Other Covered Services

Compression stockings (two pair per calendar year for the following conditions only: diabetes, varicose veins, varicose ulcers, statis dermatitis, post-phlebitic syndrome, and lymphedema);
Coverage abroad (coverage outside of the U.S. or international coverage), as follows:

Dental procedures resulting from a congenital or medical disorder or accidental injury (treatment must be received within 12 months of the accident). Includes surgical removal of wisdom teeth only if procedure is done in a medical setting. Please Note: The charges must not be covered by the JPMorgan Chase Dental Plan or any other dental plan that you might be enrolled in.
Diabetes services, diabetes self-management and training, and diabetic eye examinations/foot care — outpatient self-management training for the treatment of diabetes, education and medical nutrition therapy services. Services must be ordered by a physician and provided by appropriately licensed or registered health care professionals. Covered services also include medical eye examinations (dilated retinal examinations) and preventive foot care for diabetes.
Diabetic self-management items — Insulin pumps and supplies and continuous glucose monitors for the management and treatment of diabetes, based upon your medical needs. An insulin pump is subject to all the conditions of coverage stated under durable medical equipment (DME), and Prosthetics. Benefits for blood glucose meters, insulin syringes with needles, blood glucose and urine test strips, ketone test strips and tablets and lancets, and lancet devices are described under the separate prescription drug plan. Please note: Specific insulin pumps may also be covered under the Prescription Drug benefit. Contact CVS Caremark for additional information on which insulin pumps are covered under the Prescription Drug Plan.
External cochlear devices and systems;
Gender Affirmation Surgery (may be referred to by our healthcare companies as Gender Reassignment Surgery or GRS). To be eligible, the participant must meet certain medically established guidelines that are outlined in your healthcare companies clinical polices (which may align with the WPATH Standards of Care v7), for obtaining the surgery which require the participant to, among other things:
Be at least 18 years old;
Have a gender identity disorder diagnosis;
Have been approved for hormone therapy;
Have at least one year's real life experience living in desired gender; and
Have two letters endorsing surgery, including one from a mental health provider at the master's degree level.

Hearing aids: 2 hearing aides every 36 months.
Hearing aids do not need to be prescribed by or obtained from an in-network provider or from an in-network Durable Medical Equipment (DME) provider in order to be considered a covered, eligible charge. You will be subject to out-of-network pricing if you obtain your hearing aide from an out-of-network provider/DME equipment provider. Hearing aid evaluations and hearing tests (not included in the hearing aid maximum benefit).
Intensive behavior therapy, such as applied behavior analysis for autism spectrum disorder.
Local emergency ambulance service or air ambulance to the nearest hospital qualified to treat the condition if medically necessary and confirmed by a licensed provider.
Medical equipment and supplies ordered or provided by a physician including:
artificial eyes and larynx (including fitting);
artificial limbs (excluding replacements);
Apnea monitor;
blood and blood plasma (unless donated on behalf of the patient);
cane;
casts;
crutches;
custom-molded shoe inserts prescribed to treat a condition, disease or illness affecting the function of the foot;
heart pacemaker;
hospital bed;
insulin pump;
manual pump-operated enema systems;
orthopedic braces;
ostomy supplies, including pouches, face plates and belts, irrigation sleeves, bags and ostomy irrigation catheters, and skin barriers and bags;
splints;
surgical dressings;
trusses;
ventilator;
walker;
wheelchair; and
other items necessary to the treatment of an illness or injury that are not excluded under the plans.

Medically necessary visits to licensed physicians, surgeons, and chiropractors, whether in the office or in your home;
Non-emergency transportation is covered if it is provided by a licensed professional ambulance (either ground or air ambulance as determined appropriate) when the transport is:
from an out-of-network hospital to the closest in-network hospital with capabilities to care for the condition;
to a hospital that provides a higher level of care that was not available at the original hospital (when medically necessary for the patient's care);
to a more cost-effective acute care facility (as authorized by the plan) from an acute facility to the nearest sub-acute facility;
Nutritional support, including nutritional counseling (limited to six visits) and durable medical equipment, to treat inborn errors of metabolism and/or to function as the majority source of nutrition,* as long as each of the following conditions are met:
Without enteral (feeding tube) feedings, the individual is unable to obtain sufficient nutrients to maintain appropriate weight by dietary and/or oral supplements;
The administration of enteral nutrition requires ongoing evaluation and management by a physician; and
The individual has one of the following conditions that is expected to be permanent or of indefinite duration:
An anatomical or motility disorder of the gastrointestinal tract that prevents food from reaching the small bowel;
Disease of the small bowel that impairs absorption of an oral diet; or
A central nervous system/neuromuscular condition that significantly impairs the ability to safely ingest oral nutrition.
The limits noted above do not apply for nutritional counseling for behavioral disorders (eating disorders).

Enteral feeding constitutes over 50% of caloric nutritional intake as determined by clinical information submitted by the provider for review;
Calories from parenteral (intravenous) nutrition should not be considered when assessing for the sole source of nutrition; that is, transitioning to enteral feedings; and
Parenteral feedings are covered when considered "medically necessary" and used when oral or enteral alone are not possible.
Oxygen and supplies for its administration;
Prosthetic devices and related supplies, including fitting, adjustments, and repairs, and biomechanical devices, if ordered by a licensed provider. Please check with the claims administrator for frequency or other limitations. Please Note: Dentures, bridges, etc. are not considered medical prosthetic devices.
Radiation, chemotherapy, and kidney dialysis;
Rental or purchase of durable medical equipment — includes cranial orthotics (helmets) custom molded, when prescribed by physician — as determined by the claims administrator and if ordered by a licensed provider. Frequency and other limitations may apply. At the claims administrator's discretion, replacements are covered for damage beyond repair with normal wear and tear when repair costs exceed new purchase price, or when a change in the medical condition occurs sooner than the end of a three-year time frame. Repairs, including the replacement of essential accessories, such as hoses, tubes, mouthpieces, etc., for necessary durable medical equipment are only covered when required to make the item/device serviceable and the estimated repair expense does not exceed the cost of purchasing or renting another item/device. Requests for repairs may be made at any time and are not subject to the three-year time line for replacement.
Services and supplies that are part of an alternate care proposal. This is a course of treatment developed and authorized by the claims administrator as an alternative to the services and supplies that would otherwise have been considered covered services and supplies. Unless specified otherwise, the provisions of the Plan related to benefits, maximum amounts, and copayments will apply to these services.
Skilled nursing facility for up to 365 days per lifetime (combined in-network and out-of-network). The lifetime maximums reflect services received across all JPMorgan Chase Medical Plans.
Speech aid devices and tracheo-esophageal voice devices required for treatment of severe speech impediment or lack of speech directly attributed to sickness or injury.
Termination of pregnancy:
Voluntary (i.e., abortion)
Involuntary (i.e., miscarriage)
Urgent care;
Voluntary sterilization; and
Wigs up to a $500 per year limit, for burns, chemotherapy or radiation, accidental injury, after a diagnosis of alopecia, or for other medically necessary reasons.