medical benefits - healthx

This is not a guarantee of Benefits. This is a general summary of benefits available under this plan and is not intended to be used as an authorization for services to be provided. We are providing this summary without knowledge of the diagnosis or type of treatment you plan to provide. All specific plan exclusions and limitations will be applied at the time the claim is processed. Participant's eligibility and benefits are based upon the information currently

available to us. Both are subject to change without notice to you. All covered charges will be limited to reasonable and customary charges. Benefits will be coordinated with another carrier, if other coverage is involved.

Teamsters and Food Employers Security Trust Fund of 13

MEDICAL BENEFITS Fund Name: Teamsters and Food Employers Security Trust Fund SPD Version: January 1, 2015 Fund ID: L500 Revised: 9/9/21 RG Who is Covered: Active Members, Retirees & Dependents

Trust Fund Contact Information To access eligibility, claim status, summary of benefits for medical, dental and/or vision as well as to contact

the Trust Fund Office for general questions, please visit out Provider Portal or send us an email:

www.memberbenefitsonline.com [email protected]

Correspondence and Appeals:

PO Box 2340 West Covina, CA 91793

Mail Medicare Claims to:

Teamsters and Food Employers Security Trust Fund PO Box 1618

San Ramon, CA 94583 Medicare claims also crossover through a Medicare

clearinghouse.

PPO Medical Network: Anthem Blue Cross

Pre-certification: (800)274-7767

Pricing: (800)688-3828

Find a PPO Provider: www.anthem.com/ca

Mail medical claims to: Anthem Blue Cross

PO Box 60007 Los Angeles, CA 90060

EDI Payor ID: 47198

Group#: 277537

Alpha Prefix: GBU

HMO Medical Option: (Not administered by BeneSys)

Kaiser

(800) 464-4000

*Kaiser Members use BMR Rx unless drug is on the Kaiser Base list.

HMO Medical Option: (Not administered by BeneSys)

Aetna

Active: (877) 647-3776 Retirees: (888) 267-2637

www.aetna.com Plan Name: Aetna Value Network HMO

Active Grp: 0866084, Early-Retiree Grp: 459257, Medicare Retiree Grp: 459260

Mental Health & Substance Abuse Network (E-MAP):

HMC Health Works

Member: (800)431-5036 Provider: (855)487-8914

Mail claims to: PO Box 981605

El Paso, TX 79998-1605 Electronic Payor ID: 75318

(Aetna & PPO members utilize HMC)

Podiatry Network: Podiatry Plan of CA (PPOC)

Find a PPO Provider:

(800)367-7762, or www.podiatryplan.com

Mail all podiatry claims to:

4304 18th Street, PO Box 14671

San Francisco, CA 94114-9991

or fax: (415)928-0228

Chiropractic Network: American Specialty Health Network (ASHN)

Members: (800)678-9133 Providers: (800)972-4226 www.ashcompanies.com

Mail ASHN claims to:

PO Box 509001 San Diego, CA 92150

Mail out-of-network claims to local Blue Cross.

Prescription Benefit Management: Broadreach Medical (BMR)

(Not administered by BeneSys)

Retail: ProCare Rx (877)718-2379 Ext. 4 Mail Order: OptumRx 855-577-6328

Our System is ICD-10 Compliant for Claims after 10/1/15

http://www.memberbenefitsonline.com/

mailto:[email protected]

http://www.anthem.com/ca

http://www.podiatryplan.com/

http://www.ashcompanies.com/




PPO Medical Summary of Benefits:

Benefit Comment

Appeals Timely Filing Claimant will have 180 days from the date of denial.

Claims Timely Filing 1 year from the date of the service.

Coordination of Benefits

Active Employee / Early Retiree

(Non-Medicare Primary)

If the primary plan has a PPO negotiated rate, this Plan (as secondary) will pay the difference between what is paid by the primary plan up to the maximum amount negotiated in the PPO contract.

This Plan will not coordinate with any HMO coverage.

Medicare Primary Retirees

This Plan as a secondary will pay 20% of Medicare’s allowable.

Participant will need to satisfy this Plan’s deductible.

This Plan will deny any services Medicare denies and deems not medical necessary.

Any services that is typically covered under this Plan and is not a covered service under Medicare, will be covered under this Plan. Prior authorization is not required when Medicare is primary, unless it is a service that is not covered by Medicare, and this Plan has a

prior authorization requirement for that service (e.g. home infusion therapy will require prior authorization by this Plan).

With respect to a Retiree and/or Spouse age 65 years or older and a Retiree and/or Spouse entitled to Medicare as a result of a disability, the benefits payable will be reduced by the

benefits payable under Medicare Part A and B, regardless whether the Retiree and/or Spouse actually enrolls for Medicare.

Except for copayments and deductibles which result in out-of-pocket expenses for the Participant, this Plan will not pay benefits for

expenses covered by HMO coverage.

Dependent Age Limit Up to age 26.

Disabling Conditions Only

Should you or your Dependent be disabled on the date your coverage terminates, Hospital, medical and surgical benefits will be continued for you or your Dependent, with respect to such Disability only, provided that:

1. The Plan is in effect when the expense is incurred. 2. the disability continues until treatment is received.

3. Hospital confinement commences within 3 months of the termination of coverage. 4. the surgical procedure is performed within 3 months of the termination of coverage.

5. The medical treatment is covered within any part of the 3 month period immediately following the termination date. In no event will the benefit provided under this section extend beyond the 3 months following the Participant's loss of coverage.

Grandfathered Status This Plan is not grandfathered.

Plan Year January 1 through December 31.




Traveling Outside of the United States

Non-emergency and elective services outside of the United States are not covered.

Participants cannot assign benefits to a Provider for services rendered outside the United States or its territories.

Situations Where Non-PPO Providers Claims Process at PPO Provider Benefit Level

The benefit reduction to 60% of Covered Expenses will not apply in the following situations: 1. The patient receives services from an anesthetist who is a Non-Contract Provider during the course of a surgery performed

in a Contract Hospital. 2. The patient receives medical services during the course of surgery in a Contract Hospital from an assistant surgeon who is a

Non-Contract Provider. 3. The patient receives services in a Contract Hospital from an emergency physician or emergency physicians group who are

Non-Contract Providers. 4. The patient receives services from a laboratory that is a Non-Contract Provider when medical tests taken by Contract

Provider are sent to that provider to a Non-Contract Provider laboratory. This exception is a onetime exception per Employee or Dependent.

5. The patient receives services from a specialist physician who is a Non-Contract Provider when there are no physicians of that specialty who are Contract Providers in the county in which the Employee or Dependent resides.

Situations Where Non-PPO Claims Process at PPO Benefit

Level

There are 3 situations when a Non-PPO Hospital can be reimbursed at the PPO rate. Those situations are: 1. When there is no PPO Hospital in the County where services are received; or 2. When specialized services are needed and not available at a PPO Hospital (a rare occurrence which requires prior approval

from Anthem Blue Cross); or Emergency Services. However, if admission is required, the Plan may require that the patient be transferred to a PPO Hospital as soon as it is medically safe for the patient to be transported. If the patient decides to remain in the Non-PPO Hospital after the

acute emergency period, the Plan’s Non-PPO Hospital Benefit will apply.

Benefit In-Network Out-of-Network (UCR) Comment/Limitation

Annual Maximum None

Deductible $300 individual / $900 family In-network and out-of-network deductibles satisfy each other.

Applicable to primary Medicare members.

Deductible Carry Over Last 3 months (October, November, December).

Lifetime Maximum None

Out-of-Pocket Maximum

$900 per person

Effective 1/1/17: $14,300

Effective 1/1/16:

$13,700 per family

None

Per person out-of-pocket maximum includes deductible, mental health & substance abuse.

Effective 1/1/16, family out-of-pocket maximum includes medical and

prescription drugs.

Prior to 1/16: family out-of-pocket maximum includes medical, mental health & substance abuse, and prescription drugs.

Abortion (Voluntary) Not Covered




Accident

Plan requires a signed lien and TPL in order to review claims for possible payment but it does not require the auto dec page or police report.

If 2 or more eligible members are injured in the same accident, the covered expenses which result from the accident will be combined and only one deductible will be charged regardless of the number of family members injured. If the same accident results in covered expenses

in the next calendar year, another single deductible only will be applied for these expenses.

Work Related Not Covered

MVA 80% 60%

Fight 80% 60%

Accidental Dental 80% 60%

Acupuncture Not Covered

Allergy Services

Injections 80% 60%

Testing 80% 60%

Ambulance

Must be medically necessary.

Effective 3/1/17, all covered ambulance services accumulate to the out-of-pocket maximum.

Air 80% 80%

Ground 80% 80%

Birth Control See the Routine/Preventive Section under Contraceptives.

Biofeedback 80% 60% EEG Biofeedback for Mental Health Disorders is not covered.

Chiropractic

This Plan uses a Closed Panel of Chiropractors through the American Specialty Health Network (ASHN).

Members: (800)678-9133 Providers: (800)972-4226

ashcompanies.com

The ASHN Network is limited to: Arizona, California, New Mexico, Nevada, Oregon, Utah

& Washington.

In-network claims do not apply to the deductible and out-of-pocket.

Mail ASHN claims to:

ASHN PO Box 509001

San Diego, CA 92150-9001

Medicare Primary members do not need to use ASHN network. Medicare pricing is used as well as the Plan’s guidelines. Example: Medicare doesn’t

cover chiropractic x-rays but the Plan will.

If a non-ASHN provider is used, where a ASHN provider is available, the service is not covered.

If there is no ASHN Provider in the county where services are received, benefits

will be paid at 80% UCR after the deductible and the visit limits below apply: 12 visits 1st Month

8 visits 2nd & 3rd month 4 visits 4th month (Further treatment subject to review)

Blue Cross providers are out of network and receive out-of-network benefits.

Mail out-of-network claims to local Blue Cross.

Office Services 90% Not Covered




Massage Therapy Not Covered

Modalities 90% Not Covered

X-Ray 90% Not Covered

Clinical Trials The Plan covers Clinical Trials. Please see applicable benefit section for cost share information.

Court Ordered Treatment Not Covered

Dental 80% 60% Accidental injury to natural teeth only.

Orthognathic Not Covered

Diabetic Supplies 80% 60%

Diagnostic Labs / X-Rays 80% 60% ONE-TIME exception per employee or dependent: Lab ordered by a PPO

Provider at a Non-PPO laboratory will be covered at 80%.

Durable Medical Equipment (DME)

80% 60%

DME costing $1,000 and over require prior authorization.

Stockings, CPAP & Supplies are covered with review of Medical Necessity.

Corrective shoes are not covered.

See Routine/Preventive section for breast pump benefits.

Compression Stockings 80% 60%

Diabetic Shoes/Inserts 80% 60%

Educational or Training Programs

Not Covered, except as provided under the Routine/Preventive Section.

Emergency Care

Emergency Facility 80% 80%

Services provided in an ER or Urgent care facility which are not due to an Emergency shall be covered as an Office visit with a Physician and the facility

charges shall not be covered.

Emergency Physician 80% 80%

Emergency Misc. 80% 80%

Emergency with Admit. 80% 80%

Urgent Care Facility 80% 80%

Urgent Care Physician 80% 80%

Urgent Care Lab/X-Rays 80% 80%

Urgent Care Misc. 80% 80%

Extended Care Facility See Skilled Nursing Facility. Custodial care is not covered.

Foot Care (Routine)

The Plan requires the use of a Podiatry Plan of California (PPOC) panel provider (including Medicare primary participants).

Find a PPOC provider go to www.podiatryplan.com or call 800-367-7762

If there is no PPOC provider in the area, the out-of-network podiatrists can contact PPOC and sign up under a "special contract" for one patient.

http://www.podiatryplan.com/




NOTE: Although there are no specific limitations set forth by the Plan, if denied by PPOC the member will need to appeal to PPOC and then appeal to the BOT if still denied. Guidelines for the foot care benefit are determined medically necessary by PPOC.

Mail podiatry claims to:

PPOC 203 Willow St., #204

San Francisco, CA 94109 OR via fax: 415-928-0228

Medicare claims do not crossover to PPOC. Submit claims and Medicare EOB to PPOC.

Foot Care 100% Not Covered

Routine foot care is not covered.

Must be medically necessary due to an underlining medical condition.

Deductible does not apply.

Orthotics / Supports 100% Not Covered Prior authorization through PPOC is required.

Deductible does not apply.

Genetic Testing Not covered, except as provided under the Routine/Preventive Section.

Hearing Aids

Not Covered through the Plan. However, there is a discount program available to Plan Participants:

EPIC Hearing Healthcare Services 866-956-5400

Office Visits / Testing 80% 60%

Home Health 80% 60% Must be in lieu of hospitalization.

Prior authorization is required.

Home Infusion 80% 60% Prior authorization is required.

Hospice 80% 60%

Must be in lieu of hospitalization.

Must be recommended by the attending physician.


Bereavement 80% 60%

Hospital Inpatient admission requires prior authorization.

Room & Board 80% 60% Standard semi-private room rate.

Inpatient Physician 80% 60%

ICU/CCU 80% 60%

Ancillary 80% 60%




Inpatient Pathology 80% 60%

Inpatient Radiology 80% 60%

Inpatient Surgery 80% 60%

Pre-Admission Testing 80% 60% (If done within 7 days prior to admission for approved Hospital stay. Duplicate

pre-admit tests done in the hospital not covered)

Infertility Not Covered

Injections 80% 60%

Maternity Care Dependent-child maternity is not covered except as provided under the Routine/Preventive Section.

Pre/Post Natal Care 100% 60% For services that are Routine/Preventive in nature, please see that section.

Delivery 80% 60%

Newborn Nursery 80% Not Covered

Midwife 80% 60%

Birthing Center 80% 60%

Home Birth Not Covered

Mental Health & Substance Abuse

All Retirees and their dependents enrolled in the

Indemnity PPO Plan, and Aetna Medicare retirees and

Medicare dependents of Aetna retirees are NOT eligible for Mental Health & Substance

Abuse.

Kaiser members must use Kaiser’s benefits.

Mental Health & Substance Abuse network (E-MAP):

HMC Health Works To locate a Preferred Provider or to obtain approval/precertification call: (800)431-5036

All inpatient services, non-routine outpatient surgeries such as electric convulsive treatment, psychological testing, neuropsychological

testing require precertification. Other outpatient services may require pre-approval. Providers are required to call HMC to verify if services need approval/precertification.

If approval/precertification is not obtained where it is required, benefits will not be paid.

Eating Disorders are covered under Mental Health.

ABA Therapy is not covered for PPO Plan Participants; however, ABA Therapy is covered for Aetna participants that are qualify for

Mental Health benefits.

Deductible does not apply. PPO out-of-pocket accumulates to the $900 out-of-pocket.

Submit Aetna & PPO Claims:

HMC Health Works PO Box 981605

El Paso, TX 79998-1605

Electronic Payor ID: 75318




Aetna Plan Participants

Aetna Inpatient $350 per admission copay Not Covered In-network copays are paid to the provider.

Out-of-network charges are not covered, unless of an emergency. Aetna Outpatient $20 copay Not Covered

PPO Plan Participants (Active Plans Only)

Inpatient Physician 90%

$300 out-of-pocket max per year

60%

Inpatient Semi Private Rm 90%


60%

Outpatient Physician 90%


60%

Residential/Day Treatment 90%


60%

Group Therapy/Family/Marriage

90% $300 out-of-pocket max

per year 60%

Emergency Care 90%


90% (Emergency room, ambulance, urgent care facility)

HMC must be notified within 1 day of an Emergency inpatient admission.

Anesthesia for Electric Convulsive Treatment

90% $300 out-of-pocket max

per year 60%

Ambulance 90%


60% (to hospital for mental health treatment & substance abuse)

Nursing Care 80% 60% Private Duty Nursing is not covered.

Morbid Obesity/ Bariatric Surgery

80% 60%

Precertification is required.

Must be medically necessary.

Pre/Post-Operative office visits for approved surgery are covered, however records may be requested for review of lap-band adjustments to verify that

patient still meets criteria.

(See the Routine/Preventive Section for services covered under ACA.)




Office Visits Home visits are not covered.

Primary Care Physician 80% 60%

Specialists 80% 60%

Online Office Visit through Live Health Online

80% N/A

Available through www.livehealthonline.com.

Visits are subject to the deductible. Deductible and coinsurance will accumulate towards the out-of-pocket.

Patient pays their coinsurance with a credit card at the time of the visit.

Telehealth 80% 60%

Pain Management 80% 60%

Prosthetics 80% 60%

Prosthetics Bra 80% 60%

Wig Not Covered

Routine/Preventive – Adult & Women

No Coverage for Out of Network Preventive Services (except Pap and Mammogram).

Routine Exam 100% Not Covered

Well-Woman Visits 100% Not Covered (to receive services below for women under 65)

Abdominal Aortic Aneurysm 100% Not Covered (one-time screening for men ages 65-75 who have ever smoked)

Alcohol Misuse Screening/Counseling

100% Not Covered

Anemia Screening 100% Not Covered (on a routine basis for pregnant women)

Aspirin 100%

(Through the Prescription Plan)

Not Covered (To prevent cardiovascular disease for men ages 45 - 79 & women ages 55 - 79)

Blood Pressure Screening 100% Not Covered (for all adults)

Breast Cancer Genetic Test (BRCA) Counseling

100% Not Covered (for women at higher risk of breast cancer)

Breast Cancer Mammography Screening

100% 60% (every 1-2 years for women over 40)

Breast Cancer Chemoprevention Counseling

100% Not Covered (for women at higher risk)

Breastfeeding Comprehensive Support/Counseling

100% Not Covered (from trained provider for pregnant/nursing women)

Breast Pump/Supplies 100% Not Covered (for pregnant and nursing women)

Cervical Cancer Screening (PAP)

100% 60%

(for sexually active women)

Effective 1/1/18 the following limitations are applicable:

• Ages 21-29 covered every 3 years.

http://www.livehealthonline.com/




• Ages 30-65, HPV testing with pap smear every 5 years, or a pap smear alone every 3 years.

Chlamydia Infection Screening 100% Not Covered (for younger women, and women at higher risk)

Cholesterol Screening 100% Not Covered (Adults over age 50)

Colorectal Cancer Screening 100% Not Covered Cologuard is covered under the Diagnostic Lab benefit, not the Preventive

Care benefit. Subject to Deductible and Co-insurance.

Contraception

100% (Oral contraceptive

through the Prescription Plan)

Not Covered

(FDA approved contraceptive methods, Sterilization procedures, and patient education and counseling as prescribe by a health care provider for women with reproductive capacity. Not including abortifacient drugs. This does not apply to health plans sponsored by certain exempt "religious employers".)

Depression Screening 100% Not Covered (for all adults)

Diabetes (Type 2) Screening 100% Not Covered (for adults with high blood pressure)

Diet Counseling 100% Not Covered (for adults at higher risk of chronic disease)

Domestic/Interpersonal Violence Screening/Counseling

100% Not Covered (for all women)

Folic Acid Supplements 100%


Not Covered (for women who may become pregnant)

Gestational Diabetes Screening 100% Not Covered (for women who are 24-28 weeks pregnant and those at high risk of gestational

diabetes)

Gonorrhea Screening 100% Not Covered (for all women at higher risk)

Hepatitis B Screening 100% Not Covered (for pregnant women at first prenatal visit)

HIV Screening 100% Not Covered (for everyone ages 15-65 and those at high risk)

Human Papillomavirus (HPV) DNA Test

100% Not Covered (every 3 years for women with normal cytology results who are 30 or older)

Immunization Vaccines 100%

(Also through the Prescription Plan)

Not Covered

(For adults. Doses, recommended ages, and recommended populations vary) Hepatitis A & B, Herpes Zoster (shingles), Human Papillomavirus (Gardasil),

Influenza (flu shot), Measles Mumps & Rubella (MMR), Meningococcal, Pneumococcal, Tetanus, Diphtheria, Pertussis, Varicella (chicken pox)

Obesity Screening/Counseling 100% Not Covered (for all adults)

Osteoporosis Screening 100% Not Covered (for women over age 60 depending on risk factors)

Rh Incompatibility Screening 100% Not Covered (for all pregnant women and follow-up testing for women at higher risk)

Sexually Transmitted Infection (STI) Prevention Counseling

100% Not Covered (for adults at higher risk & sexually active women)

Syphilis Screening 100% Not Covered (for adults at higher risk, and sexually active women)

Tobacco Use Screening 100% Not Covered (for all adults, and expanded counseling for pregnant tobacco users)

Tobacco Cessation Interventions

100% (Through the Prescription

Plan) Not Covered (for tobacco users. Also covered at a pharmacy through Rx benefits)




Urinary Tract/Other Infection Screening

100% Not Covered (for pregnant women)

Routine/Preventive - Children No Coverage for Out of Network Preventive Services.

Alcohol and Drug Use Assessments

100% Not Covered (for adolescents)

Autism Screening 100% Not Covered (for children at 18 and 24 months)

Behavioral Assessment 100% Not Covered (for children at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years,

11 to 14 years, 15 to 17 years)

Blood Pressure Screening 100% Not Covered (for children at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years,


Depression Screening 100% Not Covered (for adolescents)

Developmental Screening 100% Not Covered (for children under age 3)

Dyslipidemia Screening 100% Not Covered (for children at higher risk of lipid disorders at the following ages: 1 to 4 years,

5 to 10 years, 11 to 14 years, 15 to 17 years)

Fluoride Chemoprevention Supplements

100% (Through the Prescription

Plan) Not Covered (for children without fluoride in water source)

Gonorrhea Preventive Medication

100% Not Covered (for the eyes of all newborns)

Hearing Screening 100% Not Covered (for all newborns)

Height, Weight and Body Mass Index Measurements

100% Not Covered (for children at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years,


Hematocrit or Hemoglobin Screening

100% Not Covered (for children)

HIV Screening 100% Not Covered (for adolescents at higher risk)

Hypothyroidism Screening 100% Not Covered (for newborns)

Immunization Vaccines 100%

(Also through the Prescription Plan)

Not Covered

(for children from birth to age 18 —doses, recommended ages, and recommended populations vary)

Diphtheria, Tetanus, Pertussis, Haemophilus influenzae type b, Hepatitis A & B, Human Papillomavirus (Gardasil), Inactivated Poliovirus, Influenza (Flu Shot),

Measles, Meningococcal, Pneumococcal, Rotavirus, Varicella.

Iron Supplements 100%


Not Covered (for children ages 6-12 months at risk of anemia)

Lead Screening 100% Not Covered (for children at risk of exposure)

Medical History 100% Not Covered (for all children throughout development at the following ages: 0 to 11 months,

1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years)

Obesity Screening/Counseling 100% Not Covered

Oral Health Risk Assessment 100% Not Covered (for young children Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years)




Phenylketonuria (PKU) Screening

100% Not Covered (for this genetic disorder in newborns)

Sexually Transmitted Infection (STI) Prevention

Counseling/Screening 100% Not Covered (for adolescents at higher risk)

Tuberculin Testing 100% Not Covered (for children at higher risk of tuberculosis at the following ages: 0 to 11 months,

1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years)

Vision Screening 100% Not Covered (for all children)

Must be billed as a preventive visit.

Respite Care Not Covered

Skilled Nursing Facility 80% 60%


If Medicare is primary and did not deny, no prior authorization is required under this Plan.

Up to 100 days.

Sleep Apnea

Sleep Study/Titration 80% 60%

Smoking Cessation See Routine/Preventive Section Under "Tobacco Use."

Sterilization Female Only. Not Subject to Deductible.

Tubal Ligation 100% Not Covered

Vasectomy Not Covered

Reversal Not Covered

Surgery If no precertification is obtained, claim will pay at 60%.

Inpatient Facility 80% 60%

Inpatient Physician 80% 60%

Outpatient Facility 80% 60%

Office Procedure 80% 60%

Assistant Surgeon 80% 60%

CRNA 50% 50%

Phys. Assistant 65% 65%

Anesthesiology 80% 60%

TMJ (By an MD only)

80% 60%

ASC 80% 60% up to $1,000/day

Refractive Eye Surgery Not Covered

Therapy/Rehabilitative




Frequency and Limitations for Physical/Occupational/Speech

only.

Rx required Fax (626)262-4722

Frequency of treatment begins with 1st day of treatment and is per diagnosis. 1st month 3 treatments per week 2nd month 2 treatments per week 3rd month 1 treatment per week

4th month 2 treatments per month

Any treatment exceeding the frequencies listed above will require review of medical necessity. Submit request for additional visits with all progress notes and Rx via fax to: PHT (626)262-4722.

Physical Therapy 80% 60%

Occupational Therapy 80% 60%

Speech Therapy 80% 60% Licensed Speech Therapist only.

Limited to therapy for speech lost or impaired due to sickness or injury.

Cardiac Rehab 80% 60%

Pulmonary 80% 60%

Radiation 80% 60%

Chemo 80% 60%

Developmental Not Covered

Transplants

Transplants R & B 80% 60%

Transplant Organ Procedure 80% 60%

Transplant Fees 80% 60%

Donor Search Not Covered

medical benefits - healthx

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