Page 29 - 2016-2021-ASU

(h) The annual and lifetime maximum for each covered member under

the basic medical component shall be unlimited.

(i) Services for examinations and/or purchase of hearing aids shall be a
covered basic medical benefit and shall be reimbursed up to a maximum of

$1,500, per hearing aid, per ear, once every four years, not subject to
deductible or coinsurance. For children 12 and under the same benefits can

be available after 24 months, when it is demonstrated that a covered child's
hearing has changed significantly and the existing hearing aid(s) can no

longer compensate for the child's hearing impairment.
(j) Covered charges for medically appropriate local professional

ambulance transportation will be a covered basic medical expense subject
only to a $35 copayment. Effective January 1, 2019, medically appropriate

local professional ambulance transportation will be a covered basic
medical expense subject only to a $70 copayment. Volunteer ambulance

transportation will continue to be reimbursed for donations at the current
rate of $50 for under 50 miles and $75 for 50 miles or over. These amounts

are not subject to deductible or coinsurance.
(k) Mastectomy brassieres prescribed by a physician, including

replacements when it is functionally necessary to do so, shall be a covered
benefit under the Empire Plan. External mastectomy prostheses will be a

covered in full benefit, not subject to deductible or coinsurance. Coverage
will be provided by the medical carrier as follows:

• Benefits are available for one single/double mastectomy prosthesis

in a calendar year.
• Pre-certification through the Home Care Advocacy Program is

required for any single external prosthesis costing $1,000 or more.
If a less expensive prosthesis can meet the individual’s functional

needs, benefits will be available for the most cost-effective
alternative.

(l) The Pre-Tax Contribution Program will continue unless modified or
exempted by the Federal Tax Code.

(m) A Medical Flexible Spending Account (MFSA) will continue to be
provided. The Joint Committee on Health Benefits shall work with the

State to provide ongoing oversight of the MFSA.
(n) The Empire Plan Centers of Excellence Programs will include Cancer

Resource Services. The Cancer Resource Program will provide:

28