What the Medical Plans Cover

Services or supplies must be considered medically necessary by the Claims Administrator, be delivered for the treatment of illness or injury, and be performed or prescribed by a licensed physician to be covered by the SAIC self-insured medical plans. The services listed below are subject to any applicable annual deductibles, coinsurance, co-payments, and plan maximums. See Comparing the SAIC Medical Plans for more detail.

The SAIC self-insured medical plans cover:

• Physician's office visits;
• Other physician's services;
• Emergency or urgent care;
• Professional ambulance service to transport a person from the place where he or she is injured or stricken by disease to the first hospital where treatment is given;
• Hospital expenses including:
  • Inpatient hospital expenses: Charges for room and board, and other hospital services and supplies for a person confined as a full-time inpatient;
  • Outpatient hospital expenses: Charges for hospital services and supplies for a person who is not confined as a full-time inpatient; and
  • Convalescent facility expenses: Charges for a person who is confined to convalesce from a disease or injury for room and board and general expenses made in connection with room occupancy, use of special treatment rooms, X-ray and lab work; physical, occupational or speech therapy; oxygen and other gas therapy; and medical supplies. Benefits will be paid for up to the maximum number of days during any one convalescent period for the same or related cause beginning on the day the person is confined in a convalescent facility if he or she:
    • Was confined in a hospital while covered under the plan for treatment of a disease or injury;
    • Is confined in the facility within 15 days after discharge from the hospital; and
    • Is confined in the facility for services needed to convalesce from the condition that caused the hospital stay.
  Benefits end when the person has not been confined in a hospital, convalescent facility or other place giving nursing care for 90 days in a row.
• Periodic health assessments including seven exams per calendar year up to age 12 months, two exams per year age 13 months to age 24 months; one exam per year age 25 months through age 17; one exam per 24 months age 18 through age 64; and one exam each year for ages 65 and older;
• Immunizations;
• Home health care expenses when the charge is made by a home health care agency, the care is given under a home health care plan, and the care is given to a person in his or her home for part-time or intermittent care by an R.N. (or L.P.N. when an R.N. is not available); part-time or intermittent home health aide patient care services; and physical, occupational and speech therapy. There is a maximum of 100 visits covered in a plan year and a visit equates to up to four hours by a home health aide;
• Hospice care expenses for part-time or intermittent care by an R.N. (or L.P.N. when an R.N. isn't available) up to eight hours a day, medical social services under the direction of a physician, psychological and dietary counseling, consultation or case management services by a physician, and physical and occupational therapy. This includes charges for bereavement counseling if it is given to the person's immediate family, is given during three months following the person's death, and is directly related to the person's death;
• Drugs and medicines which by law need a physician's prescription, including medically necessary weight control drugs;
• Acupuncture - when performed by a physician or certified acupuncturist for treatment of a disease or injury, to alleviate chronic pain given, or as a form of anesthesia in connection with a surgery;
• Diagnostic lab work and X-rays - routine and non-routine - up to plan maximum;
• X-ray, radium and radioactive isotope therapy;
• Anesthetics and oxygen;
• Rental of durable medical or surgical equipment, including repair of such equipment or replacement when it is proved that it is needed due to a change in the person's physical condition or it is likely to cost to purchase a replacement than to repair existing equipment;
• Maternity;
• Mammograms;
• Routine pap smears - one diagnostic test per calendar year;
• Chiropractic care, if medically necessary;
• Prostate specific antigen (PSA) age 40+ ;
• Infertility treatment for a female employee, the wife or registered domestic partner of an SAIC employee, including in vitro fertilization, uterine embryo lavage, embryo transfer, gamete intrafallopian tube transfer (GIFT), zygote intrafallopian tube transfer (ZIFT), low tubal ovum transfer and prescription drug therapy used specifically for infertility, will be covered up to $5,000 per lifetime. The following conditions must be met:
  • The female participant must have been unable to conceive after having unprotected intercourse for one year or more;
  • The female participant must have been unable to attain a successful pregnancy through less costly treatment covered under the plan;
  • The female participant must have FSH levels which are less than or equal to 19 miU on day 3 of her menstrual cycle;
  • The procedure cannot involve surrogates; and
  • The procedure must be performed at a medical facility that conforms to generally accepted medical standards.
• Artificial insemination;
• Voluntary sterilization;
• Separate accident benefit (applies to MedPlus only);
• Skilled nursing care expenses made by an R.N. or L.P.N. or a nursing agency for skilled nursing care, which includes visiting nursing care from an R.N. or L.P.N. for up to four hours for the purpose of performing skilled nursing tasks, and private duty nursing from an R.N. or L.P.N. for up to eight hours if the person's condition requires skilled nursing services and visiting nursing care is not adequate. Private duty nursing benefit is combined with home health care benefits with a maximum of 100 visits per year;
• Spinal disorders;
• Treatment of the mouth, jaws and teeth due to a medical condition affecting the teeth, mouth, jaws, jaw joints or supporting tissue (including bones, muscles and nerves) based on medical, not dental, necessity;
• TMJ or malocclusion involving the joints or muscles (includes medically necessary, non-dental, bite blocks, splints, arch bars, and occlusal guards);
• Physical therapy, if medically necessary, and maintenance therapy (both limited to 52 visits) for certain chronic medical conditions seriously limiting a member's activities of daily living;
• Occupational therapy, if medically necessary;
• Speech therapy for loss of speech, or speech impaired or developmentally delayed due to a diagnosed disease, injury or congenital defect;
• Artificial limbs and eyes;
• Cotton balls for diabetic insulin injections; and
• Wigs for hair loss due to injury, disease or treatment of disease, including costs for repair or replacement.
• Listed transplants are covered only if performed by the Administrator's contracted Institutes (or Centers) of Excellence (IOE) facilities. List of IOE Procedure and Treatment types - heart transplant, lung transplant, liver transplant, bone marrow transplant, heart/lung transplant, kidney transplant, pancreas transplant, kidney/pancreas transplant.
• For IOE procedure and treatments - The Plan will pay for transportation and lodging between participant's home and the IOE to receive services in connection with IOE procedure or treatment. Travel and lodging expenses for IOE patient and one companion/parent/guardian traveling with the IOE patient must be approved in advance by Administrator. The Plan will reimburse a maximum of $50 per person per night for lodging expenses. The Plan will reimburse travel and lodging expenses incurred up to maximum of $10,000 per episode of care. The Plan will pay expenses incurred during a period which begins on the day a participant becomes an IOE patient and ends on the earlier of one year after the day the procedure is performed or the date the IOE patient ceases to receive any service from the IOE in connection with the procedure. Benefits reimbursed for travel and lodging expenses do not count against the lifetime maximum benefit.