BlueDirect Gold 90 HSA Eligible ($2600 Deductible / $5 Preventive Drug List) - 37160ND2410022 Health Insurance Plan

Exclusions: Not covered except for those necessary to prevent the death of the woman. No benefits are available for removal of all or part of a multiple gestation.

An accidental injury is defined as an injury that is the result of an external force causing a specific impairment to the jaw, sound natural teeth, dentures, mouth or face. Covered Services must be initiated within 6 months of the date of injury and completed within 24 months of the start of treatment or longer if a dental treatment plan approved by BCBSND is in place.

Benefit includes serum, direct skin testing and patch testing when ordered by a Professional Health Care Provider and performed in accordance with medical guidelines and criteria established by BCBSND.

Limit: 1.0 Procedure(s) per Lifetime

Bariatric surgery when Precertification is received from BCBSND. Covered Services must be received from a surgical facility approved by BCBSND. Benefits are subject to a Lifetime Maximum of 1 operative procedure per Member. Psychiatric and substance use services are excluded from the Lifetime Maximum. Guidelines and criteria are available upon request. Benefits for all proposed surgical procedures for the treatment of complications resulting from any or all types of bariatric surgery are available only when Precertification is received from BCBSND.

Limit: 20.0 Visit(s) per Benefit Period

Exclusions: Maintenance care that is typically long-term. This includes care provided after maximum therapeutic improvement, without a trial of withdrawal of treatment, to prevent symptomatic deterioration or it may be initiated with patients without symptoms in order to promote health and to prevent further problems. All forms of thermography for all uses and indications. Clinical ecology, orthomolecular therapy, vitamins or dietary nutritional supplements, or related testing.

Chiropractic services provided on an inpatient or outpatient basis when Medically Appropriate and Necessary as determined by BCBSND and within the scope of licensure and practice of a Chiropractor, to the extent services would be covered if provided by a Physician.

Exclusions: Collection and storage of umbilical cord blood. Abortion except for those necessary to prevent the death of the woman.

Limit: 2.0 Exam(s) per Benefit Period

Diabetes Prevention Program for Members age 18 and older

Exclusions: Benefits are not available for prosthetic limbs or components required for work-related tasks, leisure or recreational activities or to allow a member to participate in sport activities.

Medically Appropriate and Necessary Ambulance Services to the nearest facility equipped to provide the required level of care, including transportation: from the home or site of an Emergency Medical Condition; between hospitals; and between a Hospital and Skilled Nursing Facility. Benefits for air transportation are available only when ground transportation is not Medically Appropriate and Necessary as determined by BCBSND.

Limit: 1.0 Item(s) per Benefit Period

Frames are limited to one every other benefit period. Lenses are limited to one pair per benefit period.

Exclusions: Drugs for weight loss, hair loss, cosmetic purposes, sexual dysfunction, infertility and medications obtained without a prescription order. Drugs and associated expenses and devices not approved by the FDA for a particular use except as required by law (unless the practitioner certifies off-label use with a letter of medical necessity).

Prescription Medications or Drugs and nonprescription diabetic supplies are subject to a dispensing limit of a 90-day supply. Prescription Medication listed on the Value Drug list will apply a $5 copayment amount, then 100% of allowed charge. Preventive medications required under PPACA and the USPSTF are covered at 100%. An additional drug list is being added to address higher out-of-pocket costs on a sub-set of medications for individuals diagnosed with diabetes, hypertension, high cholesterol, asthma, etc.; i.e. chronic conditions.

Limit: 30.0 Visit(s) per Benefit Period

Habilitative Physical Therapy, Occupational Therapy, or Speech Therapy. Therapy is care provided for conditions which have limited the normal age appropriate motor, sensory or communication development. To be considered habilitative, functional improvement and measurable progress must be made toward achieving functional goals within a predictable period of time toward a Member?s maximum potential. Functional skills are defined as essential activities of daily life common to all Members such as dressing, feeding, swallowing, mobility, transfers, fine motor skills, age appropriate activities and communication. Problems such as hearing impairment including deafness, a speech or language impairment, a visual impairment including blindness, serious emotional disturbance, an orthopedic impairment, autism spectrum disorders, traumatic brain injury, deaf-blindness, or multiple disabilities may warrant Habilitative Therapies. Measurable progress emphasizes accomplishment of functional skills and independence in the context of the Member?s potential ability as specified within a care plan or treatment goals. Benefits are subject to the Maximum Benefit Allowance listed in the Schedule of Benefits, Section 1, for each type of therapy under an individual medical plan (IMP) developed for each Member. Benefits are not available for Maintenance Care. Psychiatric and substance use services are excluded from the Maximum Benefit Allowance.

Limit: 1.0 Visit(s) per 3 Years

Exclusions: No benefits are available for a tinnitus masker.

Subject to a Maximum Benefit Allowance per Member of 1 hearing aid per ear every 3 years.

Limit: 40.0 Visit(s) per Benefit Period

Covered Services include: 1. The professional services of an R.N., Licensed Vocational Nurse or L.P.N.; 2. Physical, Occupational or Speech Therapy; 3. Medical and surgical supplies; 4. Administration of prescribed drugs; 5. Oxygen and the administration of oxygen; and 6. Health aide services for a Member who is receiving covered Skilled Nursing Services or Therapy Services. A visit is considered up to 4 continuous hours. Psychiatric and substance use services are excluded from the Maximum Benefit Allowance.

Hospice benefits are provided only for the treatment of Members diagnosed with a condition where there is a life expectancy of 6 months or less. Precertification is required.

PET Scan Benefits are available every six months per Member per Benefit Period with a Prostate Cancer Diagnosis.

Covered Services include the provision of nutrients, antibiotics, and other drugs and fluids intravenously, through a feeding tube, or by inhalation; all Medically Appropriate and Necessary supplies; and therapeutic drugs or other substances. Covered Services also include Medically Appropriate and Necessary enteral feedings when such feedings are the sole source of nutrition for a Member age 1 and older.

Exclusions: Inpatient services performed primarily for diagnostic examinations, physical therapy, rest cure, convalescent care, custodial care, maintenance care or sanitaria care.

Exclusions: Genetic testing when performed in the absence of symptoms or high risk factors for a heritable disease; genetic testing when knowledge of genetic status will not affect treatment decisions, frequency of screening for the disease, or reproductive choices; genetic testing that has been performed in response to direct to consumer marketing and not under the direction of the members physician.

Diagnosis and treatment of periodontal disease when recommended by a Health Care Provider based on health related impacts or further deterioration in existing acute or chronic disease state due to gum disease, including but not limited to periodontal scaling and root planing.

Benefits are available for the inpatient treatment of psychiatric illness, including management of medical problems related to an eating disorder diagnosis, when provided by an appropriately licensed and credentialed Hospital or Psychiatric Care Facility. Precertification may be required for Inpatient Hospital Admissions.

Exclusions: Special education, Including lessons in sign language to instruct a Member whose ability to speak has been lost or impaired to function without that ability. Counseling or therapy services, Including bereavement, codependency, marital dysfunction, family dysfunction, sex or interpersonal relationship.

Home and Office Visits Including assessment, counseling, case management services, Behavioral Modification Intervention for Autism Spectrum Disorder (Including Applied Behavioral Analysis (ABA), treatment planning, coordination of care, psychotherapy and group therapy; precertification may be required. Precertification is required for residential treatment.

Exclusions: Drugs for weight loss, hair loss, cosmetic purposes, sexual dysfunction, infertility and medications obtained without a prescription order. Drugs and associated expenses and devices not approved by the FDA for a particular use except as required by law (unless the practitioner certifies off-label use with a letter of medical necessity).

Limit: 12.0 Visit(s) per Benefit Period

12 visits each per benefit period for hyperlipedemia, gestational diabetes, diabetes mellitus, hypertension and other diabetes related diagnosis or a chronic illness or condition. Intensive Behavioral Interventions for Obesity allow 26 visits per Member per Benefit Period. Psychiatric and substance use services are excluded from the Maximum Benefit Allowance.

Limit: 1.0 Treatment(s) per Lifetime

Only for 'the treatment of improper alignment of biting or chewing surfaces of upper and lower teeth through the installation of orthodontic appliances.'

Exclusions: Services provided and billed by a registered nurse (other than an advanced practice registered nurse), intern (professionals in training), licensed athletic trainer or other paramedical personnel.

Includes dental anesthesia and hospitalization for dental care to members under age 9 who have a medical condition that requires hospitalization.

Limit: 30.0 Visit(s) per Benefit Period

Exclusions: Therapy Maintenance Care, work hardening programs, prevocational evaluation, functional capacity evaluations or group speech therapy services. Health and athletic club membership or facility use, and all services provided by the facility, including physical therapy, sports medicine therapy and physical exercise.

Rehabilitative Services: therapies that are designed to restore function following a surgery or medical procedure, injury or illness. 30-visit limit is for each of PT, OT, and ST. Psychiatric and substance use services are excluded from the Maximum Benefit Allowance. Benefits are not available for Maintenance Care.

Exclusions: Drugs for weight loss, hair loss, cosmetic purposes, sexual dysfunction, infertility and medications obtained without a prescription order. Drugs and associated expenses and devices not approved by the FDA for a particular use except as required by law (unless the practitioner certifies off-label use with a letter of medical necessity).

Prescription Medication listed on the Value Drug list will apply a $5 copayment amount, then 100% of allowed charge. Preventive medications required under PPACA and the USPSTF are covered at 100%. An additional drug list is being added to address higher out-of-pocket costs on a sub-set of medications for individuals diagnosed with diabetes, hypertension, high cholesterol, asthma, etc.; i.e. chronic conditions. Formulary insulin drugs & diabetes supplies obtainable with a Prescription Order shall not exceed a Cost Sharing Amount of $25.00 for a 30-day supply. Cost Sharing Amounts shall not exceed $25.00 for a 30-day supply of Nonformulary insulin drugs & diabetes supplies obtainable with a Prescription Order, when the Member follows the exceptions process for clinically appropriate drugs not listed on the formulary listing.

Office visits for pre and post-natal care waive all cost sharing amounts.

Exclusions: Immunizations for Foreign Travel. Contraceptive products that do not require a prescription order or dispensing by a healthcare provider. Evaluations and related procedures to evaluate sterilization reversal procedures and the sterilzation reversal procedure.

Preventive screening services for Members age 6 and older according to A or B Recommendations of the U.S. Preventive Services Task Force and issued by the Health Resources and Services Administration.

Precertification is required. Benefits are available for externally worn breast prostheses and surgical bras, including necessary replacements following mastectomy, subject to a Maximum Benefit Allowance of 2 external prostheses and 2 bras per Member per Benefit Period. For a double mastectomy, allow a Maximum Benefit Allowance of 4 external prostheses and 2 bras per Member per Benefit Period.

Exclusions: Services or procedures with the primary purpose to improve appearance and not primary to restore bodily function or correct deformity resulting from disease, trauma, congenital or developmental anomalies or previous therapeutic processes, or which primarily improve or alter body features which are variations of normal development.

Reconstructive surgery to restore bodily function or correct deformity resulting from disease, trauma, congenital or developmental anomalies or previous therapeutic processes.

Limit: 30.0 Visit(s) per Year

Exclusions: Therapy Maintenance Care, work hardening programs, prevocational evaluation and functional capacity evaluations. Health and athletic club membership or facility use, and all services provided by the facility, including physical therapy, sports medicine therapy and physical exercise.

Rehabilitative Services: therapies that are designed to restore function following a surgery or medical procedure, injury or illness. 30-visit limit is for each of PT, OT, and ST. Psychiatric and substance use services are excluded from the Maximum Benefit Allowance. Benefits are not available for Maintenance Care.

Limit: 30.0 Visit(s) per Year

Exclusions: Speech Therapy Maintenance Care and group speech therapy services.

Rehabilitative Services: therapies that are designed to restore function following a surgery or medical procedure, injury or illness.

Limit: 1.0 Exam(s) per Benefit Period

Covered services include custom diabetic shoes and inserts, and the care of corns, calluses and toenails when medically appropriate and necessary for members with diabetes. Benefits are available for the care of corns, calluses and toenails when medically appropriate and necessary for members with circulatory disorders of the legs or feet.

Limit: 30.0 Days per Benefit Period

Precertification is required. Psychiatric and substance use services are excluded from the Maximum Benefit Allowance.

Exclusions: Drugs for weight loss, hair loss, cosmetic purposes, sexual dysfunction, infertility and medications obtained without a prescription order. Drugs and associated expenses and devices not approved by the FDA for a particular use except as required by law (unless the practitioner certifies off-label use with a letter of medical necessity).

Preferred and Non-Preferred Specialty Drugs are subject to a dispensing limit of a 30-day supply. In limited circumstances Specialty Drugs may be available for a greater than 30-day supply. Non-Preferred Specialty drugs apply deductible and 50% coinsurance.

Exclusions: Services by a vocational residential rehab center, a community reentry program, halfway house or group home.

Benefits are available for the inpatient treatment of substance use, including medically managed inpatient detoxification, medically monitored inpatient detoxification, medically managed intensive inpatient treatment or medically monitored intensive inpatient treatment, when provided at an appropriately licensed and credentialed Substance Use Facility. Benefits available for residential treatment. Benefits available for partial hospitalization. Precertification is required. For SUD, Precertification is required for inpatient and residential.

Home and Office Visits: Benefits Including assessment, counseling, case management services, treatment planning, coordination of care, psychotherapy, group therapy and Opioid Treatment Program provided by a licensed and/or credentialed independent provider in accordance with the Health Care Provider's scope of licensure as provided by law. Precertification may be required. Outpatient benefits include diagnostic, evaluation and treatment services provided by a licensed and credentialed indepedent provider in accordance with the health care provider's scope of licensure as provided by law.

Limit: 1.0 Exam(s) per Transplant

Exclusions: Benefits are not available for transportation services for the member. Benefits are not available for artificial organs, donor search services or organ procurement if the organ or tissue is not donated. Benefits are not available if the member is the donor for transplant services.

One evaluation is allowed per transplant procedure. Services must be performed at a qualified transplant center. Pre-transplant review or second opinion prior to the member's evaluation at the transplant center, are covered under the professional office visit benefit or the second surgical opinion benefit. Similarly, the post-transplant evaluation would be covered under the professional office visit benefit.

Limit: 2.0 Treatment(s) per Lifetime

Exclusions: No benefits will be provided for orthodontic services or osseointegrated implant surgery.

Benefits are subject to a Lifetime Maximum of 2 surgical procedures per Member and a Maximum Benefit Allowance of 1 splint per Member per Benefit Period.

Limit: 11.0 Visit(s) per 3 Years

Well Child Care through age 6, 100% of Allowed Charge. Deductible Amount is waived.