Eligible Dependents/Qualified Dependents
If you have elected Family Coverage, your eligible dependents are:
- your lawful spouse of the opposite sex;
- your children who are under 26 years of age.
Your children include:
- your natural children;
- your legally-adopted children or those for whom adoption proceedings have been started and who have been placed in your home by a licensed placement agency for the purpose of adoption; and
- your step-children if the child’s natural parent lives with you.
If a dependent was covered up to the date coverage would otherwise end because of reaching age 26, and if on that date the dependent:
- is incapable of self-support due to mental retardation or physical handicap which began before the child attained age 26;
- is dependent upon you for more than one-half of his or her financial support and maintenance; and
- resides with you permanently and regularly for more than one-half of each year or lives in a treatment center,
then that dependent will be covered for so long as the incapacity and dependency continue, but not beyond the date on which your coverage ends.
Legal documentation of your dependent’s status, such as by an original registered marriage certificate, certified government-issued birth certificate or divorce decree, may be required by the Benefits Fund Office.
If both husband and wife are eligible as full-time employees, their dependent children are covered as dependents under both the wife and husband.
Medically Necessary
Services, supplies, treatments and confinements that are:
- generally recognized by physicians as effective and essential for treatment of the injury or sickness for which it is ordered;
- provided at the appropriate level of care and in the most appropriate setting based on the diagnosis;
- based on generally recognized and accepted standards of medical practice in the U.S. and is the type of care that could not be omitted without adversely affecting the patient’s condition or the quality of medical care; and
- when hospital-confined, a service or supply is a medical necessity only if the diagnosis and treatment cannot be safely provided on an outpatient basis.
Services, supplies, treatments and confinements are not considered medically necessary if they are:
- Experimental.
- Investigative or primarily limited to research in their appplication to the injury or sickness.
- Primarily for scholastic, educational, vocational or developmental training.
- Primarily for the comfort, convenience or administrative ease of the provider or the patient or the patient's family or caretaker.
The fact that a physician or other health care provider orders or recommends services, supplies, treatment or procedures does not in itself make them medically necessary.
Retail Prescription Program
The Prescription Drug Benefit is managed by informedRx, a prescription benefit manager with a large network of pharmacies, called "participating pharmacies." You receive the highest level of benefits when you fill your prescription at a participating retail pharmacy.
Usual and Customary Fee and Plan-Limited Allowance
Payment of benefits is limited to the usual and customary fee for covered services or to the Plan-limited allowances for certain surgeries or for certain equipment.
For treatment in the geographic area served by the PPO, the negotiated discounted fee amounts are the usual and customary fees. For treatment outside the area served by the PPO, the usual and customary fee is determined based on the average charge made by the majority of providers located within the geographic area.
For durable medical equipment and for home health care, the usual and customary fee is the charge negotiated between the Plan and providers who have agreed in writing to provide the equipment or services.
The Plan-limited allowance applies to
- certain surgeries when performed at a non-PPO facility; and
- the purchase price for certain medical equipment.