These data reflect the most commonly purchased benefits package for each of the health plans in
the year 2000. Coventry/Principal would not supply updated information.

HMO Prosthetic Devices
Aetna US Healthcare Covers: Artificial aids such as cardiac pacemakers, artificial heart valves, initial corrective lenses following cataract surgery. Also covers initial provision of prosthetic appliance used to treat congenital defects.

Limits: Precertification required
Blue Cross Blue Shield Covers: Purchase, fitting, necessary adjustments, repairs, and replacements of prosthetic devices and supplies that replace all or part of an absent body part. Coverage includes contiguous tissue or the replacement of all or part of the function of permanently inoperative or malfunctioning body parts.

Cost Sharing: Coinsurance applies.

Excludes: Dental appliances and replacement of cataract lenses, unless new cataract lenses are needed because of a prescription change.
CIGNA / Healthsource Covers: Prosthetic appliances. CHCNC reserves the right to determine whether rental or purchase is more appropriate.

Limits: Repair and replacement of these items are covered with prior authorization when requested by a participating provider.

Cost Sharing: Copayment and maximum benefit apply.

Excludes: Repair or replacements when due to misuse or loss.
Doctors Health Plan Covers: Prosthetics, including repair and replacement with prior authorization when requested by a participating provider.

Limits: Doctors’ reserves the right to determine whether rental or purchase is more appropriate. Coverage for prosthetics requires precertification or prior authorization from Doctors and must be provided by a participating provider or facility unless there is not a participating provider available.

Cost Sharing: Copayments may apply.

Excludes: Repair or replacement of prosthetics needed because of misuse, normal wear, damage or loss.
Generations Covers: Initial and medically necessary replacement prosthesis when on Medicare’s list of approved prosthetic appliances and approved by Generations’ medical director. Also covers surgically implanted prosthetic devices.

Exclusions: Deluxe versions of durable medical equipment or prosthetic devices unless medically necessary.
Optimum Choice Covers: Orthopedic devices, braces, and prosthetic devices medically necessary to substitute for body organs, and artificial limbs and eyes.

Excludes:

  • Penile devices.
  • Medical and first aid supplies that can be directly purchased by the member.
PARTNERS Covers: Selected, medically necessary prosthetics, when prescribed and arranged by PCP and authorized in advance by plan. Plan maintains a list of covered prosthetics and the conditions under which they are covered. Covers maintenance, repair and replacement (due to physical changes in member) and because of wear and tear.

Limits: Prosthetics must be authorized by plan. Partners reserves right to select source from which prosthetic is purchased or leased, as well as the model or style. Penile prosthesis benefit limited to $3,400 and not subject to scheduled DME coinsurance.

Coventry/Principal Health Care of the Carolinas Covers: Certain prosthetic devices, including external devices such as artificial limbs, eyes and breast following a mastectomy. Also covers internal devices such as hip prosthesis, lens implant and breast implant following a mastectomy.

Limits: External devices are limited to one each per member per lifetime, except if a bilateral mastectomy is performed.

Excludes: Dental prosthesis, bionics, special shoes, breast pumps and penile prostheses. Also excludes the replacement and repair of prosthetic devices unless deemed medically necessary by Coventry/Principal.

QualChoice Covers: Artificial limbs, breast prosthesis, implanted lenses after cataract surgery, and one prosthesis per foot per benefit year. May also cover other prosthetic devices that replace all or part of an absent, permanently inoperable or malfunctioning body part.

Limits: Prosthetics must be ordered by a physician and provided by a participating provider or supplier. Qual Choice will determine whether the equipment will be rented or purchased.

Cost Sharing: Cost sharing may apply. The maximum payment is the purchase price of the equipment.
The Wellness Plan of North Carolina, Inc. Covers: Internal prosthetics and initial external prosthetics.

Limits: Replacement external prosthetics are covered when the old prosthesis no longer fits (for example, the person outgrows the appliance), and for normal wear and tear after 24 months of use.

United HealthCare Covers: The initial purchase of artificial limbs, breast prostheses, and artificial eyes needed because of sickness or injury.

Limits: Prior approval required if prosthetic is over $500.

Cost Sharing: Copayment may apply.

Excludes: Repair, replacements, and duplicates except when a child outgrows the equipment.
WellPath Covers: Internal, non-cosmetic prosthetic devices, including permanent aids and supports for defective body parts. Coverage includes joint replacements, cardiac pacemakers, permanent lenses following cataract surgery, and minor devices such as screw nails, sutures, and wire mesh.

Limits: Prosthetics must be prescribed by PCP and approved in advance by WellPath. Replacement limited to no more often than once every 12 months.

Excludes:

  • Artificial limbs, hearing aids, or durable medical equipment unless covered by a supplemental policy.
  • Penile or testicular prostheses.
  • Implantable insulin pumps or mechanical organ replacement devices such as artificial hearts or left ventricular assist devices.
  • Splints and braces (unless they are used instead of casts).

Supplemental policy: Covers purchase of external prosthetic devices that replace all or part of a defective body part. This includes artificial arms and legs, eyes and hands, hearing aids and breast prosthesis. Most groups purchase the prosthetic device rider.

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