Specifically Covered. This Healthcare Benefit Plan helps pay for healthcare expenses that are Medically Necessary and Specifically Covered in this Agreement. Specifically Covered means only those Healthcare Benefits that are expressly listed and described in the Benefits Section of the Agreement. In addition, you should refer to the Exclusions Section that lists services that are not Covered under your Healthcare Benefit Plan. All other benefits and services not specifically listed as Covered in the Benefits Section shall be excluded, except for Clinical Preventive Health Services and except as required by state or federal law. There are no annual or lifetime limits on the dollar value of essential health benefits, as defined under the Affordable Care Act. Presbyterian Health Plan will not deny coverage, deny or limit coverage of a claim, or impose additional cost-sharing or other limitations or restrictions on coverage, for any health services that are ordinarily or exclusively available to individuals of one sex, to a transgender individual based on the fact that an individual’s sex assigned at birth, gender identity, or gender otherwise recorded is different from the one to which such health services are ordinarily or exclusively available. We determine whether a Healthcare Service or supply is a specifically Covered Benefit. The fact that a Practitioner/Provider has prescribed, ordered, recommended, or approved a Healthcare Service or supply does not guarantee that it is a Covered Benefit even if it is not listed as an Exclusion. Specifically, Covered Benefits are subject to the Limitations, Exclusions, Prior Authorization and other provisions of this Agreement. Medical Necessity This Healthcare Benefit Plan helps pay for healthcare expenses that are Medically Necessary and specifically Covered in this Agreement. Clinical Preventive Health Services do not have to be “Medically Necessary.” Medical Necessity or Medically Necessary means Healthcare Services determined by a Practitioner/Provider, in consultation with Presbyterian Health Plan (PHP), to be appropriate or necessary, according to any applicable generally accepted principles and practices of good medical care or practice guidelines developed by the federal government, national or professional medical societies, boards and associations, or any applicable clinical protocols or practice guidelines we developed consistent with such federal, national, and professional practice guidelines, for the diagnosis or direct care...
