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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.