Prosthetics. Crowns and Bridges (Plan B) paying for 60% of the approved Schedule of Fees.
Prosthetics. Artificial substitutes for body parts and tissues and materials inserted into tissue for functional or therapeutic purposes. Covered services include purchase, fitting, needed adjustment, repairs, and replacements of prosthetic devices and supplies that:
Prosthetics. Bridges, dentures, partials and re- lining or re-basing dentures, adding teeth to par- tial denture to replace extracted teeth, full and partial denture repairs, stayplate, special tissue conditioning per denture (limited to one course of treatment per six (6) month period), and den- ture duplication (jump case).
Prosthetics. Crowns and Bridges (Plan B) paying for fifty percent (50%) (effective 2012 November 01, sixty percent (60%)) of the approved schedule of fees (to a maximum of $1500.00) per person per calendar year).
Prosthetics. 80% of eligible charges after the deductible. Not covered. Hearing aids for members under age 19 for hearing loss that is not correctable by other covered procedures. Coverage limited to one hearing aid per ear every 3 years. 80% of eligible charges after the deductible. Not covered. Wigs for hair loss resulting from alopecia areata are limited to one wig per calendar year. 80% of eligible charges after the deductible. Not covered. • Special dietary treatment for phenylketonuria (PKU) is covered when recommended by a physician, physician assistant or advanced practice registered nurse. • Limited coverage for amino-acid based elemental formulas that are consumed orally and treat cystic fibrosis or certain other metabolic and malabsorption errors. • Enteral feedings when they are prescribed by a physician, physician assistant or advanced practice registered nurse and are required to sustain life. 80% of eligible charges after the deductible. Not covered. Diabetic supplies Coverage includes over-the-counter diabetic supplies, glucose monitors, syringes, blood and urine test strips, and other diabetic supplies as medically necessary. 80% of eligible charges after the deductible. Not covered. PIC covers equipment and services ordered by a physician, physician assistant or advanced practice registered nurse and provided by DME/prosthetic/orthotic vendors. For verification of eligible equipment and supplies, contact PIC Customer Service at the address and phone number shown on the inside cover of this contract. If you are over age 18, contact lenses and their related fittings are not eligible for coverage unless they are prescribed as medically necessary for the treatment of keratoconus. Members must pay for lens replacement. Amino-acid based elemental formulas are covered only when 1) they are consumed orally, 2) are ordered by a physician, physician assistant, or advanced practice registered nurse for a person who is five years or younger, 3) are medically necessary, and 4) treat the following metabolic and other malabsorption conditions that have been diagnosed by a specialist:
Prosthetics. This benefit covers prosthetic devices for functional reasons to replace a missing body part, including artificial limbs, external breast prostheses following a mastectomy, and maxillofacial prostheses. Prosthetic devices or appliances that are surgically inserted into the body are covered under the appropriate Hospital Care benefit. Rehabilitation Services Coverage for disabling conditions is provided through inpatient and outpatient rehabilitation therapy services. Examples of such services include: physical therapy, speech therapy, and occupational therapy. The following conditions must be met: • Services are to restore and significantly improve function that was previously present but lost due to acute Injury or Illness; • Services are not for palliative, recreational, relaxation or maintenance therapy; and • Loss of function was not the result of a work-related Injury. Coverage for cardiac rehabilitation requires that Members have experienced a cardiac event in the preceding 12 month period, such as myocardial infarction, chronic stable angina, heart transplant or heart and lung transplants. Inpatient Rehabilitation Inpatient rehabilitation services require Pre-Authorization and must be furnished and billed by a rehabilitative unit of a Hospital or by another approved rehabilitation facility. When rehabilitation follows acute care in a continuous inpatient stay, this benefit starts on the day the care becomes primarily rehabilitative. Inpatient care includes room and board, services provided and billed by the inpatient facility, and therapies performed during the rehabilitative stay. Outpatient Rehabilitation Outpatient rehabilitation benefits are subject to the following provisions: • You must not be confined in a Hospital or other Medical Facility; and • Services must be billed by a Hospital, physician, or physical, occupational, speech or massage therapist. Speech therapy is covered only when required as a result of brain or nerve damage secondary to an accident, disease or stroke. Once the benefits under this provision are exhausted for a particular condition, coverage may not be extended by using the benefits under any other provision. NOTE: Outpatient rehabilitation therapy services are subject to a combined total maximum of 25 visits per Member per Calendar Year. Skilled Nursing Facility Services Inpatient Skilled Nursing Facility care requires Pre-Authorization. Benefits include inpatient services and supplies of a Skilled Nursing Facility for...
Prosthetics including supply of all body extremities including therapeutic ocular prosthetics, segmental instrument tray and spine fusion in scoliosis and vertebral surgery;
Prosthetics. Crowns, Bridges and Implants (Plan B) paying for 70% of the approved Schedule of Fees to a lifetime maximum of $3,000 for implants per person.
Prosthetics crown and bridge procedures - 60%.
Prosthetics arm, hand, hook, leg, foot, breast, eye, larynx. Includes coverage for brassieres following a mastectomy, prosthetic modifications and repairs, sheath, suspension sleeves, stockinette and xxxxx socks. Prosthetic eyewear (glasses/contact lenses) is limited to once per lifetime following cataract surgery. Respiratory/Cardiology: heart rate monitor (apnea), compressor, inhalant devices, tracheotomy supplies, oxygen (liquid, concentrator, cylinder) including portable unit and oxygen supplies. Vascular compression: intermittent compression pump and sleeve, pressure gradient surgical stockings limited to 2 pairs per calendar year. Musculo-Skeletal: cold and heat therapy, muscle/nerve stimulator (T.E.N.S.) and supplies, traction equipment.
