| Service |
Coverage |
Authorization Requirements |
Co-Pay: Active duty dependents & retirees with Medicare Part B |
Co-Pay: Retirees without Medicare Part B |
| Sauna Bath |
Not covered |
N/A |
N/A |
N/A |
| Scale |
Not covered |
N/A |
N/A |
N/A |
| School Physical Exam |
Covered between the ages of 5 and 11 when required for school enrollment |
No |
No |
No |
| Scooter, electric |
Limited |
Yes - Mt Holly Surgical Supply is the preferred vendor for NJ and PA |
No |
Yes |
| Scooter, motorized |
Limited |
Yes - Mt Holly Surgical Supply is the preferred vendor for NJ and PA |
No |
Yes |
| Seat Lift |
Covered |
Yes |
No |
Yes |
| Second Opinion |
Covered |
Yes - if out of network |
No |
Yes |
| Shampoo Tray |
Not covered |
N/A |
N/A |
N/A |
| Shoe Inserts |
Not covered |
N/A |
N/A |
N/A |
| Shoe Lifts |
Not covered |
N/A |
N/A |
N/A |
| Shoes, custom molded, extra depth and related inserts |
Limited |
Yes |
No |
Yes |
| Shower bench/chair/seat |
Not covered |
N/A |
N/A |
N/A |
| Sigmoidoscopy |
Covered |
No |
No |
Yes |
| Sitz Bath |
Covered |
Yes |
No |
Yes |
| Skilled Nursing Facility Admission |
Covered; No pre-set limit to the number of days available, each SNF day must meet standardized medical necessity criteria. |
Yes |
No |
Yes |
| Sleep Study (Polysomnography) |
Covered |
No - routine diagnostic study; Yes - unattended home study |
No |
Yes |
| Sleep Study (Polysomnogrraphy) |
Covered |
No |
No |
Yes |
| Sling, arm |
Covered |
No |
No |
Yes |
| Smoking Cessation Systems |
Not covered |
N/A |
N/A |
N/A |
| Sonogram |
Covered |
No |
No |
No |
| Speech Therapy, home care |
Covered |
Yes |
No |
Yes |
| Speech Therapy, inpatient |
Covered |
Yes |
No |
No (included under admission) |
| Speech Therapy, outpatient |
Covered |
Yes |
No |
Yes |
| Speech Training Device |
Not covered |
N/A |
N/A |
N/A |
| Splints |
Covered |
No |
No |
Yes |
| Sryringes |
Covered |
Obtain from Maxor Mail Order |
Yes |
Yes |
| Stair glide or lift |
Not covered |
N/A |
N/A |
N/A |
| Standing Table |
Not covered |
N/A |
N/A |
N/A |
| Steam Pack |
Covered |
Yes |
No |
Yes |
| Stereotactic Radiosurgery |
Covered |
Yes |
No |
Yes |
| Sterilization |
Covered |
Contact Adaptis |
No |
Yes |
| Stethoscope |
Not covered |
N/A |
N/A |
N/A |
| Stool tests |
Covered |
No - LabCorp is the Plan's preferred lab |
No |
No |
| Stress Test |
Covered |
No |
No |
Yes |
| Subacute Rehabilitation Facility Admission |
Covered |
Yes |
No |
Yes |
| Suction Machine |
Covered |
Obtain from Apria |
No |
Yes |
| Sunlamp |
Not covered |
N/A |
N/A |
N/A |
| Supportive device for feet (wedges, fillers, heel straps, pad, shanks) |
Not covered |
N/A |
N/A |
N/A |
| Surgical Dressing Supplies |
Covered |
No |
No |
Yes |
| Surgical Services (inpatient and ambulatory) |
Covered |
Yes |
No |
Yes |
| Sweat Test |
Covered |
No |
No |
Yes |
