Georgia Health Insurance Benefits Guide

Allergy conditions
Benefits are provided as stated in the Summary of Benefits.

Ambulance Service
Local service to a Hospital in connection with care for a Medical Emergency or if otherwise Medically Necessary. Also covers services to the nearest facility that is equipped to treat/care for the Participant's condition/Injury whether you are in or out of BCBSHP's Service Area. Such service also covers your transfer from one Hospital to another if Medically Necessary. Air ambulance is covered subject to Medical Necessity.

Anesthesia Services for Certain Dental Patients General anesthesia and associated Hospital or ambulatory surgical facility charges are covered in conjunction with dental care provided to the following:

• patients age 7 or younger or developmentally disabled.
• an individual for whom a successful result cannot be expected by local anesthesia due to neurological disorder.
• an individual who has sustained extensive facial or dental trauma, except for a Workers' Compensation claim.

Anesthesia services administered by a Certified Registered Nurse Anesthetist (CRNA) are also covered.

Pre-certification is required.

Assistant Surgery
If Medically Necessary, services rendered by an assistant surgeon are covered in conjunction with a surgery which has been coordinated by the Participant's surgeon.

Attention Deficit Disorder (Medical Treatment of)
Drugs may be prescribed by your Primary Care Physician. Only specific Prescription Drugs will be covered.

Breast Cancer Patient Care
Covered Services are provided for Inpatient care following a mastectomy or lymph node dissection until the completion of an appropriate period of stay as determined by the attending Physician in consultation with the Participant. Follow-up visits are also included and may be conducted at home or at the Physician's office as determined by the attending Physician in consultation with the Participant.

Breast Reconstructive Surgery
Covered Services are provided following a mastectomy for reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance. Other services required by the Women's Health and Cancer Rights Act of 1998 - including breast prosthesis and treatment of complications are provided in the same manner and at the same level as those for any other covered health service.

Cardiac Rehabilitation
Programs require prior authorization and Individual Case Management.

Chiropractic Care
Covered Services for In-Network spinal manipulation are available only if stated in the Summary of Benefits. If these services are not stated in the Summary of Benefits, then there is no coverage for these services. If you have any questions, please contact customer service.

Clinical Trial Programs for Treatment of Children's Cancer
Covered Services include routine patient care costs incurred in connection with the provision of goods, services, and benefits to Participants who are dependent children in connection with approved clinical trial programs for the treatment of children's cancer. Routine patient care costs mean those pre-certified as Medically Necessary costs as provided in Georgia law (OCGA 33-24-59.1)

Colorectal Cancer Examinations and Laboratory Tests
Covered Services include colorectal cancer examinations and laboratory tests specified in current American Cancer Society guidelines for colorectal cancer screening. Benefits shall be provided for Participants who are 50 years of age or older and less than 50 years of age and at high risk for colorectal cancer according to the current colorectal cancer screening guidelines of the American Cancer Society.

Complications of Pregnancy
Benefits are provided for Complications of Pregnancy (see "Definitions"), resulting from conditions requiring Hospital confinement when the pregnancy is not terminated. The diagnoses of the complications are distinct from pregnancy but are adversely affected or caused by pregnancy.

Benefits for a normal or difficult delivery are not covered under this provision. Such benefits are determined solely by the maternity section of this Plan.

Consultation Services
Covered when the special skill and knowledge of a consulting Physician is required for the diagnosis or treatment of an illness or Injury.

Diabetes
Equipment, supplies, pharmacological agents, and outpatient self-management training and education, including nutritional therapy for individuals with insulin-dependent diabetes, insulin-using diabetes, gestational diabetes, and non-insulin-using diabetes as prescribed by the Physician. Covered Services for outpatient self-management training and education must be provided by a certified, registered or licensed health care professional with expertise in diabetes.

Dialysis Treatment
Dialysis treatment is covered if care has been pre-certified by and coordinated through your Primary Care Physician.

Durable Medical Equipment
In addition to meeting criteria for Medical Necessity and applicable pre-certification requirements, the equipment must also be used to improve the functions of a malformed part of the body or to prevent or slow further decline of the Participant's medical condition. The equipment must be ordered and/or prescribed by a Physician and be appropriate for in-home use. The in-network DME provider will verify benefits and coordinate authorization for the rental/purchase of equipment.

The equipment must meet the following criteria:

• It can stand repeated use;
• It is manufactured solely to serve a medical purpose;
• It is not merely for comfort or convenience;
• It is normally not useful to a person not ill or injured;
• It is ordered by a Physician;
• The Physician certifies in writing the Medical Necessity for the equipment. The Physician also states the length of time the equipment will be required. The Plan Administrator may require proof at any time of the continuing Medical Necessity of any item;
• It is related to the patient's physical disorder.

Emergency Care

• Life-threatening emergency care or treatment for a Medical Emergency is covered on a 24-hour basis at any Hospital emergency room. Go to the nearest Hospital emergency room if you experience a life -threatening Medical Emergency. See "Definitions".
• The emergency room Copayment is required for initial services for Medical Emergencies rendered in the emergency room of a Hospital. Primary Care Physician notification, if not completed prior to emergency room visit, should occur within 48 hours of seeking emergency room care.
• Use of the emergency room for conditions that are not Medical Emergencies is not covered.
• A Participant is responsible for the required Copayment which is waived if a Participant is admitted to the Hospital through the emergency room.
• Covered Services for Medical Emergencies include Medically Necessary mental health emergency care provided in the emergency room. This service is not limited by the twenty (20) outpatient In-Network visit limitation. Emergency care coverage includes care related to Medical Emergencies associated with Substance Abuse.
• Follow-up care must be coordinated by your Primary Care Physician.

General Anesthesia Services
Covered when ordered by the attending Physician and administered by another Physician who customarily bills for such services, in connection with a covered procedure.

Such anesthesia service includes the following procedures which are given to cause muscle relaxation, loss of feeling, or loss of consciousness:

• spinal or regional anesthesia;
• injection or inhalation of a drug or other agent (local infiltration is excluded).

Anesthesia services administered by a Certified Registered Nurse Anesthetist (CRNA) are only covered when billed by the supervising anesthesiologist.

Home Health Care Services
Home Health Care provides a program for the Participant's care and treatment in the home. Your coverage is outlined in the Summary of Benefits. A visit consists of up to 4 hours of care. The program consists of required intermittent skilled care, which may include observation, evaluation, teaching and nursing services consistent with the diagnosis, established and prescribed in writing by the Participant's attending Physician.

Some special conditions apply:

• The Physician's statement and recommended program must be pre-certified.
• Claims will be reviewed to verify that services consist of skilled care that is medically consistent with the diagnosis. Note: Covered Services available under Home Health Care do NOT reduce outpatient benefits available under the Physical Therapy section shown in this Plan.
• A Participant must be essentially confined at home.

Covered Services Include:

• Visits by an RN or LPN - Benefits cannot be provided for services if the nurse is related to the Participant.
• Visits by a qualified physiotherapist, speech therapist or by an inhalation therapist certified by the National Board of Respiratory Therapy.
• Visits to render services and/or supplies of a licensed Medical Social Services Worker when Medically Necessary to enable the Participant to understand the emotional, social, and environmental factors resulting from or affecting the Participant's illness.
• Visits by a Home Health Nursing Aide when rendered under the direct supervision of an RN.
• Administration of prescribed drugs.
• Oxygen and its administration.

Covered Services for Home Health Care do not include:

• Food, housing, homemaker services, sitters, home-delivered meals.
• Home Health Care services which are not Medically Necessary or of a non-skilled level of care.
• Services and/or supplies which are not included in the Home Health Care plan as described.
• Services of a person who ordinarily resides in the patient's home or is a member of the family of either the patient or patient's Spouse.
• Any services for any period during which the Participant is not under the continuing care of a Physician.
• Convalescent or Custodial Care where the Participant has spent a period of time for recovery of an illness or surgery and where skilled care is not required or the services being rendered are only for aid in daily living, i.e., for the convenience of the patient.
• Any services or supplies not specifically listed as Covered Services.
• Routine care and/or examination of a newborn child.
• Dietitian services.
• Maintenance therapy.
• Dialysis treatment.
• Purchase or rental of dialysis equipment.
• Private duty nursing care.