Coverage

Medically necessary durable medical equipment (DME) is covered under all health plans. Refer to the Schedule of Benefits and the member's Certificate of Insurance or Evidence of Coverage (EOC) as applicable to determine exclusions and limitations, as applicable. Apria Healthcare is the preferred provider for DME for PPO and EPO plans.

DME benefits include but are not limited to:

• Wheelchairs
• Walkers
• Crutches
• Canes
• Braces - Orthopedic appliance or apparatus used to support, align, prevent, or correct deformities, or to improve the function of moveable parts of the body. Coverage includes leg, arm, back, and neck braces, and trusses. Back braces include special corsets and sacroiliac, sacrolumbar and dorsolumbar corsets and belts
• Intermittent positive-pressure breathing machines
• Oxygen
• Blood glucose monitoring devices, if authorized. Blood glucose test strips and lancets are covered under the pharmacy benefit. Insulin-dependent and non-insulin-dependent diabetics may receive these supplies:
  • Members are offered blood glucose monitoring devices and supplies as listed in the Health Net Recommended Drug List (RDL). New members may change their current blood glucose monitoring device for one of the preferred brands at no charge

  Members who do not have diabetic supply coverage through their pharmacy benefit, have a benefit for diabetic supplies under their DME coverage. They should obtain test strips and supplies from a contracted DME vendor. For more information regarding a member's benefits, refer to the introduction pages in the Schedule of Benefits. Refer to the Schedule of Benefits to determine coverage.

• Insulin pumps are covered through DME when specific medical criteria are met. For more information, refer to Health Net's medical policy on insulin pumps, available on the Health Net provider website
• Infant apnea monitor - This item is covered for use in the hospital or at home
• Phototherapy (bilirubin lights)
• Medically necessary lactation DME (electric breast pump) - Health Net's preferred breast pump provider is Pumping Essentials

Prescriptions for lactation-related DME must be written by a licensed physician, physician's assistant, nurse practitioner, certified nurse midwife, or certified lactation consultant with a license to practice medicine or nursing. Health Net requires a prescription from the member's physician for a breast pump from Pumping Essentials; however, no prior authorization is needed.

Lactation-related DME, including electric pumps (if the member prefers, battery operated pumps can be substituted) and pump kits (one per member), do not require prior authorization from the PPG for the first two months of use. Longer use requires documentation of continued clinical need and current successful use.

Custom footwear and custom shoe inserts are not a standard covered benefit, and are only covered on specific plans. However, custom footwear and custom shoe inserts are covered for members with diabetes, to prevent or treat diabetes-related complications. For members with diabetes the extra foot orthotic benefit coverage includes one pair of extra depth or custom molded shoes (including non-customized removable inserts provided with the shoes) and three pairs of inserts each calendar year.