Samaritan Select

Limitations applicable to your plan

• Treatment for chemical dependency and/or mental illness
• Biofeedback therapy
• Bariatric surgery
• Transplants
• General exclusions
• Benefits to be paid by other sources

Note: Other limitations affecting benefits for medications, maternity care and nursing services are described in your benefits booklet.

Treatment for chemical dependency and/or mental illness

The benefits for Mental Health Services under Samaritan Select have been improved to provide coverage for mental health conditions the same as any other medical condition, except as noted otherwise in your benefits booklet. This means that the inpatient and outpatient visit limitations no longer apply; however, services are still subject to medical necessity and preauthorization requirements. Residential treatment is limited to 45 days per 12-month period.

Important information about accessing chemical dependency treatment and/or mental health services

Your provider must call Samaritan Select for preauthorization for inpatient or residential treatment of chemical dependency or metal illness. If a preferred provider renders services and preauthorization is not obtained, the preferred provider won’t be paid by your plan for his or her services. You will not be responsible for these charges. Outpatient treatment for chemical dependency and/or mental health treatment allows you to directly access provider and does not require preauthorization. However, your preferred provider must have an approved treatment plan in order to be paid if you have exceeded ten visits. Subsequent authorizations will be coordinated between the provider and Samaritan Select. If your provider does not submit and have an approved treatment plan, the provider will be responsible for his or her charges and you will not be billed for these services. You may contact the Samaritan Select Customer Service Department at 800-569-4616 or 541-768-6900 to inquire if a preauthorization or treatment plan has been submitted and approved.

Definitions

The following definitions apply only to benefits for treatment of chemical dependency (including alcoholism) and/or mental illness.

Chemical dependency conditions means substance-related disorders included in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association.  Chemical dependency is an addictive relationship with any drug or alcohol characterized by a physical or psychological relationship or both, that interferes on a recurring basis with an individual’s social, psychological, or physical adjustments to common problems.  Chemical dependency does not include addiction to or dependency on tobacco, tobacco products or foods.

For inpatient care, a health facility means a hospital or other facility licensed for such care under state law or accredited by the Joint Commission on Accreditation of Hospitals, or the Commission on the Accreditation of Rehabilitation Facilities which provides American Society of Addiction Medicine (ASAM) Level 4.0 acute treatment for alcoholism or drug addiction, or a hospital with a psychiatric unit licensed to admit patients who require 24-hour acute care for mental illness.

Outpatient care means treatment under a program, which meets the standards, established by the Office of Mental Health and Addiction Services or the Oregon Mental Health Division (or the equivalent agency, if services are provided outside Oregon) or by one of the following:

• A physician;
• A psychologist;
• A psychiatric mental health nurse practitioner;
• A licensed professional counselor or marriage and family
• therapist; or
• A residential/partial hospitalization/day care facility.

A residential/partial hospitalization/day care facility means a residential facility, hospital or other facility which provides an organized full-day or part-day program of treatment and is licensed or approved for the particular level of care for which reimbursement is being sought by the Office of Mental Health and Addiction Services or by the Oregon Mental Health Division in accord with ORS 743.556 (or the equivalent agencies, if the services are provided outside Oregon.)

An emergency admission is when a covered person’s condition requires admission to a health care facility, residential facility or partial hospitalization/day care facility because of the risk of immediate harm to the covered person’s health.

Samaritan Select will use the following criteria to determine the appropriate setting for care for the treatment of chemical dependency and/or mental illness:

• Expenses for inpatient health facility care will be covered only when the health facility records reflect that the patient’s medical circumstances require 24-hour skilled nursing supervision and physician assessment meeting medical necessity or utilization management criteria;
• Expenses for residential/partial hospitalization/day care will be covered only when the facility records reflect that the patient requires intensive non-medical supervision, protection, assistance and treatment. In determining the patient’s need for residential/partial hospitalization/day care, the following factors will be taken into consideration:
  • The patient’s existing social, occupational and living situations which would adversely affect treatment provided on an outpatient basis;
  • Potential life-threatening risk to the patient or others;
  • The patient’s readiness and/or willingness to participate consistently in treatment; and
  • Other clinical issues in light of medical necessity and Utilization Management criteria.
• Expenses for outpatient mental health services will be covered when treatment is justified considering the patient’s history and current medical, occupational, social and psychological situation and the overall prognosis.

An approved treatment plan for office-based care will be required in order to maintain benefits for outpatient treatment by a preferred provider exceeding ten visits. The frequency, duration and clinical plan are subject to review for medical necessity and overall utilization at periodic intervals. The patient’s behavioral health provider should contact Samaritan Select for treatment plan review.

Preauthorization for the treatment of chemical dependency and mental illness

The following preauthorization procedure should be followed before you or your covered dependent receives treatment for chemical dependency and/or mental illness in order to decrease the possibility that benefits will be reduced or denied for inappropriate treatment setting or length of stay.

Prior to receiving treatment in:

• An inpatient program; or
• Any residential, or partial hospitalization or day treatment program

The patient’s program or facility should contact Samaritan Select for preauthorization. If you or your covered dependent needs to speak with a Samaritan Select Customer Service Agent about a preauthorization or request for case management or help obtaining care, call 800-569-4616 or 541-768-6900.

The Preauthorization Department will then recommend the expected length of stay and the appropriate treatment setting. Residential treatment is limited to 45 days per 12-month period. Notification of our decision will be communicated by letter to the facility, the physician, and/or you or your covered dependent within two working days. The determination will be valid for 90 days from the date of the letter.

If an emergency admission must take place when our office is closed, please have the program contact us immediately at the earliest opportunity during regular business hours. Only emergency services will be reimbursed when preauthorization has not been obtained. We may require transfer to a facility/ program, which is medically appropriate, based on the criteria given previously.

Benefits for chemical dependency

Benefits for the treatment of chemical dependency, including alcoholism, are subject to medical necessity and utilization management criteria, and except in cases of emergencies, must be preauthorized and delivered in a chemical dependency licensed program in order to be paid. Benefits are subject to all applicable coinsurance, and/or co-payment amounts.

Benefits for mental illness

Benefits for mental illness are limited with regard to certain diagnoses (see GENERAL EXCLUSIONS Section) and with regard to residential or partial hospitalization. Otherwise, all benefits are subject to medical necessity or utilization management criteria, and may be subject to periodic review.

“Dual diagnosis” or benefits for both chemical dependency and mental illness

If, during a 12-consecutive-month period, a covered person receives covered services and supplies at a facility, or facilities licensed for both chemical dependency and mental illness treatment, benefits will be calculated on the basis that only one 45-day residential benefit period per 12 month will be allowed, regardless of diagnosis or combination of diagnosis.

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Biofeedback therapy

Eligible charges for biofeedback therapy services are limited to treatment of tension headaches or migraine headaches.

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Bariatric surgery

Surgical treatment of morbid obesity

The Plan will only cover the Roux-en-Y gastric bypass for the treatment of morbid obesity, and only when the criteria defined below are met. No other surgical procedures are covered by the Plan, including, but not limited to gastric banding, adjustable gastric banding, vertical banded gastroplasty, mini-gastric bypass (gastric bypass using a Billroth II type of anastomosis), distal gastric bypass (long-limb gastric bypass), biliopancreatic bypass, and biliopancreatic bypass with deudenal switch.

The Roux-en-Y gastric bypass may be covered for the treatment of morbid obesity when all of the following criteria are met:

1. BMI > 35 mg/k2 with a diagnosis of diabetes; or
   BMI > 40 mg/k2 with any comorbid condition; or
   BMI > 50 mg/k2 with or without comorbid conditions.
2. A 6-month work-up is completed that includes all of the following:
   • Dietary counseling and education; and
   • Medical evaluation; and
   • Psychological evaluation; and
   • Weight loss of > 5 percent over the 6 months.
3. Surgery is performed in a Center of Excellence recognized by Samaritan Select for the performance of such a procedure.
4. Preauthorization from Samaritan Select is obtained.

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Transplants

Benefits for services and supplies (including medications) rendered in connection with a transplant, including pretransplant procedure such as ventricular assist devices (VADs), organ or tissue harvesting (donor costs), post-operative care (including antirejection medication treatment), and transplant related chemotherapy for cancers are limited as described here.

A covered transplant means a medically necessary transplant of one of the following organs or tissues only and no others:

• Heart;
• Heart/lung or lung;
• Liver;
• Kidney;
• Pancreas;
• Small bowel;
• Small bowel/liver;
• Autologous hematopoietic stem cells whether harvested from bone marrow or, peripheral blood when determined to be medically necessary, or from any other source, but only if required in the treatment of the following and no others:
  • Lymphoma;
  • Neuroblastoma;
  • Acute lymphocytic leukemia;
  • Acute myleogenous (nonlymphocytic) leukemia;
  • Germ cell tumors of the testes, ovaries, mediastinum, and retroperitoneum;
  • Ewing’s sarcoma, high risk or relapsed;
  • Hodgkin’s disease;
  • Medulloblastoma;
  • Wilm’s tumor; high risk, recurrent;
  • Primitive neuroectodermal tumor;
• Allogeneic or syngeneic hematopoietic stem cells whether harvested from bone marrow or, peripheral blood when determined to be medically necessary, or from any other source, but only if required in the treatment of:
  • Aplastic anemia;
  • Acute leukemia;
  • Neuroblastoma;
  • Severe combined immunodeficiency;
  • Infantile malignant osteopetrosis;
  • Chronic myleogenous leukemia;
  • Lymphoma;
  • Wiscott-Aldrich syndrome;
  • Myelodysplastic syndrome;
  • Mucolipidoses;
  • Homozygous beta-thalessemia;
  • Myeloproliferative disorders;
  • Sickle cell anemia;
  • Kostmann’s syndrome;
  • Leukocyte adhesion deficiencies;
  • X-linked lymphoproliferative syndrome;
  • Hodgkin’s disease;
  • Wilm’s tumor; high risk, recurrent; and
• Other transplants determined by us to be a medically necessary covered transplant since this booklet was issued.

Donor costs means all costs, direct and indirect (including program administration costs), incurred in connection with:

• Medical services required to remove the organ or tissue from either the donor’s or the self-donor’s body;
• Preserving it; and
• Transporting it to the site where the transplant is performed.

A transplant means a procedure or a series of procedures by which an organ or tissue is either:

• Removed form the body of one person (called the donor) and implanted in the body of another person (called a recipient); or
• Removed from and replaced in the same person’s body (called a self-donor).

For purposes of this limitation, the term “transplant” includes a ventricular assist device (VAD) when used as a bridge to a heart transplant for a patient who is suffering from severe congestive heart failure, is in imminent risk of dying before a heart is available, and has been approved as a heart transplant candidate. In addition, in treatment of cancer, the term “transplant” includes any chemotherapy and related course of treatment, which the transplant supports.

For purposes of this limitation, the term “transplant” does not include transplant of blood or blood derivatives (except hematopoietic stem cells), or cornea. These services are considered as non-transplant related and are covered elsewhere in the policy.

Benefits

Benefits for a Covered Transplant are payable as follows:

Facility benefits
We will waive any otherwise applicable coinsurance of the policy and pay 100 percent of the Contracted Amount for Facility Transplant Services:

• For covered persons residing in our service area, if a Covered Transplant is performed at a Contracting Transplant Facility; and,
• For covered persons residing outside our service area, if a Covered Transplant is performed at a Contracting Transplant Facility nearest to the covered person’s permanent residence.

Payment of the Contracted Amount at 100 percent does not accumulate towards the annual out-of-pocket maximum amount (the point at which coinsurance is no longer payable) under the policy.

We will pay 60 percent of reasonable charges towards the cost of Facility Transplant Services:

• For covered persons residing either inside or outside our service area if a Covered Transplant is performed at other than a Contracting Transplant Facility.

In either case, the percentage of payment (60 percent) will remain the same (no maximum out-of-pocket amount) throughout the calendar year. Payments at 60 percent do not accumulate toward the annual out-of-pocket maximum amounts under the policy.

The exception to the above facility benefits payment schedule is when the Covered Transplant is for a ventricular assist device (VAD), in which case we pay facility expenses according to the benefits for facilities under the policy.

Professional provider benefits
We will pay for Professional Provider Transplant Services according to the benefits for professional providers under the policy.

Benefits for donor costs
If the recipient or self-donor is covered under this policy, we will pay up to a maximum of $8,000 per Covered Transplant for Donor costs. If the donor is covered under this policy and the recipient is not, we will not pay toward Donor costs. Complications and unforeseen effects of the donation will be covered as any other illness under the terms of the policy if the donor or self-donor is covered under the policy.

Benefits for anti-rejection medications
For anti-rejection medications following the Covered Transplant, we will pay according to the benefits for prescriptions, if any, under the policy.

Limited waiver of policy maximum benefits
If the expenses of a Transplant at a Contracting Transplant Facility would cause a covered person to exceed his or her lifetime maximum benefit under the policy, we will waive the lifetime limit to the extent such expenses for Facility and Professional Provider Transplant Services and Donor Costs exceed the limit. This waiver will not apply to the cost of anti-rejection medications, a Transplant at a Non-contracting facility or to any subsequent Transplants.

Preauthorization

All transplant procedures must be preauthorized for type of transplant and be medically necessary according to criteria established by us.

Preauthorization is a part of the benefit administration of the policy and is not a treatment recommendation. The actual course of medical treatment you or your covered dependent chooses remains strictly a matter between you or your covered dependent and you or your covered dependent’s physician.

Preauthorization procedures
To preauthorize a transplant procedure, your or your covered dependent’s physician must contact Samaritan Select’s Preauthorization Department before the transplant admission. Preauthorization should be obtained as soon as possible after you or your covered dependent has been identified as a possible transplant candidate. See the Preauthorization provision in the ELIGIBLE CHARGES Section of your benefits booklet for a description of the preauthorization process.

Only written approval from us on a proposed transplant will constitute preauthorization. If time is a factor, preauthorization will be made by telephone followed by written confirmation.

24-Month exclusionary period
No benefits for Covered Transplants will be payable during the first 24 months an individual is covered under this policy except as follows:

• The 24-month exclusionary period will not apply if the covered person or self-donor has been continuously covered under this policy since birth; or
• We will reduce the duration of the 24-month exclusion period by the amount of you or your covered dependent’s combined period of prior creditable coverage if the most recent period of creditable coverage ended within 63 days of your or your covered dependent’s effective date of coverage under this policy. Creditable coverage means any of the following coverages:
  • Group coverage (including FEHBP and Peace Corp);
  • Individual coverage (including student health plans);
  • Medicaid;
  • Medicare;
  • CHAMPUS/Tricare
  • Indian Health Service or tribal organization coverage;
  • Plan of a state, the U.S., a foreign country, or a political subdivision of one of these;
  • State high risk pool coverage; and,
  • Public health plans.

Prior creditable coverage is determined separately for each covered person. However, if benefits for the transplant would not have been payable under the previous coverage for any reason, no credits for such prior creditable coverage will be given under this policy toward the 24-month exclusion period. The covered person is responsible for furnishing evidence of the terms of transplant coverage under the previous coverage.

Exclusions

In addition to the exclusions listed in the GENERAL EXCLUSIONS Section, we will not pay for the following:

• Any transplant procedure that has not been preauthorized;
• Any transplant performed outside of the United States;
• Purchase of any organ or tissue;
• Donor or organ procurement services and costs incurred outside the United States, unless specifically approved by us;
• Donation related services or supplies provided to a covered donor if the recipient is not covered under this plan and eligible for Transplant benefits. This exclusion does not apply to complications or unforeseen infections resulting from the donation of tissue;
• Dervices or supplies for any Transplant not specifically named as covered including the Transplant of animal organs or artificial organs; and,
• Chemotherapy with autologous, allogeneic or syngeneic hematopoietic stem cells transplant for treatment of any type of cancer not specifically named as covered.

Other services

Benefit amounts for medically necessary services not previously specified, such as Outpatient Rehabilitation, Injectibles and Therapeutic Injectibles, Cardiac Rehabilitation, Home Health and Skilled Nursing Facility services are subject to a 15 percent preferred or 30 percent non-preferred coinsurance amount. On the part time plan the coinsurance amounts are 20 percent preferred and 50 percent non-preferred.

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General Exclusions

We will not pay for any of the following:

Treatment prior to enrollment: Services or supplies you or a covered dependent received before you were first covered by this plan.

Treatment after insurance ends: Services or supplies you or a covered dependent receives after your insurance coverage under this plan ends. The only exception is when you
or a covered dependent is in the hospital on the day the coverage ends, we will continue to pay toward eligible charges for that hospitalization until your discharge from the hospital or your benefits have been exhausted, whichever comes first.

Services provided by a member of your immediate family.

Treatment not medically necessary: Service and supplies that are not medically necessary for the treatment of an illness or injury (see ELIGIBLE CHARGES in your benefits booklet)

Routine services and supplies: Services and supplies that are not medically necessary for the treatment of an illness or injury. These include:

• Routine tests and screening procedures, except as specifically listed;
• Treatment for corns and calluses, removal of nails (except complete removal), and other routine foot care;
• Eye examinations, the fitting, provision or replacement of eyeglasses;
• Othoptics (eye exercises), visual aids and appliances and vision therapy;
• Telephone consultations, missed appointments, travel related expenses, completion of claim forms, or completion of reports requested by Samaritan Select in order to process claims;
• Self-help or training programs including, but not limited to court-ordered treatment, those to control weight or provide general fitness; also excluded are those programs that teach a person how to use durable medical equipment or how to care for a family member;
• Instruction programs, including, but not limited to, those to learn to self-administer medications or nutrition, except as specially provided for under the “Outpatient Diabetic Instruction” benefit of this policy;
• Appliances or equipment primarily for comfort, convenience, cosmetics, environmental control, or education, such as air conditioners, humidifiers, air filters, whirlpools, hot tubs, heat lamps, or tanning lights;
• Maintenance supplies or equipment commonly used for purposes other than medical care;
• Private duty nursing, including ongoing hourly shift care in the home, or personal items such as telephones, televisions, and guest meals in a hospital or skilled nursing facility; and,
• Speech therapy unless it is to improve or restore lost function due to illness or injury.

Surgery to alter refractive character of the eye: Surgical procedures which alter the refractive character of the eye, including, but not limited to, radial keratotomy, myopic keratomileusis and other surgical procedures of the refractive keratoplasty type, the purpose of which is to cure or reduce myopia or astigmatism. Additionally, reversals or revisions of surgical procedures, which alter the refractive character of the eye and complications of all these procedures, are excluded.

Massage or massage therapy: Except as may be provided by a physical therapist or licensed chiropractor. Massage therapists are not eligible providers.

Orthopedic shoes or arch supports.

Replacement or repair of a prosthetic device or of durable medical equipment necessitated by misuse or loss.

Hypnosis, hypnotherapy and related services.

Cosmetic/reconstructive services and supplies: Services and supplies (including medications) rendered for cosmetic or reconstructive purposes, including complications resulting from cosmetic or reconstructive surgery, except as follows:

• If the surgery is performed to correct a functional disorder or as the result of an accidental injury;
• If the surgery is performed for correction of congenital anomalies in children under age 18; or,
• The surgery is related to breast reconstruction following a mastectomy necessary because of illness or injury in accordance with the Women’s Health and Cancer Rights benefit (see your benefits booklet)

“Cosmetic” means services and supplies that are applied to normal structures of the body primarily for the purpose of improving or changing appearance or enhancing self-esteem.

“Reconstructive” means services, procedures and surgery performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance.

Orthognathic surgery: Orthognathic surgery to change the position of a bone of the upper or lower jaw (except when medically necessary for the purpose of correcting a dysfunction).

Orthognathic surgery is not reimbursable as a benefit for temporomandibular joint (TMJ). Because TMJ is not directly related to the tooth or supporting services, we consider TMJ to be medical treatment. TMJ medical therapy services are limited to the examination, x-rays, physical therapy, TMJ splint, and surgical procedures appropriate for TMJ. Services directly related to the tooth or supporting structure are considered dental procedures even when provided to a patient diagnosed with TMJ. Examples of these services include occlusal equilibration, full mouth reconstruction, orthodontia services, and dentures.

Infertility medications, in vitro and in vivo fertilization: Including services related to or supporting in vitro fertilization, reversal of sterilization procedures, or GIFT and ZIFT procedures.

Dental examinations and treatments: Except as specially provided in the “Special Dental Care” and/or, if applicable, the “Covered Dental Expenses” or “Dental Benefits” section of the policy (see your benefits booklet). For the purposes of this exclusion, the term “dental examinations and treatment” means services or supplies provided to prevent, diagnose, or treat diseases of the teeth and supporting tissues or structures, including services or supplies rendered to repair defects which have developed because of tooth loss and services or supplies rendered to restore the ability to chew.

Physical exercise program: Even though they may be prescribed for a specific condition.

Paraphilia: Services and supplies to diagnose rule out or treat Paraphilia as defined by the most current version of the Diagnostic and Statistical Manual of Mental Disorders.

Gender identity disorder: Services and supplies to diagnose, rule out or treat gender identity disorders (including sex change procedures) as defined by the most current version of the Diagnostic and Statistical Manual of Mental Disorders. However, treatment of children under age 19 for such diagnoses may be covered, but only when preauthorized by Samaritan Select. See the Preauthorization provision in the ELIGIBLE CHARGES Section of the Select Member Handbook for a description of the preauthorization process.

Custodial care: Including routine nursing care and rest cures; and hospitalization for environmental change.  

Behavior modification: Psychological enrichment or self-help programs for mentally healthy individuals, including assertiveness training, image therapy, sensory movement groups, marathon group therapy, wilderness experience programs and sensitivity training.

Counseling or treatment in the absence of illness: Including individual or family counseling or treatment for marital, social, behavioral, family, occupational, or religious problems; or treatment of “normal” transitional response to stress.

Experimental or investigational services: Treatments, procedures, equipment, medications, devices, and supplies (hereafter called services) which are, in our judgment, experimental
or investigational for the specific illness or injury of the covered employee or covered family member receiving services are excluded. Services, which support or are performed in connection with the experimental or investigational services, are also excluded. For purposes of this exclusion, experimental or investigational services include, but are not limited to, any services, which at the time they are rendered and for the purpose and in the manner they are being used:

• Have not yet received final U.S. Food and Drug Administration (FDA) approval for other than experimental, investigational, or clinical testing. However, if a medication is prescribed for other than its FDA approved use and the medication is recognized as effective for the use for a particular diagnosed condition, benefits for the medication when so used will not be excluded under this exclusion. To be considered effective for other than its FDA approved use, the Oregon Health Resources Commission must have determined that the medication is effective for the treatment of the condition; or
• Are determined by us to be in an experimental and/or investigational status. The following will be considered in making the determination whether the service is in an experimental and/or investigational status:
  • Whether there is sufficient scientific evidence to permit conclusions concerning the effect of the services on health outcomes. “Scientific evidence” consists of:
    • Well-designed and well-conducted clinical trails documenting improved health outcomes published in peer reviewed medical (or dental) literature. Peer reviewed medical (or dental) literature means a U.S. scientific publication which requires that manuscripts be submitted to acknowledged experts inside or outside the editorial office for their considered opinions or recommendations regarding publication of the manuscript. Additionally, in order to qualify as peer reviewed medical (or dental) literature, the manuscript must actually have been reviewed by acknowledged experts before publication; and
    • Evaluations by national professional medical (or dental) organizations, national consensus panels or other national technology evaluation bodies which have published a technology assessment or practice guideline based on peer reviewed medical (or dental) literature;
  • Whether the scientific evidence demonstrates that the services improve health outcomes as much or more than established alternatives;
  • Whether the scientific evidence demonstrates that the services’ beneficial effects outweigh any harmful effects; - whether the scientific evidence improves health outcomes as much or more than established alternatives;
  • Whether any improved health outcome from the service is attainable outside investigational settings; and
  • The advice of participating professional providers medical (or dental).

Please note: An experimental or investigation service is not made eligible for benefits by the fact that other treatment is considered by your doctor to be ineffective or not as effective as the service or that the service is prescribed as the most likely to prolong life.

Service-related conditions: The treatment of any condition caused by or arising out of service in the armed forces of any country.

Work-related conditions: Services or supplies for treatment of illness or injury arising out of or in the course of employment or self-employment for wages or profit, whether or not the expense for the service or supply is paid under workers’ compensation. The only exception would be if you or your covered dependent is exempt from state or federal workers’ compensation law.

Services otherwise available: A category that includes:

• Services or supplies for which payment could be obtained in whole or in part if you or your dependent had applied for payment under any city, county, state, or federal law, except for Medicaid coverage;
• Services and supplies you could have received in a hospital or program operated by a government agency or authority; unless reimbursement under this policy is otherwise required by law;
• Charges for services and supplies you or your dependent cannot be held liable for because of an agreement between the provider rendering the service and another third party payor which has already paid for such service or supply; and
• Services or supplies for which no charge is made, or for which no charge is normally made in the absence of insurance.

Charges over usual and customary or reasonable: Any charge over the usual and customary or reasonable charge for services or supplies.

Standby charges when the provider renders no actual treatment to the patient.

Benefits not stated: Services and supplies not specifically described as benefits under this policy.

Care of inmates: Services and supplies you or your covered dependent receives while in the custody of any state or federal law enforcement authorities or when in jail or prison.

Growth hormones: Growth hormone conditions other than growth hormone deficiency in:

• Children or growth failure in children secondary to chronic renal insufficiency prior to transplant; or
• Adults, with a destructive lesion of the pituitary or peripituitary, or as a result of treatment such as cranial irradiation, or surgery. Growth hormone for the treatment of these listed conditions is covered when our medical policy criteria are met (preauthorization is required).

Impotence medications: Any medication therapy for the treatment of impotence regardless of cause.

Prescription medications: For prescription medication plan exclusions, see PRESCRIPTION MEDICATION PROGRAM Section of the Samaritan Select Member Handbook

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Benefits to be paid by other sources

Situations may arise in which health care expenses are also covered by a source other than Samaritan Select. If so, we won’t provide benefits that duplicate the other coverage.

Motor vehicle coverage

In addition to liability insurance, most motor vehicle insurance policies are required by law to provide primary medical payments insurance and uncovered motorist insurance. Many motor vehicle policies also provide underinsurance coverage. Benefits for health care expenses are excluded under this policy to the extent that you or your covered dependent is able to or is entitled to recover form any type of motor vehicle insurance coverage.

Here are some rules, which apply with regard to motor vehicle insurance coverage:

• If a claim for health care expenses arising out of a motor vehicle accident is filed with us and motor vehicle insurance has not yet paid, we may advance benefits as long as you or your covered dependent agrees in writing:
  • To give information about any motor vehicle insurance coverage which may be available to you or your covered dependent; and
  • To hold the proceeds of any recovery from motor vehicle insurance in trust for us and reimburse us as provided in the following paragraphs.
• If we have paid benefits before motor vehicle insurance has paid, we are entitled to have the amount of the benefit we have paid separated from any subsequent motor vehicle insurance recovery or payment made to or on behalf of you or your covered dependent held in trust for us. This is true whether such recovery or payment is from primary medical payments coverage, uninsured motorist coverage or underinsured motorist coverage.
• If you or your covered dependent incurs health care expenses for treatment of an
  illness or injury arising out of a motor vehicle accident after receiving a recovery from uninsured or underinsured motor vehicle coverage, we will exclude benefits for otherwise eligible charges until the total amount of health care expenses incurred after the recovery exceed the Net Recovery Amount (as defined in the “Third Party Liability” provision).
• You or your covered dependent who was involved in a motor vehicle accident may have rights both under motor vehicle insurance coverage and against a third party who may be responsible for the accident. In that case, both this provision and the “Third Party Liability” provision apply.

Third-party liability

This provision applies when you or a covered dependent incurs health care expenses in connection with an illness or injury for which one or more third parties may be responsible. In that situation, benefits for such expenses are excluded under this policy to the extent you or your covered dependent receives a recovery from or on behalf of the responsible third party.

Here are some rules, which apply in these third-party liability situations:

• If a claim for health care expense is filed with us and you have not yet received recovery from the responsible person, we may advance benefits for covered expenses if you or your covered dependent agrees to hold, or directs you or your covered dependent attorney or other representative to hold, the recovery against the other party in trust for us up to the amount of benefits we paid in connection with the illness or injury. We will require that you or your covered dependent sign and deliver to us an agreement (called a trust agreement) guaranteeing our rights under this provision before we advance any benefits.
• If we pay benefits, we will be entitled to have the amount of the benefits we have paid separated from the proceeds of any recovery you or your covered dependent receives from or on behalf of the third party and held in trust for payment to us.
• We are entitled to the amount of benefits we have paid in connection with the illness or injury, regardless of whether you or your covered dependent has been made whole, from the proceeds of any settlement, arbitration award, or judgment that results in a recovery for you or your covered dependent, the third party’s insurer, or any other insurance recovery. This is so regardless of whether:
  • The third party or the third party’s insurer admits liability;
  • The health care expenses are itemized or expressly excluded in the third-party recovery; or
  • The recovery includes any amount (in whole or in part) for services, supplies, or accommodations covered under the policy. The amount to be in trust shall be calculated based upon claims that are incurred on or before the date of settlement or judgment, unless agreed to otherwise by the parties.
• If you or your dependent makes a recovery and fails to hold in trust for us the amount of paid benefits and to pay us that amount as required by this Third Party Liability provision, we may exclude future benefits for otherwise covered expenses for any illness or injury up to the amount of benefits we paid for the illness or injury caused by the third party.
• As long as you or your covered dependent has signed a trust agreement, we will allow a deduction of a proportionate share of the reasonable expenses of obtaining a recovery, such as attorney fees and court costs from the amount to be reimbursed to us.
• If you or your dependent incurs health care expenses for treatment of the illness or injury after recovery, we will exclude benefits for otherwise eligible charges until the total amount of health care expenses incurred after the recovery exceeds the net recovery amount.

The term “net recovery amount” is calculated as follows:

• The amount of recovery;
  plus
• The amount you or your covered dependent recovered from any other source such as other insurance as a result of the illness or injury;
  minus
• The difference between the total amount of third-party related health expenses incurred prior to the recovery and the benefits we paid before the recovery toward such expense;
  minus
• The amount you or your covered dependent reimbursed to us out of the recovery for benefits we paid before the recovery;
  minus
• The total costs paid by you or your covered dependent or on your or your covered dependent’s behalf in obtaining the recovery such as reasonable attorney fees and court costs;
  shall equal
• The “net recovery amount.”

Workers’ compensation

This provision applies if you or your covered dependent has made or is entitled to make a claim for workers’ compensation. Benefits for treatment of an illness or injury arising out of or in the course of employment or self-employment for wages or profit are excluded under this policy. The only exception would be if you or your covered dependents are exempt from state or federal workers’ compensation law.

Here are some rules, which apply in situations where a workers’ compensation claim has been filed

• You must notify us in writing within 5 days of filing a workers’ compensation claim.
• If the entity providing workers’ compensation coverage denies your claims and you have filed an appeal, we may advance benefits if you or your covered dependent agrees in writing to hold any recovery you or your dependent obtains form the entity providing workers’ compensation coverage in trust for us according to the Third-Party Liability provision.

Medicare

In certain situations, this plan is primary to Medicare. This means that when you or your covered dependent is insured in Medicare and this policy at the same time, we pay benefits for eligible charges first and Medicare pays second. Those situations are:

• When you or your spouse is age 65 or over and by law Medicare is secondary to your employer group health plan.
• When you or your covered dependent incurs eligible charges for kidney transplant or kidney dialysis and by law Medicare is secondary to your employer group health plan; and
• When you or your covered dependent is entitled to benefits under section 226(b) of the social Security Act (Medicare disability) and by law Medicare is secondary to your employer group health plan.

In all other instances, we will not pay benefits toward any part of a covered expense to the extent the covered expense is actually paid or would have been paid under Medicare Part A or B had you or your covered dependent properly applied for benefits.

Furthermore, when we are paying secondary to Medicare, we will not pay any part of expenses a Medicare eligible covered member incurs from providers who have opted out of Medicare participation.

Coordination of benefits

Under Construction.

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