Durable Medical Equipment – 90%

Benefits are provided for durable medical equipment prescribed by a physician including, but not limited to, crutches, wheelchairs, oxygen-related equipment, and standard hospital beds. All durable medical equipment (rental or purchase) must be preauthorized with the Trust Office. To preauthorize equipment, the individual or the individual’s physician must request a Certificate of Medical Necessity form from the Trust Office. The physician must complete the form and return it to the Trust Office. If the rental or purchase is not preauthorized, the plan may deny the charge in part or whole. The fact that an item may serve a useful medical purpose does not ensure that benefits will be provided. The plan may elect to provide benefits for a less costly alternative item.

To be covered, the equipment must meet certain criteria established by the plan:

• The equipment must withstand repeated use.
• The only function of the equipment is for treatment of the medical condition or it contributes to the improvement of function related to the condition.
• The equipment is for the individual only.
• The equipment is appropriate for home use. For purposes of rental or purchase of durable medical equipment, an individual’s home may be the individual’s own dwelling, an apartment, a relative’s home, a nursing home, or some other type of institution. A hospital, skilled nursing facility or rehabilitation facility is not considered the individual’s home.

Helpful Hint

If you preauthorize durable medical equipment with the Trust Office, we can negotiate the price of the equipment with the equipment supplier, allowing your benefit dollars to go further.

Benefits are not provided for:

1. Equipment purchased or dispensed when a plan benefit is not in effect or when the individual is not covered under this plan.
2. Rental in excess of a reasonable purchase price.
3. Personal convenience items such as, but not limited to, heating pads, enuresis (bed wetting) training equipment, whirlpool baths, bath aids, raised toilet seats, exercise equipment, muscle stimulators, weights, keyboard communication devices, adjustable beds, three-wheeled scooters, orthopedic chairs, customized car seats or strollers, feeding chairs, personal hygiene items, blood pressure devices, breast pumps, or deluxe items such as motorized equipment.
4. Freight, postage or delivery charges.
5. Supportive environmental services or equipment such as, but not limited to, wheelchair ramps, support railings, air conditioners, humidifiers, or air filter systems.
6. Equipment for which the primary purpose is preventing illness or injury; equipment primarily designed to assist a person caring for the individual; or equipment not useful in the absence of the individual’s condition.
7. Routine periodic servicing, such as testing, cleaning, regulation, and checking of the individual’s equipment. Extensive maintenance based on the equipment manufacturer’s recommendations to be performed by authorized technicians is covered as a covered repair.
8. Repair or replacement of equipment until five years have elapsed, unless medical necessity is proven.

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