SERVICES MUST BE MEDICALLY NECESSARY
ONLY OUTPATIENT SERVICES COVERED –
INPATIENT SERVICES AND EMERGENCY DEPT SERVICES NOT COVERED
*Chemotherapy services - Not Covered
SERVICES THAT REQUIRE PRIOR AUTHORIZATION (PA) FOR PAYMENT
SERVICES |
ADDITIONAL INFORMATION |
Infusion Services |
Limited benefit |
Injection Medications |
Limited benefit |
Genetic Testing |
|
Physical or Occupational Therapy |
Max 20 visits per year |
Radiation Therapy |
|
Reconstructive Surgeries |
|
Skin Procedures and Surgeries |
|
Vascular Surgeries/Treatment |
|
Unclassified Procedures |
Limited Benefit |