Care from a Specialist
A specialist is a provider whose practice is limited to a
specific disease (for example, an oncologist), specific parts
of the body (podiatrist), a specific age group (pediatrician)
or a specific procedure (oral surgeon). Some specialists
may also provide the general medical services of a PCP.
You do not need a referral to visit a specialist. However,
the specialist may decide you need a procedure or treatment
that requires advance approval.
See here for a list of procedures and treatments
that require prior approval. Types of specialty care that
are covered under the Plan include:
- Care provided by any medical specialist including a
cardiologist, a pulmonologist, a gastroenterologist, a
neurologist, a rheumatologist and so forth;
- Podiatry, for the treatment of corns, calluses, weak or
flat feet, fallen arches, chronic foot strain or instability
of the feet, toenails (including removal of nail matrix
or root), treatment of any metabolic or peripheral
vascular disease or neurological condition;
- Rehabilitation therapy, which includes physical and
occupational therapy, speech therapy, cardiac and
pulmonary rehabilitation therapy and cognitive
therapy for up to 60 outpatient visits per calendar year;
- Acupuncture or acupressure (from an In-Network
provider only) with the Plan benefit limited to an allowable charge of no more than $80 per visit with only one covered visit per day;
- Nurse midwife services (from an In-Network
provider only);
- Extraordinary nutrition such as hyperalimentation or Total Parenteral Nutrition (TPN) except hyperalimentation or Total Parenteral Nutrition (TPN) for persons recovering from or preparing for surgery. Benefits will not be paid for a period longer than 3 months unless the patient is in a course of treatment which is being managed under Case Management and such continued treatment is deemed Medically Necessary by the Claims Administrator; and
- Treatment for conditions affecting the joints
between the jawbone and the skull, known as
temporomandibular joint and craniomandibular
joint disorders.