Coverage Explanation

Provider Type

  • Physicians
  • Participating Physician Groups (PPG)
  • Ancillary

Prostheses are covered on most plans. Prostheses needs may be referred to any Health Net participating provider.

Prostheses and supplies include:

  • Artificial limbs
  • Artificial eyes
  • Artificial larynx devices after a laryngectomy
  • Breast prostheses
  • Colostomy and ostomy supplies
  • Contact lenses after cataract surgery
  • C.V., midline and peripheral catheters
  • Enteral supplies (including formula)
  • Lmphedema sleeves and gloves
  • Phenylketonuria (PKU) formulas and food products
  • Tacheostomy supplies
  • Ventilator supplies

When reconstructive breast surgery (after a medically necessary mastectomy) is performed, prescribed prostheses are covered and replaceable when no longer functional. In addition, prescribed prostheses are covered and replaceable when no longer functional if surgery to the healthy breast is performed to restore and achieve symmetry. Benefits for prostheses include two mastectomy bras each year. If the original mastectomy was not medically necessary, the cost of a new prosthetic is not covered.

Repair or replacement of prostheses is covered. Repair or replacement due to misuse or loss is not covered. Supplies required for prostheses maintenance are covered.

Formula is covered under the prostheses benefit as follows:

  • When given by a feeding tube
  • When given for severe metabolic disorders (for example, PKU), whether by mouth or a feeding tube (as outlined in Health and Safety Code 1374.56 and Insurance Code 10123.89)