. Custodial Care, respite care, day care, t...
