Cusd.claremont.edu

PLAN NAME - "EMPLOYER GROUP PLANS" HMO NGF Plan
(Std 15_30_500)
PROFESSIONAL SERVICES
Visit to Physician, Physician Assistant or Nurse Practitioner at a PPG.
Periodic health evaluations. Includes annual preventive physical examinations, preventive vision/hearing screenings, well-woman exam and preventive laboratory tests and x-rays.
Vision examinations for refractive eye exams.
Specialist consultations (except podiatrist). Includes OB/GYN self-referral for non-preventive services.
Podiatrist (all services) Physician visit to member's home (at discretion of physician) .
Physician visit to hospital or skilled nursing facility (excluding care for mental Other immunizations (except foreign travel/occupational-see below).
Immunizations for foreign travel/occupational purposes. Allergy injection services (serum not included).
Injections related to infertility services.
Surgeon/assistant surgeon in hospital or PPG.
--Complex radiology (CT, SPECT, MRI, MRA, MUGA and PET). Rehabilitation therapy (outpatient physical, speech, occupational and respiratory therapy). Provided as long as significant improvement is Dental services (when medically necessary to properly monitor, control or treat a severe medical condition when excluded dental services are being HMO NGF Plan
(Std 15_30_500)
CARE FOR CONDITIONS OF PREGNANCY (professional services only)
Normal delivery, Cesarean section. Includes newborn inpatient care provided by a member physician.
Complications of pregnancy, including medically necessary abortions.
FAMILY PLANNING (professional services only)
Depo-Provera Medication (contraceptive injection) Infertility services (including professional services, inpatient and outpatient care, treatment by injection and prescription drugs, if applicable).
ALCOHOL/DRUG REHABILITATION and MENTAL DISORDERS
Administered by Managed Health Network (MHN)
OTHER SERVICES
Durable medical equipment.
Nebulizers, peak flow meters, face masks and tubing for the treatment of asthma of dependent children under the age of 19 are covered with NO COPAYMENT and not applicable towards annual benefit maximum. Corrective footwear. Custom inserts and shoes.
Nuclear medicine (professional services only).
Organ and bone marrow transplants (non-experimental and noninvestigative. Professional services only).
Chemotherapy/radiation therapy (professional services only).
Renal dialysis (professional services only). HMO NGF Plan
(Std 15_30_500)
HOSPITAL AND SKILLED NURSING FACILITY SERVICES
Unlimited days of hospital care in a semi-private room or ICU with ancillary services. Excluding care for mental disorders.
Organ and Bone Marrow Transplants - inpatient. Travel expenses not covered.
Confinement for infertility services.
Confinement in a skilled nursing facility (limited to 100 days a cal yr).
Maternity care. Includes routine nursery charges.
Outpatient services other than surgery.
Oupatient surgery at hospital or ambulatory surgical center EMERGENCY SERVICES/URGENTLY NEEDED CARE
The copayment will not be required if the member is admitted as a hospital inpatient directly from the emergency room or urgent care center. Use of emergency room (facility and professional services).
Use of urgent care center (facility and professional services).
OUT OF POCKET MAXIMUM
OTHER BENEFITS OR COVERAGE
MAIL ORDER (Administered by CVS Caremark) VISION BENEFITS (Administered by Eyemed)

Source: http://www.cusd.claremont.edu/hr/pdfs/benefits1213/healthnet_hmo_gridr1.pdf