agency pays $50 & above (Prior Authorization (Pre-Certification Required) Required) $4.00 copay, 30 visits per $4.00 copay, 30 visits per 20 visits per Fiscal Year. Fiscal Year. Includes the Fiscal Year. Includes the Includes the maintenance, maintenance, acquisition, and maintenance, acquisition, and Plan pays 100%(PA acquisition, and restoration of restoration of skills in an restoration of skills in an Occupational Therapy required) Limited to skills in an inpatient and inpatient and outpatient inpatient and outpatient outpatient hospital only. outpatient services only. services only. services only. (PA and Justification are (PA and Justification are (PA and Justification are required for additional visits) required for additional visits). required for additional visits) Not covered Not covered Not covered Not covered Transplant Plan pay 100%. Orthopedic Orthopedic Conditions internal and external Plan pay 100%. Plan pay 100%. Plan pay 100%. prosthetic devices are not Internal and External covered. Prosthesis Physical Therapy/Occupational 30 visits per Fiscal Year. 30 visits per Fiscal Year. Therapy Plan pays 100%. Includes Includes the maintenance, Includes the maintenance, the maintenance, acquisition, and restoration acquisition, and restoration Plan pays 100%(PA acquisition, and restoration of skills in an inpatient and of skills in an inpatient and required) Limited to of skiIIs in an inpatient and outpatient services only. outpatient services only. outpatient hospital only. outpatient services only. (PA (PA and Justification are (PA and Justification are (Pre-Certification Required) required) required for additional required for additional visits) visits)
agency pays $50 & above (Prior Authorization Required) (Pre-Certification Required) Occupational Therapy Plan pays 100%(PA required) Limited to outpatient hospital only. 20 visits per Fiscal Year. Includes the maintenance, acquisition, and restoration of skills in an inpatient and outpatient services only. (PA and Justification are required for additional visits) $4.00 copay, 30 visits per Fiscal Year. Includes the maintenance, acquisition, and restoration of skills in an inpatient and outpatient services only. (PA and Justification are required for additional visits). $4.00 copay, 30 visits per Fiscal Year. Includes the maintenance, acquisition, and restoration of skills in an inpatient and outpatient services only. (PA and Justification are required for additional visits) Not covered Not covered Not covered Not covered Transplant Orthopedic Conditions Plan pay 100%. Orthopedic internal and external prosthetic devices are not covered. Plan pay 100%. Plan pay 100%. Plan pay 100%. Internal and External Prosthesis Physical Therapy/Occupational Therapy Plan pays 100%(PA required) Limited to outpatient hospital only. Plan pays 100%. Includes the maintenance, acquisition, and restoration of skiIIs in an inpatient and outpatient services only. (PA required) 30 visits per Fiscal Year. Includes the maintenance, acquisition, and restoration of skills in an inpatient and outpatient services only. (PA and Justification are required for additional visits) 30 visits per Fiscal Year. Includes the maintenance, acquisition, and restoration of skills in an inpatient and outpatient services only. (PA and Justification are required for additional visits) (Pre-Certification Required)
Bill%20No.%20132-34%20(COR).docx