For off-island emergencies, Plan must be contacted and advised within 48 End Renal Disease / Hemodialysis Plan pays 100% Plan pays 100% Plan pays 100% Plan pays 100% Audiological examinations, Hearing Aids Plan pays 100%. Limited every 3yrs (PA required) $500 every 3yrs (PA required) $500 every 3yrs (PA required) $500 every 3yrs (PA required) Maximum $500 per member per plan year Hospitalization & Inpatient Benefits Plan pays 100%. Prior Authorization is required after the first 60 days that includes weekends. Plan pays 100%. Prior Authorization is required after the first 60 days that includes weekends. $75.00 copay, per day up to 10 days. No copay after 10 days. Authorization is required after the first 30 days that includes weekends. $75.00 copay, per day up to 10 days. No copay after 10 days. Authorization is required after the first 30 days that includes weekends. 1. Room & Board for a room, intensive care, coronary care and surgery 2. All other inpatient hospital services including laboratory, x-ray, operating room, anesthesia and medication 3. Physician's hospital services Implants
agency pays $50 & above (Prior Authorization Required) (Pre-Certification Required) Occupational Therapy Plan pays 100%(PA required) Limited to outpatient hospital only. 20 visits per Fiscal Year. Includes the maintenance, acquisition, and restoration of skills in an inpatient and outpatient services only. (PA and Justification are required for additional visits) $4.00 copay, 30 visits per Fiscal Year. Includes the maintenance, acquisition, and restoration of skills in an inpatient and outpatient services only. (PA and Justification are required for additional visits). $4.00 copay, 30 visits per Fiscal Year. Includes the maintenance, acquisition, and restoration of skills in an inpatient and outpatient services only. (PA and Justification are required for additional visits) Not covered Not covered Not covered Not covered Transplant Orthopedic Conditions Plan pay 100%. Orthopedic internal and external prosthetic devices are not covered. Plan pay 100%. Plan pay 100%. Plan pay 100%. Internal and External Prosthesis Physical Therapy/Occupational Therapy Plan pays 100%(PA required) Limited to outpatient hospital only. Plan pays 100%. Includes the maintenance, acquisition, and restoration of skiIIs in an inpatient and outpatient services only. (PA required) 30 visits per Fiscal Year. Includes the maintenance, acquisition, and restoration of skills in an inpatient and outpatient services only. (PA and Justification are required for additional visits) 30 visits per Fiscal Year. Includes the maintenance, acquisition, and restoration of skills in an inpatient and outpatient services only. (PA and Justification are required for additional visits) (Pre-Certification Required)
Radiation Therapy Plan pays 100% Plan pays 100% $4.00 $4.00 (Pre-Certification Required) Robotic Surgery/Robotics Suite not covered not covered not covered not covered (Pre-Certification Required) Skilled Nursing Facility Plan pays 100%. Limited to 180 days maximum per fiscal year. Plan pays 100%. 60 days max per fiscal year. $75.00 copay, per day up to 10 days. No copay after 10 days. PA required. 180 days maximum per fiscal year $75.00 per day up to 10 days. No copay after 10 days. PA required. 180 days maximum per fiscal year (Pre-Certification Required) Sleep Apnea Plan pays 100% (PA required) Plan pays 100% (PA required) $4.00 $4.00 copay Diagnostics and Therapeutic Procedure (Pre-Certification Required) Sterilization Procedures (Tubal Ligation and Vasectomy) Vasectomy (Outpatient Only) Plan pays 100% (PA required) Plan pays 100% (PA required) $4.00 copay, no PA required. $4.00 copay, no PA required.
Rh incompatibility screening: first pregnancy visit The USPSTF strongly recommends Rh (D) blood typing and antibody testing for all pregnant women during their first visit for pregnancy-related care. Claims USPSTF Hepatitis B screening: pregnant The USPSTF strongly recommends screening for hepatitis B virus infection in pregnant women at their first prenatal visit Claims USPSTF Breastfeeding interventions The USPSTF recommends providing interventions during pregnancy and after birth to support breastfeeding. Claims USPSTF Syphilis screening: pregnant women The USPSTF recommends that clinicians screen all pregnant women for syphilis infection. Claims USPSTF Preeclampsia prevention: aspirin The USPSTF recommends the use of low-dose aspirin (81 mg/d) as preventive medication 12 weeks of gestation in women who are at high risk for preeclampsia Claims USPSTF Immunizations The Advisory Committee on Immunization Practices (ACIP) approves immunization schedules recommended for persons living in the United States. The adult immunization schedule provides a summary of ACIP recommendations on the use of licensed vaccines routinely recommended for adults aged 19 years or older. The adult immunization schedule is also approved by the American College of Physicians (), the American Academy of Family Physicians (), the American College of Obstetricians and Gynecologists (), and the American College of (). Database DPHSS Database ” Section 65. A new § 6107.22, Chapter 6, Division 1, 10 of the Guam Code Annotated is hereby added to read: