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The following services and supplies are covered under your MAJOR MEDICAL benefits:
• Physician charges for office visits
and office consultations for the diagnosis or treatment of an injury, illness, or disease
• Allergy extract and extract injections
• Pre- and post-natal care visits
• Contraceptive devices (one per year) that require a prescription or
physician insertion or removal
• First contact lens(es) obtained within one year of cataract
surgery
• Medical emergencies not covered as BASIC benefits
• Professional ambulance service charges beyond the $25 maximum payable as a
BASIC benefit
• Eye and ear examinations for the diagnosis and treatment of an illness,
injury or disease
• Authorized Christian Science Practitioner charges for office visits and
office consultations
• Chelation therapy* for certain diagnoses
• Physical, occupational, and speech therapy* to restore or improve a
functional loss caused by injury, illness, disease, or congenital anomaly
• Private-duty nursing* charges for skilled care, except for care
provided by a person who ordinarily resides in your home or who is a member of your family
or that of your spouse.
* These services are payable based on
certain medical guidelines and are not covered in every circumstance. In order to avoid
incurring expenses not payable by the State Health Plan Advantage, it is strongly
recommended that you obtain prior approval for the services indicated. To obtain prior
approval, you may call the BCBSM State of Michigan Customer Service Center or submit your
prior approval request in writing to the Lansing office. Telephone numbers and addresses
are listed in the Customer Service section beginning on page i.
In addition to those items listed above,
MAJOR MEDICAL benefits also cover the following:
CHIROPRACTIC CARE BENEFIT
Chiropractic manipulations, an
initial office examination, first aid treatment of musculoskeletal injury, and X-rays
relating to the back and spine, when performed by a physician, including a chiropractor
acting within his or her scope of licensure.
ACUPUNCTURE THERAPY BENEFIT
Up to a maximum of 20 acupuncture
therapy treatments in a calendar year are covered. These services must be directly
performed by a licensed physician (MD or DO). Services are not payable when
performed by any other type of practitioner, including Oriental Medical Doctors (OMDs),
whether or not they are performed under the direction of the physician. Acupuncture
is covered only for the treatment of the following conditions:
• Sciatica
• Neuritis
• Postherpetic neuralgia
• Tic douloureux
• Chronic headaches (e.g., migraine)
• Osteoarthritis
• Rheumatoid arthritis
• Myofascial complaints (e.g., neck and lower back pain)
DURABLE MEDICAL EQUIPMENT
The rental or purchase of durable
medical equipment is covered when the equipment is reasonably and medically necessary for
your illness, injury, or disease. This equipment must be prescribed by your physician and
used in the course of your medical treatment. Insulin pumps are covered under the BASIC
Medical Surgical benefit.
If the rental fee exceeds the purchase price,
based on your physician’s estimated duration of need, you will be advised to purchase
(rather than rent) the equipment. The purchase of new and used equipment is covered
provided the equipment is purchased only from a professional supplier.
Benefits also are available for the repair of
purchased durable medical equipment due to normal wear and tear. The replacement of
purchased equipment is covered due to:
• Loss or irreparable damage of your
equipment
• A change in your condition or size
Benefits are NOT available for routine
maintenance expenses, such as the cost of batteries. Also, benefits are NOT available for
non-medical equipment or equipment used primarily for comfort, convenience or safety.
If you have questions as to whether or not a
certain piece of equipment will be covered, you should send a written
inquiry to the BCBSM State of Michigan Customer Service Center and include:
• Information about your condition or
diagnosis
• A copy of your physician’s prescription
• The name and description of the prescribed equipment
A BCBSM representative will contact
you if additional information is required.
PROSTHETIC AND ORTHOTIC APPLIANCES
These appliances (see the Glossary
for definitions) are covered when they are prescribed by your physician (within the scope
of his or her licensure) as medically necessary.
Benefits include:
• Prosthetic and Orthotic appliances
that are pre-fabricated, custom-fitted, and custom made
• The repair, fitting and/or adjustment of a covered appliance
• The replacement of appliances when they are damaged beyond repair or worn
out, or because of a change in your condition or size
If you have questions as to whether or not a
certain appliance will be covered, you should send a written inquiry to the BCBSM State of
Michigan Customer Service Center and include:
• Information about your condition or
diagnosis
• A copy of your physician’s prescription
• The name and description of the prescribed equipment
A BCBSM representative will contact you if
additional information is required. |
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