 2-D screening mammograms can be shared, not 3-D or
other similar types of mammograms.
(t) MRIs.
For MRIs in a non-hospital environment EasyShare limits sharing to a fixed amount of $400 per
visit/series with the member responsible for any amount above that limit. All outpatient MRI imaging have
a 90-day waiting period, are sharable only with a physician prescription and must be procured at a free
standing in-network diagnostic center unless received as an admitted patient.
(u) Naturopathic and/or Alternative Treatments.
N/A
(v) Occupational Therapy.
N/A
(w) Organ Transplant.
Expenses incurred in connection with any organ or tissue transplant are treated like any other
hospitalization and surgical procedure and are subject to the same sharing limitations.
(x) Physical Therapy.
N/A
(y) Physician Services.
The EasyShare Program allows for immediate sharing for Primary Care, Specialty Care, Pediatric, and
Urgent Care office visit physicians charges, as well as Preventive Services (the 90-day waiting period
does not apply to these office visits). You must pay a Consultation Fee for each visit; this fee will be due
at the time of your visit. After your payment of the Consultation Fee, the remaining portion of the
physician charges for the office visit only will be eligible under this sharing category. Charges other than
the actual Office Visit fee billed for physician services from that visit, such as testing, screening, imaging,
and procedures, may be sharable if applicable, subject to requirements and limitations. (If multiple visits
are required for an immunization that is eligible for sharing, the Member Consultation Fee will apply to the
initial visit and the cost of the immunization and the subsequent office visit to complete the immunization
will all be eligible for sharing.) If imaging is done both without and with a contrast agent, that is considered
two separate imaging series and the Member Consultation Fee must be paid for both. Similarly, if imaging
is done on two different body parts (e.g., head and leg), that is considered two separate imaging series
and the Member Consultation Fee must be paid for both.UHFR093021E100121 Page 110
(z) Plastic Surgery for Disfiguration.
Medical care and treatment provided for disfiguration caused by amputation, mastectomy, disease or
accident, including reconstructive mammoplasty or similar procedure performed by a general surgeon, is
eligible for sharing. Any other plastic surgery or cosmetic care or treatment is ineligible for sharing,
including but not limited to, pharmacological regimens; nutritional procedures or treatments; cosmetic
surgery; salabrasion, chemosurgery and other such skin abrasion procedures associated with the
removal or revision of scars, tattoos or actinic changes.
(aa) Prescription Drugs.
The 