Skip to main content
Toggle Menu

HSA Plan

Network

20% coinsurance after deductible

Non-Network

40% coinsurance after deductible

PPO 750 Plan

Network

20% coinsurance after deductible

Non-Network

40% coinsurance after deductible

PPO 1250 Plan

Network

20% coinsurance after deductible

Non-Network

40% coinsurance after deductible

DME is covered when ordered by a provider to treat an injury or illness. DME includes, but is not limited to, insulin pumps, oxygen, augmentative communication devices, manual and powered mobility devices, and blood pressure cuffs/monitors with a diagnosis of diabetes.

Disposable supplies that do not withstand prolonged use and are periodically replaced including, but are not limited to, colostomy and ureterostomy bags, and prescription compression stockings. Prescription compression stockings are limited to two pairs or four individual stockings per plan year. No coverage for non-reusable disposable supplies, including, but not limited to, bandages, wraps, tape, disposable sheets and bags, fabric supports, surgical face masks, incontinence pads, irrigating kits, pressure leotards, surgical leggings and support hose, over-the-counter medications and supplies including oral appliances.

Repair and replacement of DME is covered when any of the following criteria are met:

  • Repairs, including the replacement of essential accessories, necessary to make the item or device serviceable are covered;
  • Routine wear and tear of the equipment renders it nonfunctional and the member still requires the equipment; or
  • The physician provides documentation that the condition of the member changes or if growth-related.

Breast pumps: Rental or purchase price for a breast pump covered at one hundred percent (100%) if provided by a network durable medical equipment provider. Visit the Breast Pump Benefit page for more detailed information. If provided by a non-network provider, covered only if mother and baby are separated due to a medical condition.

Preauthorization by medical plan required for durable medical equipment over $1,500 and/or rentals over $500/month.


Back to Top