Allergy treatment

The Plan pays for all allergy treatments including testing, extracts/injections. If you use a preferred provider, the Plan pays 100% of the covered expenses. A $5 co-pay is required for injections. If you use a non-preferred provider, the Plan pays 80% of the covered expenses after you have satisfied a $250 per individual or $500 per family calendar year deductible. Ambulance transportation (pre-certification required for non-emergency services) The Plan pays for local ambulance service including air ambulance when medically necessary. Coverage is limited to transportation to and from the nearest hospital that can give necessary care and treatment. If you use a preferred provider, the Plan pays 90% of the covered expenses. If you use a non-preferred provider, the Plan pays 80% of the covered expenses after you have satisfied a $250 per individual or $500 per family calendar year deductible. Failure to pre-certify non-preferred, non-emergency services as required will result in a 20% reduction in benefits payable for these services. Ambulatory Surgery Benefit (pre-certification required) The Plan pays for outpatient services and supplies furnished in connection with the performance of a surgical procedure by an ambulatory surgical facility, the outpatient department of a hospital or a Short Procedure Unit (SPU). The procedure must meet these tests: It is not expected to result in extensive blood loss, require major or prolonged invasion of a body cavity or involve any major blood vessels. It can safely and adequately be performed only in an ambulatory surgical facility, in a hospital or in an SPU. It is not normally performed in an office of a physician or a dentist. The Plan pays for the following: Services and supplies furnished by the ambulatory surgical facility, hospital or SPU on the date of the procedure. Services of the operating physician for the procedure and for the related pre- and post-operative care and the administration of the anesthetic. Services of any other physician for the administration of an anesthetic. This does not include a local anesthetic. The Plan does not pay for the following: Services of a physician who renders technical assistance to the operating physician, unless required in connection with the procedure. Charges incurred while the person is confined as an inpatient in a hospital. If you use a preferred provider, the Plan pays 95% of the covered expenses for the facility's services and supplies and 90% of the covered expenses for the surgeon's services and anesthesia. If you use a non-preferred provider, the Plan pays 90% of the covered expenses for the facility's services and supplies and 80% of the covered expenses for the surgeon's services and anesthesia after you have satisfied your $250 per individual or $500 per family calendar year deductible. Failure to obtain pre-certification as required will result in a 20% reduction in benefits payable. Anesthesia benefit   The Plan pays for the administration of anesthetics by a doctor or registered nurse anesthetist (R.N.A.), including acupuncture when used in place of anesthesia. If you use a preferred provider, the Plan pays 90% of the covered expenses. If you use a non-preferred provider, the Plan pays 80% of the covered expenses after you have satisfied a $250 per individual or $500 per family calendar year deductible. Bereavement Benefits (pre-certification required) Bereavement counseling benefits are available as part of the Hospice Care Benefit. Supportive services are provided by members of the hospice team for up to six months following the death of the terminally ill person. If you use a preferred provider, the Plan pays 100% of the covered expenses. If you use a non-preferred provider, the Plan pays 80% of the covered expenses after you have satisfied a $250 per individual or $500 per family calendar year deductible. Failure to obtain pre-certification as required will result in a 20% reduction in benefits payable. Blood and blood plasma The Plan pays the charges for blood and blood plasma, and blood plasma expanders when not replaced on behalf of the patient. If you use a preferred provider, the Plan pays 90% of the covered expenses. If you use a non-preferred provider, the Plan pays 80% of the covered expenses after you have satisfied a $250 per individual or $500 per family calendar year deductible. Chiropractic or Manual Manipulative Care - Restorative Services (pre-certification required) All covered chiropractic benefits must be pre-certified. Benefits shall be provided for restorative services when performed by a provider in order to restore loss of function of a body part. Restorative services are any services, other than those specifically detailed under Therapy Services, provided in accordance with a specified plan of treatment related to the covered person's condition which generally involve neuromuscular training as a course of treatment over weeks or months. Examples of restorative services include, but are not limited to, manipulative treatment of functional loss from back disorder, therapy treatment of functional loss following foot surgery, and treatment of oculomotor dysfunction. Following a determination by a provider that restorative services are required, a specific plan of treatment must be pre-certified by Personal Choice. If you use a preferred provider, the Plan pays 100% of the covered expenses after you make a $5 co-payment. If you use a non-preferred provider, the Plan pays 80% of the covered expenses after you have satisfied your $250 per individual or $500 per family calendar year deductible. Failure to obtain pre-certification as required will result in a 20% reduction in benefits payable. Consultation expense benefit - Inpatient Benefits are payable for charges by a physician for consultation services, provided that the consultation services are: Asked for by the attending physician. Given to a person while confined as an inpatient in a hospital. A "consultation" consists of an examination of the patient, a review of his/her x-ray and lab exams and medical history. It will include a written report by the consulting physician if the attending physician requests one. If you use a preferred provider, the Plan pays 90% of the covered expenses. If you use a non-preferred provider, the Plan pays 80% of the covered expenses after you have satisfied a $250 per individual or $500 per family calendar year deductible. Dental services Dental benefits provider under the Personal Choice plan are limited to services required as a result of accidental injury to the jaw, sound natural teeth. You are eligible for additional dental coverage for dental care under a separate Fund benefit; please refer to the section titled "Dental Coverage" for more information. The Plan pays for dental services rendered by a provider and/or facility which are required as a result of accidental injury to the jaws, sound natural teeth, mouth or face. Injury as a result of chewing or biting shall not be considered an accidental injury. Charges for treatment of the teeth will be covered for the following procedures without limitation: Removal of a cyst; Removal of totally or partially bony impacted teeth, including charges for anesthesia; and Cutting operation of the periodontium If you use a preferred provider, the Plan pays 90% of the covered expenses. If you use a non-preferred provider, the Plan pays 80% of the covered expenses after you have satisfied a $250 per individual or $500 per family calendar year deductible. Please note, you are eligible for additional coverage for dental services under a separate portion of your Plan. Please refer to the section titled "Dental Coverage" for more information. Diabetic education program Benefits are provided for outpatient diabetes self-management training and education, including medical nutrition, for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes and non-insulin using diabetes when prescribed by a provider legally authorized to prescribe such items under law. The Plan pays 100% of covered expenses for outpatient diabetic education services when provided by a preferred facility provider or preferred ancillary provider. The diabetic education program must be conducted under the supervision of a licensed health care professional with expertise in diabetes, and subject to the requirements of the Plan. These requirements are based on the certification programs for outpatient diabetic education developed by the American Diabetes Association and the Pennsylvania Department of Health. Outpatient diabetic education services are NOT covered when performed by a non-preferred provider. Covered services include outpatient sessions that include, without limitation, the following information:   initial assessment of the patient’s needs;   family involvement and/or social support;   psychological adjustment for the patient;   general facts/overview on diabetes;   nutrition, including its impact on blood glucose levels;   exercise and activity;   medications (refer to the section titled "Prescription Drug Benefits" for coverage of insulin);   monitoring and use of the monitoring results;   prevention and treatment of complications for chronic diabetes (i.e., foot, skin and eye care);   use of community resources; and   pregnancy and gestational diabetes, if applicable. The attending physician must certify that a covered person requires diabetic education on an outpatient basis under the following circumstances: (1) upon the initial diagnosis of diabetes; (2) a significant change in the patient's symptoms or condition; or (3) the introduction of new medication or a therapeutic process in the treatment or management of the patient's symptoms or condition. Diabetic supplies Benefits for diabetic equipment and supplies shall be provided if pre-certified and furnished by a  durable medical equipment supplier. Please refer to your Personal Choice directory for a list of ancillary providers. Please refer to Durable Medical Equipment for coverages available. Diagnostic Services (pre-certification required) The Plan pays for the following diagnostic services when ordered and billed by a provider and/or facility:   Diagnostic X-ray, consisting of radiology, ultrasound, and nuclear medicine;   Diagnostic laboratory and pathology tests;   Diagnostic medical procedures consisting of ECG, EEG, and other diagnostic medical procedures approved by Personal Choice; and,   Allergy testing, consisting of percutaneous, intracutaneous and patch tests and immunotherapy. Pre-certification is required for the following diagnostic procedures if you use a non-preferred provider: Operative and Diagnostic Endoscopies; MRI; and CAT Scan If you use a preferred provider, the Plan pays 90% of the covered expenses. If you use a non-preferred provider, the Plan pays 80% of the covered expenses after you have satisfied your $250 per individual or $500 per family calendar year deductible. Failure to obtain pre-certification as required for the above diagnostic procedures will result in a 20% reduction in benefits payable. Durable medical equipment (pre-certification required) The Plan pays for the rental, purchase, or necessary repair of durable medical equipment. Durable medical equipment is equipment prescribed by the attending physician which is: medically necessary; primarily and customarily used to serve a medical purpose; designed for prolonged use; for a specific therapeutic purpose in the treatment of an illness or injury; and appropriate for use in the home. The Plan pays for the rental (but not to exceed the total allowance of purchase) or, at the option of Personal Choice, the purchase of durable medical equipment when prescribed by a professional provider and required for therapeutic use, when determined to be medically appropriate/medically necessary by Personal Choice. Diabetic Equipment and Supplies - Benefits shall be provided for the following diabetic equipment and supplies furnished by a durable medical equipment supplier: Diabetic Equipment* blood glucose monitors; insulin pumps; insulin infusion devices; and orthotics and podiatric appliances for the prevention of complications associated with diabetes. * Pre-certification is required for the purchase of equipment if the billed amount exceeds $100. Diabetic Supplies blood testing strips; visual reading and urine test strips; insulin and insulin analogs; injection aids; insulin syringes; lancet and lancet devices; monitor supplies; pharmacological agents for controlling blood sugar levels; and glucagon emergency kits. Medical foods and nutritional formulas - Benefits shall be payable for medical foods when provided for the therapeutic treatment of phenylketonuria, branched-chain ketonuria, galactosemia and homocystinuria. Coverage is provided when administered on an outpatient basis either orally or through a tube. Benefits are also payable for nutritional formulas when they are the sole source of nutrition for an individual who is unable to take regular food due to a metabolic or anatomic disorder which results in an inability to absorb from regular foods the nutrients sufficient to sustain life. Coverage does not include normal food products used in the dietary management of rare hereditary genetic metabolic disorders. Benefits are payable for medical foods and nutrition formulas when provided through a durable medical equipment supplier or in connection with home infusion therapy as provided for under this coverage. Benefits are exempt from deductible requirements.   Orthotic devices - The Plan pays for mechanical supportive devices for treatment in conjunction with or following surgery.   Prosthetic devices - The Plan pays for the initial purchase of prosthetic devices. Prosthetic devices include (but are not limited to) artificial eyes, limbs, initial pair of lenses resulting from cataract surgery (contact or eyeglass) and breast prosthesis. If you use a preferred provider, the Plan pays 100% of the covered expenses. If you use a non-preferred provider, the Plan pays 80% of the covered expenses after you have satisfied your $250 per individual or $500 per family calendar year deductible. No deductible applies to Medical Food and Nutritional Formulas.) Failure to obtain pre-certification for the above supplies as required, including all rentals, will result in a 20% reduction in benefits payable. Emergency care services The Plan pays for medical, surgical, hospital and related health care services and testing, including ambulance services, required to treat a sudden, unexpected onset of a bodily injury or a serious sickness which, if not treated immediately, may result in serious medical complications, loss of life, or permanent impairment of bodily functions. Included are conditions which produce loss of consciousness or excessive bleeding or conditions which may otherwise be determined by Personal Choice in accordance with generally accepted medical standards to have been an acute condition requiring immediate medical attention. Care must be received within 48 hours of onset for the condition to qualify as a medical emergency. The non-availability of a private physician or the fact that the physician may refer you to the emergency room does not, in itself, constitute a medical emergency. If you are admitted to the hospital following an emergency room visit, the $35 co-payment is waived. You must, however, contact the pre-admission certification service within 2 business days of the emergency admission to notify them of your confinement. Whether you use a preferred provider or a non-preferred provider, the Plan pays 100% of the covered expenses less a $35 co-payment (waived if admitted) Remember, if you are admitted, you must call Personal Choice's Pre-Admission Certification Service at 1-800-332-2566 within two business days of the emergency admission to notify them of your confinement. Failure to obtain pre-certification for the admission within the time specified above will result in a $1,000 reduction in benefits payable. Gynecological and Pap Smear - Routine The Plan pays for one annual gynecological examination and Pap smear for women of any age. If you use a preferred provider, the Plan pays 100% of the covered expenses after you make a $5 co-pay. If you use a non-preferred provider, the Plan pays 80% of the covered expenses after you have satisfied a $250 per individual or $500 per family calendar year deductible. Home health care services (pre-certification required) The Plan covers certain eligible medical services provided in your home by a licensed Home Health Care Agency. For benefits to be paid, the following conditions must be satisfied:   The patient must be under the care of a doctor who submits a "home health care plan" prior to treatment in the patient's home, including certification that inpatient confinement in a hospital, convalescent nursing home, or skilled nursing facility would be required if home care was not provided; and   The services and supplies furnished would be required during a confinement. Covered home health care services and supplies are:   Ordered by the doctor;   Furnished in the patient's home;   Part-time or intermittent nursing provided by a registered nurse (R.N.);   Part-time or intermittent home health aid services, primarily for the patient's care and under the supervision of an R.N.;   Physical, occupational, speech or respiratory therapy by a qualified therapist;   Nutritional counseling provided by or under the supervision of a registered dietitian;   Medical supplies and laboratory services, prescribed by a doctor. No home health care benefits will be provided for services and supplies in connection with home health services for custodial services, food, housing, homemaker services, home delivered meals and supplementary dietary assistance. If you use a preferred provider, the Plan pays 100% of the covered expenses. If you use a non-preferred provider, the Plan pays 80% of the covered expenses after you have satisfied your $250 per individual or $500 per family calendar year deductible. Failure to obtain pre-certification as required will result in a 20% reduction in benefits payable. Hospice care benefit (pre-certification required) When the covered person's attending physician certifies that the covered person has a terminal illness with a medical prognosis of a life expectancy of six (6) months or less and when the covered person elects to receive care primarily to relieve pain, the covered person will be eligible for hospice benefits. When hospice care is provided primarily in the home, care on a short-term inpatient basis in a Medicare certified skilled nursing facility will also be covered when the hospice considers such care necessary to relieve primary caregivers in the patient's home. Up to seven (7) days of such inpatient care will be covered every six (6) months. If you use a preferred provider, the Plan pays 100% of the covered expenses. If you use a non-preferred provider the Plan pays 80% of the covered expenses after you have satisfied your $250 per individual or $500 per family calendar year deductible. Failure to obtain pre-certification as required will result in a 20% reduction in benefits payable. Benefits for covered hospice services shall be provided until the earlier of patient's death or discharge from the hospice. These benefits are in addition to and not instead of any other benefits under Personal Choice. Special Exclusions The hospice care program must deliver hospice care in accordance with a treatment plan approved and periodically reviewed by Personal Choice. No hospice care benefits will be provided for:   services and supplies for which there is no charge;   research studies directed to life lengthening methods of treatment;   services or expenses incurred in regard to the patient's personal, legal and financial affairs (such as preparation and    execution of a will or other dispositions of personal and real property);   care provided by family members, relatives, and friends; and   private duty nursing care. Hospital benefits with the exception of mental, nervous, drug & alcohol disorders* (pre-certification required) You, a member of your family, a hospital staff member, or preferably your doctor, must notify Personal Choice's Pre-Admission Certification Service at 1-800-332-2566 prior to a hospital admission. (Personal Choice preferred providers will take care of pre-certification for you.) The Plan pays the charges listed below when you are confined in a hospital:   Room and board charges.   Hospital services and supplies, including patient meals, special diets, medicines, laboratory tests, use of operating rooms and special equipment, anesthetics and x-rays.   Charges for a hospital's emergency room treatment of a sickness or injury.   Hospital services connected with outpatient surgery, including use of treatment rooms, x-rays, laboratory tests, surgical dressings and medicines.   Blood and blood plasma (not replaced on behalf of patient). Important Note: If your hospitalization begins on a weekend, and you are receiving medically necessary treatments, benefits for other medical expenses will be payable. If you use a preferred provider, the Plan pays 90% of the covered expenses. If you use a non-preferred provider, the Plan pays 90% of the covered expenses for inpatient services (80% for outpatient services) after you have satisfied your $250 per individual or $500 per family calendar year deductible. Failure to obtain pre-certification as required for outpatient services will result in a 20% reduction in benefits payable. Failure to obtain pre-certification as required for inpatient services will result in a $1,000 reduction in benefits payable. *Personal Choice does not pay for hospital benefits for mental, nervous, drug and alcohol disorders. You should refer to the section titled "Mental, Nervous, Drug & Alcohol Benefits" for an explanation of these benefits provided under the Fund. Infertility services The Plan pays for services to diagnose infertility. Services and related charges to treat infertility such as, but not limited to, artificial insemination and in-vitro fertilization are not covered. If you use a preferred provider, the Plan pays 90% of the covered expenses. If you use a non-preferred provider, the Plan pays 80% of the covered expenses after you have satisfied your $250 per individual or $500 per family calendar year deductible. Inpatient physician services Benefits are payable for charges made by a physician for medical treatment given to a person while confined as an inpatient. No charges are payable under this benefit for any of the following:   Charges for which a Surgical Services benefit is payable;   Dental work;   Eye examination for fitting of eye-glasses;   Diagnostic x-ray and laboratory services;   Drugs or medicines;   Administering an anesthetic. If you use a preferred provider, the Plan pays 90% of the covered expenses. If you use a non-preferred provider, the Plan pays 80% of the covered expenses after you have satisfied your $250 per individual or $500 per family calendar year deductible. Mammography Routine mammography services are provided for covered females once per calendar year. The Plan pays for covered females' expenses once per calendar year (January-December) for routine mammography services. If you use a preferred provider, the Plan pays 90% of the covered expenses. If you use a non-preferred provider, the Plan pays 80% of the covered expenses after you have satisfied your $250 per individual or $500 per family calendar year deductible. Maternity care - Mother's Option The Plan pays for maternity expenses for a participant, spouse or dependent daughter, including pregnancy, resulting childbirth, miscarriage, abortion, and complications of pregnancy. Benefits are payable for: (1) facility services provided by a hospital or birth center and (2) professional services performed by a provider or certified nurse midwife. Benefits payable shall include pre- and post-natal care. If you use a preferred provider, the Plan pays 90% of the covered expenses. If you use a non-preferred provider, the Plan pays 80% of the covered expenses after you have satisfied your $250 per individual or $500 per family calendar year deductible. Maternity care inpatient benefits will be provided for 48 hours for vaginal deliveries and 96 hours for caesarean deliveries, except where a longer stay is approved by Personal Choice. The Plan pays for home health care services which are provided within 48 hours after discharge following a vaginal delivery or 96 hours after discharge following a caesarean section. No deductibles, co-insurance or co-payments will apply to home health care benefits when they are provided after an early discharge from an inpatient maternity stay. Otherwise, visit(s) will be paid under Home Health Care services as provided in that section. When you, a spouse or a dependent daughter, becomes pregnant, you are eligible to participate in Personal Choice's Baby BluePrints Program.Baby BluePrints is a health education program. The major activities include education, coordination of services, risk assessment, case management for hospitalized maternity patients, gifts and coupons. Participation in the program enhances the quality of medical care for expectant mothers. For more information about Personal Choice's Baby BluePrints Program, call 1-800-598-BABY (in the Philadelphia area, call (215) 567-3430). Newborn baby care provision Charges for hospital room and board and other services and supplies furnished by the hospital for newborn care and other professional services will be considered reasonably necessary charges for treatment of the mother's pregnancy and covered under this benefit at the appropriate preferred or non-preferred benefit level. Pre-admission testing The Plan pays for outpatient laboratory testing and x-rays required before surgery or a hospital stay. If you use a preferred provider, the Plan pays 100% of the covered expenses. If you use a non-preferred provider, the Plan pays 90% of the covered expenses after you have satisfied your $250 per individual or $500 per family calendar year deductible. Preventive care For coverage of specific diagnostic tests allowed as part of routine exams, please contact the Dedicated Unit at 1-800-335-9596 The Plan pays for routine physical exams for participants and their eligible dependents as follows: Adult The Plan pays for periodic well-person routine immunizations and examinations, including physical examination, complete medical history, and certain diagnostic services. Benefits are limited to covered persons 18 years of age and older in accordance with the following schedule: Routine History, Physical Examination Ages 18-21 - 1 exam annually Ages 22-39 - 1 exam every 3 years Ages 40 and older - 1 exam annually Complete Blood Count Ages 18-21 - 1 test annually Ages 22-39 - 1 test every 3 years Ages 40 and older - one test annually Fecal Occult Blood Test Ages 50 and older - 1 test annually Rubella Titer Test and Rubella Immunization Ages 18-49 - 1 test and immunization Blood Cholesterol Test Ages 18-39 - 1 test every 4 years Ages 40 and older - 1 test annually Influenza Vaccine Ages 18 and older - 1 vaccine annually Flexible Sigmoidoscopy Ages 50 and older - 1 test every 3 years Thyroid Function Test Ages 18 and older - 1 test annually Prostatic Specific Antigen (PSA) Ages 50 and older - 1 test annually Pneumococcal Vaccine Ages 64 and older - 1 vaccine every 5 years Adult Tetanus Toxoid (TD) Ages 18 and older - once every 10 years Varicella Vaccine Women age 18-49 Urinalysis Ages 18 and older - 1 test annually   Pediatric Periodic Preventive Visits 24 exams up to age 17 - one exam during each of the following age groupings: 0-1 month 2-3 months 4-5 months 6-8 months 9-11 months 12-14 months 15-17 months 18-24 months At age 2 and each age thereafter through age 17 - One exam per year Urinalysis Birth to age 17 - 1 urinalysis annually Hemoglobin/Hematocrit Birth to 12 months - l test 1-4 years - 1 test 5-12 years - 1 test 14-17 years - 1 test Blood Lead Screening 9-12 months - 1 screening 24 months - 1 screening Rubella Titer Test 11-17 years - 1 test and immunization For specific diagnostic tests allowed as part of routine exams, please call the IBC/UFCW Local 1776 Dedicated Customer Service Unit at 1-800-335-9596. If you use a preferred provider, the Plan pays 100% of the covered expenses (subject to the above schedule) after a $5 co-payment. If you use a non-preferred provider, the Plan pays 80% of the covered expenses (subject to the above schedule) after you have satisfied a $250 per individual or $500 per family calendar year deductible. The schedule of covered services is periodically reviewed based on recommendations from organizations such as The American Academy of Pediatrics, The American College of Physicians, the U.S. Preventive Services Task Force and The American Cancer Society. Accordingly, the frequency and eligibility of services is subject to change. Therefore, Personal Choice reserves the right to modify this schedule. Pediatric immunizations The Plan pays for pediatric immunizations as determined by the Department of Health, to conform with the standards of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Pediatric Immunizations are limited to you and your spouse until you reach age 21 and to dependent children. This benefit is not subject to a deductible or co-payment. If you use a preferred provider, the Plan pays 100% of the covered expenses. If you use a non-preferred provider, the Plan pays 80% of the covered expenses. Private duty nursing - Outpatient (pre-certification required) Benefits will be provided for Private Duty Nursing performed by a Licensed Registered Nurse (RN) or a Licensed Practical Nurse (LPN) for non-hospitalized acute illness when ordered by a physician. All nursing services must be medically necessary as determined by Personal Choice and must be pre-certified. If you use a preferred provider, the Plan pays 90% of the covered expenses. If you use a non-preferred provider, the Plan pays 80% of the covered expenses after you have satisfied your $250 per individual or $500 per family calendar year deductible. Failure to obtain pre-certification as required will result in a 20% reduction in benefits payable. Benefits are not payable for:   nursing care which is primarily custodial in nature, such as care that primarily consists of bathing, feeding, exercising, homemaking, moving the patient, giving oral medication;   services provided by a nurse who ordinarily resides in the covered person's home or is a member of the covered person's immediate family; or   services provided by a home health aide or a nurse's aide. Reconstructive/corrective surgery (pre-certification required) The Plan pays for reconstructive surgery, only if such surgery is to: Improve the function of a body part (other than a tooth or structure that supports the teeth) which is malformed as a result of a severe birth defect or as a direct result of illness or surgery performed to treat an illness or injury. Repair an injury which occurs as a result of an accident. In accordance with federal law, the Plan pays for mastectomy-related services as provided above in the section titled “Other Federal Law Requirements.” If you use a preferred provider, the Plan pays 90% of the covered expenses. If you use a non-preferred provider, the Plan pays 80% of the covered expenses after you have satisfied your $250 per individual or $500 per family calendar year deductible. Failure to obtain pre-certification as required will result in a 20% reduction in benefits payable. Second surgical opinions (voluntary) The Plan pays for consultations for surgery to determine the medical necessity of an elective surgical procedure. Elective surgery is that surgery which is not of an emergency or life threatening nature. The Plan will pay for a second surgical opinion, including charges for x-ray and laboratory tests. However, no benefits will be paid for duplicate testing. The second surgical opinion must be confirmatory for automatic approval of the procedure. If the second opinion does not agree with the first opinion, charges for a third opinion are also covered. If you use a preferred provider, the Plan pays 100% of the covered expenses. If you use a non-preferred provider, the Plan pays 100% of the covered expenses after you have satisfied your $250 per individual or $500 per family calendar year deductible. Skilled nursing home benefits (pre-certification required) Benefits are provided for a skilled nursing care facility, when medically appropriate as determined by Personal Choice. The covered person must require treatment by skilled nursing personnel which can be provided only on an inpatient basis in a skilled nursing care facility.   Physician visits to the skilled nursing facility are limited as follows:   up to two visits during the first week of confinement, and   one visit per week for each consecutive week of confinement thereafter. If you use a preferred provider, the Plan pays 90% of the covered expenses. If you use a non-preferred provider, the Plan pays 80% of the covered expenses after you have satisfied your $250 per individual or $500 per family calendar year deductible. Failure to obtain pre-certification as required will result in a 20% reduction in benefits payable No benefits are payable:   when confinement in a skilled nursing facility is intended solely to assist the covered person with the activities of daily living or to provide an institutional environment for the convenience of a covered person;   for the treatment of alcohol or drug addiction, or mental illness or disorder; or   after the covered person has reached the maximum level of recovery possible for his or her particular condition and no longer requires definitive treatment other than routine custodial care. Sterilization The Plan pays for voluntary sterilization; the plan will not cover reversal procedures. The Plan pays for male or female voluntary sterilization procedures. The Plan will not cover reversal procedures. If you use a preferred provider, the Plan pays 90% of the covered expenses. If you use a non-preferred provider, the Plan pays 80% of the covered expenses after you have satisfied your $250 per individual or $500 per family calendar year deductible. Surgical services benefit (pre-certification required) The Plan pays for surgical services and supplies. Covered services include:   Surgeon's fees for the performance of necessary surgery and related post-operative care.   If more than one surgical procedure is performed by the same provider during the same operative session, the Plan pays for the highest paying procedure except where Personal Choice deems that an additional allowance is warranted. Covered surgical procedures shall include routine neonatal circumcisions and any voluntary surgical procedures for sterilization.   Assistant at surgery - Benefits will be payable for services for a covered person by an assistant surgeon who actively assists the operating surgeon in the performance of covered surgery. The condition of the covered person or the type of surgery must require the active assistance of an assistant surgeon as determined by Personal Choice. Surgical assistance is not covered when performed by a provider who himself performs and bills for another surgical procedure during the same operative session.   Dental services related to accidental injury - Benefits will be payable for dental services rendered by a provider and/or facility which are required as result of accidental injury to the jaws, sound natural teeth, mouth or face. Injury as a result of chewing or biting shall not be considered an accidental injury.   Hospital admission for dental for dental procedures or dental surgery - Benefits will be payable for a hospital admission in connection with dental procedures or surgery only when the covered person has an existing non-dental physical disorder or condition and hospitalization is medically necessary to ensure the patient's health. Dental procedures or surgery performed during such a confinement will only be covered for the services described under "Oral surgery" and "Dental services related to accidental injury".   Oral surgery - Benefits will be payable for dental or oral surgery rendered by a provider and/or facility for surgical removal of impacted teeth which are partially or completely covered by bone. If you use a preferred provider, the Plan pays 90% of the covered expenses. If you use a non-preferred provider, the Plan pays 80% of the covered expenses after you have satisfied your $250 per individual or $500 per family calendar year deductible. Failure to obtain pre-certification as required will result in a 20% reduction in benefits payable. Therapy Services (pre-certification required)   Cardiac rehabilitation therapy - Refers to a medically supervised rehabilitation program designed to improve a patient's tolerance for physical activity or exercise. Such  therapy is covered for a patient recovering from myocardial infarction or a coronary bypass procedure, or who has been diagnosed with coronary disease, angina pectoris, valvular heart disease, exercise triggered cardiac arrhythmia, or such other conditions as determined by Personal Choice.     Chemotherapy - Chemotherapy means the treatment of malignant disease by chemical or biological antineoplastic agents, monoclonal antibodies, bone marrow stimulants, antiemetic and other related biotech products. Such chemotherapeutic agents are eligible if administered intravenously or intramuscularly. The cost of drugs, approved by the Federal Food and Drug Administration, is covered for those uses for which such drugs have been specifically approved by the Federal Food and Drug Administration (FDA) as antineoplastic agents, provided they are administered as described in this paragraph. Dialysis - The treatment of acute renal failure or chronic irreversible renal insufficiency for removal of waste materials from the body by hemodialysis, peritoneal dialysis, hemoperfusion, chronic ambulatory peritoneal dialysis (CAPD), or continuous cyclical peritoneal dialysis (CCPD). Benefits will not be provided to the extent that benefits are payable by Medicare for persons who are Medicare eligible on the basis of end stage renal disease (ESRD) and for whom Medicare must pay as primary carrier. Infusion - Treatment includes, but is not limited to, infusion or inhalation, parenteral and enteral nutrition,antibiotic therapy, pain management and hydration therapy. Occupational therapy - Includes treatment of a physically disabled person by means of constructive activities designed and adapted to promote the restoration of the person's ability to satisfactorily accomplish the ordinary tasks of daily living. Coverage will also include services rendered by a registered, licensed occupational therapist. Physical therapy - Includes treatment by physical means such as heat, hydrotherapy or similar modalities, physical agents, bio-mechanical and neuro-physiological principles, and devices to relieve pain, restore maximum functions, and prevent disability following disease, injury, or loss of body part. Pulmonary Rehabilitation therapy Includes treatment through a multi-disciplinary program which combines physical therapy with an educational process directed towards the stabilization of pulmonary diseases and the improvement of functional status for chronic obstructive pulmonary disease (COPD). COPD may include, but is not limited to, diagnoses such as emphysema, chronic bronchitis, asthmatic bronchitis, pre-lung transplant and cystic fibrosis. Benefits are provided up to 12 sessions by a preferred or non-preferred provider per calendar year. Radiation therapy - The treatment of disease by x-ray, radium, or radioactive isotopes, or other radioactive substances regardless of the method of delivery, cost of radioactive materials supplied and billed by the provider Respiratory therapy - Includes the introduction of dry or mast gases into the lungs for treatment purposes. Coverage will also include services by a respiratory therapist. Speech therapy - Includes treatment for the correction of a speech impairment resulting from disease, surgery, injury, congenital anomalies, or previous therapeutic processes. Coverage will also include services by a speech therapist. The above descriptions are examples of the treatments under these therapy services. Other treatments under these therapy services may also be covered. If you use a preferred provider for the above therapy services, the Plan pays 90% of the covered expenses (except for infusion therapy, for which the Plan pays 100%).If you use a non-preferred provider for the above therapy services, the Plan pays 80% of the covered expenses after you have satisfied your $250 per individual or $500 per family calendar year deductible. Failure to obtain pre-certification as required will result in a 20% reduction in benefits payable. Transplant Services (pre-certification required) When a covered person is the recipient of transplanted human organs, marrow, or tissues, benefits are provided for all inpatient and outpatient transplants which are beyond the experimental or investigative stage. Inpatient and outpatient transplants require pre-certification with the following exceptions: transplantation of cornea or skin. Benefits are also provided for those services to the covered person which are directly and specifically related to the covered transplantation, including services for the examination of such transplanted organs, marrow, or tissue and the processing of blood provided to a covered person. The Plan also pays for organ or tissue procurement from a cadaver including removal, preservation, surgical storage and transportation of the donated organ, services and supplies furnished by a provider, treatment and surgery by a provider, and drug therapy to prevent rejection of the transplanted organ or tissue.   When both the recipient and the donor are covered persons, each is entitled to the benefits of this coverage.   When only the recipient is a covered person, both the donor and the recipient are entitled to the benefits of this coverage. The donor benefits are limited to only those not provided or available to the donor from any other source. This includes, but is not limited to, other insurance coverage, or coverage by Independence Blue Cross or any government program. Benefits provided to the donor will be charged against the recipient's coverage under the Fund.   When only the donor is a covered person, the donor is entitled to the benefits of the coverage. The benefits are limited to only those not provided or available to the donor from any other source. This includes, but is not limited to, other insurance coverage or coverage by Independence Blue Cross or any government program available to the recipient. No benefits will be provided to the non-covered transplant recipient.   If any organ or tissue is sold rather than donated to the covered recipient, no benefits will be payable for the purchase price of such organ or tissue. If you use a preferred provider, the Plan pays 90% of the covered expenses. If you use a non-preferred provider, the Plan pays 80% of covered expenses after you have satisfied your $250 per individual or $500 per family calendar year deductible. Failure to obtain pre-certification as required for inpatient services will result in a $1,000 reduction in benefits payable. Failure to obtain pre-certification as required for other services will result in a 20% reduction in benefits payable.