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More Covered Services Under the Lumenos Georgia Health Insurance Plan

Medical Supplies

Medical supplies that are prescribed by a licensed provider for a medical condition or diagnosis are covered, except for over the counter supplies. Over the counter supplies are excluded from the Lumenos plan.

Examples of medical supplies are diabetic supplies (lancets, glucometers, syringes, if not covered under the pharmacy benefit), injectables and ostomy supplies (including medical equipment and supplies directly related to ostomy care when surgery creates an opening for drainage from the kidney, the small intestines or the colon). Glucomoters and blood pressure monitors with a provider's prescription and an applicable diagnosis are also covered.

Orthotic Devices

Coverage is provided for orthotic devices (a rigid or semi-rigid supportive device which restricts or eliminates motion for a weak or diseased body part), including custom shoes and custom molded inserts, if prescribed by a physician. Orthopedic shoes are only covered when an integral part of a brace.

Podiatry

Coverage is provided for certain surgical podiatry services, including incision and drainage of infected tissue of the foot, removal of lesions of the foot, removal or debridement of infected toenails, and treatment of fractures and dislocations of bones of the foot. Podiatry services not covered are those procedures considered to be a part of a routine foot care, or of a cosmetic nature, such as treatment of corns, calluses, non-surgical care of toenails, fallen arches and other symptomatic complaints of the feet.

Preventive Care

The Lumenos plan covers preventive services based on guidelines from the U. S. Preventive Services Task Force, American Cancer Society, the Advisory Committee on Immunization Practices (ACIP), and the American Academy of Pediatrics. The preventive benefit includes screening tests, immunizations and counseling services designed to detect and treat medical conditions to prevent avoidable premature injury, illness and death. All discounted rates will be paid by the Plan at 100% up to $500 per person per Plan year for providers who offer discounts, with no out-of-pocket responsibility for preventive services. Services that fall outside of the Preventive Care Benefit and other services performed during a preventive office visit will be considered for coverage under your account and/or Traditional Health Coverage portion of your plan.

Well Baby and Well Child Care

Baby/Child Preventive Care Office Visits

• Six (6) visits the first year
• Three (3) visits the second year
• Annual visit from ages 2 through 18

Baby/Child Screening Tests (annually, unless otherwise indicated):

• Lead Level Tests (once between 9 and 12 months)
• Vision screenings
• Hearing screenings
• Routine pelvic exam, Pap test and contraceptive management (screen all females who are 18, or have been sexually active, whichever comes first)

Baby/ Child Immunizations

Note: Actual dosing regimen to be determined by physician.

• Hepatitis A
• Hepatitis B
• Diphtheria, Tetanus, Pertussis (DtaP)
• H. Influenza type b
• Polio
• Measles, Mumps, Rubella (MMR)
• Varicella (chicken pox)
• Influenza - flu shot (Over age 6 months. Doctor may give this vaccine if the child is at high risk or to reduce the risk of the child getting the flu)
• Pneumococcal Conjugate (pneumonia)

Adult Preventive Care

Adult Preventive Care Office Visits

• Periodic preventive visit (up to one annual visit, after age 18)

Adult Screening Tests (annually, unless otherwise indicated):

• Coronary Artery Disease: Periodic cholesterol and lipid screening for men beginning at age 35 and women age 45
• Clinical breast exam and mammogram - annual starting at age 40
• Routine pelvic exam, Pap test and contraceptive management (screen all females who are 18, or have been sexually active, whichever comes first)
• Colorectal Cancer Screenings: Annual fecal occult blood testing or flexible sigmoidoscopy every 3-5 years or colonoscopy every 10 years - starting at age 50
• Prostate Cancer Screenings: Digital rectal examination (DRE) and Prostate Specific Antigen (PSA) at discretion of physician and patient - starting at age 50
• Diabetes (Type II Diabetes) Screening - Periodic blood glucose testing for high-risk individuals (e.g. hypertension, hyperlipidemia)
• Osteoporosis Screening - Periodic bone density screening for women over age 65 and for women over age 60 with increased risk for osteoporotic fractures

Adult Immunizations

• Influenza
• Pneumococcal Conjugate (pneumonia)
• Tetanus /Diphtheria (DtaP)
• Measles, Mumps, Rubella (MMR) - for individuals under the age of 50 without previous immunization
• Hepatitis A - Recommended for high risk groups, such as international travelers, workers in food service or health care industry
• Hepatitis B and Varicella - Recommended for high risk individuals
• Meningococcal - Considered for college students who live in dormitories and have a slightly increased risk of getting meningococcal disease

Private Duty Nursing

Coverage is provided for the services of a private duty nurse on an outpatient basis only. Nursing services must be rendered by a nurse who does not reside in the patient's home, or who is not a member of the immediate family. To be covered, the physician in charge of the case must certify that the patient's condition requires the requested care, which can only be provided by an RN or LPN. Private duty nursing applies only for care given in the patient's home and not part of the home health care agency's plan of treatment.

Professional Services

Professional services are those services billed by a provider's office rather than by a facility - such as office visits and inpatient hospital visits. Covered professional services are:

• Office Visits - Visits made by patients to health service providers' offices for diagnosis, treatment, and follow-up.
• Inpatient Hospital Visit - A visit by a provider for persons admitted to health facilities which provide room and board, for the purpose of observation, care, diagnosis or treatment.
• Home Visit - Visit made by a provider to a patient's home for diagnosis, treatment and follow-up.

Prosthetics

Coverage is provided for the purchase and fitting of external prosthetic appliances which are used as a replacement or substitute for a missing body part, and are necessary for the alleviation or correction of illness, injury, or congenital defect. Replacement or repair, as appropriate, of external prosthetic appliances is covered if necessitated by such circumstances as normal anatomical growth, physical changes which render the device ineffective, or excessive wear.

Coverage for internal prosthetic appliances includes the purchase, maintenance, or repair of permanent or temporary internal aids and supports for defective body parts, specifically, intraocular lenses, artificial heart valves, cardiac pacemakers, artificial joints, and other surgical materials such as screw nails, sutures and wire mesh.