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Master Medical Benefits

Services listed in this section are intended as a general guideline of covered and non-covered services. To determine if a specific service is payable according to your group's coverage, please call Customer Service.


 

Ambulance

COVERED
  • Professional, ground ambulance used locally from the patient's home to a hospital, from one hospital to another hospital, or from one hospital to an extended care facility or nursing home
  • Equipment used during transportation
  • Mileage
  • Waiting time for ground ambulance
  • Professional, air ambulance when medically necessary as determined by BCBSM medical staff
     NOT COVERED
  • Use of private automobiles
  • Taxi cabs
  • Commercial airlines
  • Fire department, rescue squad or other carrier whose fee is a voluntary donation
  • Ambulance services when covered by your Basic Plan

Chiropractic Services

COVERED
  • Office visits billed by a chiropractor
  • Spinal adjustment or manipulation
  • Acute care: 20 visits are allowed for the first 90 consecutive days
  • Chronic care: Following the first 90 days, two visits per month
  • Physical therapy
     NOT COVERED
  • Medical equipment or supplements dispensed by a chiropractor
  • Treatment for a diagnosis not related to the spine

Dental Services

COVERED
  • Dental care required because of an accidental injury
  • Treatment to the face and oral cavity only
     NOT COVERED
  • Routine or periodic dental care
  • Teeth cleaning
  • Fluoride treatment
  • Preventive care
  • Orthodontic or periodontic treatment

Durable Medical Equipment

COVERED
  • Commodes
  • Traction equipment
  • Crutches
  • Oxygen equipment
  • Wheelchairs
Note: Attach the prescription to your claim 		    NOT COVERED
  • Items not prescribed by an eligible physician
  • Exercycles, tread mills and exercise equipment
  • Environmental control items (air conditioners, dehumidifiers, etc.)
  • Personal or convenience items
  • Rental charges that exceed the purchase price of a covered item
  • Purchase of used items

Medical Supplies

COVERED
  • Surgical stockings
  • Dressing packs
  • Catheterization sets
  • Syringes, needles and alcohol wipes
  • Ostomy supplies
     NOT COVERED
  • Ear molds
  • Diaphragm kits
  • Leotards
  • Routine supplies such as cotton balls, swabs and bandages

Nursing Services

COVERED
  • Visiting nurse services in your home when medically necessary
  • Around-the-clock private duty nursing in your home or accredited hospital when medically necessary
Note: Services must be provided by a registered nurse (RN) or licensed practical nurse (LPN).

Your physician must complete a Certification Statement for each month of care, and a plan of treatment. The plan must include an hour-by-hour description of services (nursing notes). Certification statements are approved on a monthly basis. Payment for one month does not ensure approval for subsequent months.		     NOT COVERED
  • Nursing services by a relative, even when that relative is a nurse
  • Services by a nurse's aide, home health aid, non-licensed or non-registered nurse
  • Custodial care, housekeeping service or rest therapy

Obstetrical Services

COVERED
  • Pre- and post-natal care when it is not available under your Basic Plan. Receipts must show itemized charges, exact dates for each service, the expected or actual delivery date and post-natal visit date.
     NOT COVERED
  • Pre-natal laboratory testing
  • Ultrasound tests
  • Delivery

Office/Clinic Services

COVERED
  • Home, office and clinic visits
  • Injections
  • Allergy testing and treatment
  • Medical consultations
     NOT COVERED
  • Routine examinations or physicals
  • Immunizations
  • Well-baby care
  • Experimental procedures or services
  • Weight loss or control

Outpatient/Speech Therapy

COVERED
  • Diathermy
  • Whirlpool
  • Ultrasound
  • Speech therapy
  • Therapeutic exercises, gait training, pool or soft tissue therapy
  • Occupational therapy
     NOT COVERED
  • Services by someone other than an approved physician or licensed registered physical therapist
  • Recreational therapy

Outpatient Mental Health Care

COVERED
  • Services in an approved outpatient mental health care facility or by a fully licensed psychiatrist (physician)
  • Prescribed drugs and medication dispensed by an approved facility or fully licensed psychiatrist (physician)
  • Psychological testing, family counseling, full or half psychiatric sessions or group therapy by an eligible physician
     NOT COVERED
  • Services used to meet an annual dollar maximum under your Basic BCBSM coverage
  • Services exceeding the benefit or lifetime mental health care maximums under your contract
  • Services that the provider or facility is not eligible to perform

Prescription Drugs

COVERED
  • Federally controlled substances
  • Federal legend drugs
  • Insulin
  • Drugs requiring a prescription from a licensed doctor
     NOT COVERED
  • Over-the-counter drugs
  • Drugs not requiring a prescription
  • Birth control pills, even if required by a prescription

Prosthetic & Orthotic Appliances

COVERED
  • Back and leg braces
  • Cervical collars
  • Shoes and shoe modification(s) when attached to a brace
  • External breast prostheses
  • Repair of covered items
  • Artificial limbs
Note: Attach a copy of the prescription order to your claim form 		    NOT COVERED
  • Items not prescribed by an approved physician
  • Hearing aids
  • Internal breast prostheses
  • Personal or convenience items