Common use of Autism Clause in Contracts

Autism. Autism means a developmental neurological disorder, usually appearing in the first three years of life, which affects normal brain functions and is manifested by compulsive, ritualistic behavior and severely impaired social interaction and communication skills. This Contract shall provide benefits for the diagnosis of Autism in accordance with the conditions, limitations as to type and scope of treatment authorized for neurological disorders, exclusions, cost-sharing arrangements and Copayment requirements which exist in this Contract for neurological disorders. This Contract provides for habilitative or rehabilitative services and other counseling or therapy services necessary to develop, maintain, and restore the functioning of an individual with Autism Spectrum Disorder (ASD). BREAST CANCER PATIENT CARE Covered Services include Inpatient care following a mastectomy or lymph node dissection for an appropriate length of stay as determined by the attending Physician in consultation with the Member. Follow-up visits are also included and may be conducted at home or at the Physician’s office as determined by the attending Physician in consultation with the Member. Additional charges may apply. Mastectomy bras are covered, up to 3 per calendar year. BREAST CANCER SCREENING Covered services include imaging services annually including digital mammography, breast tomosynthesis, breast x-ray and breast MRI for women aged 40 and over, or 35 and over as recommended by a physician. Diagnostic and supplemental breast cancer screening is also a covered benefit. BREAST RECONSTRUCTIVE CARE Covered Services include care following a mastectomy for reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, and prostheses and treatment of physical complications, including lymphedemas. CHIROPRACTIC CARE Your plan may include spinal manipulation and is subject to cost sharing. A calendar year visit limit may apply as outlined in the Summary of Benefits and Coverage. CLINICAL TRIAL PROGRAMS Satisfied to the requirements below, Covered Services include routine patient care costs for qualifying Members participating in approved clinical trials for cancer and/or another life- threatening disease or condition. You will never be enrolled in a clinical trial without Your consent. To qualify for such coverage, You must: • Be a Member; • Be diagnosed with cancer or other life-threatening disease or condition; • Be accepted into an approved clinical trial (as defined below); • Be referred by an In-Network Provider; and • Receive Prior Authorization from Alliant. An approved clinical trial means a Phase I, Phase II, Phase III or Phase IV clinical trial that is conducted in relation to the prevention, detection or treatment of cancer or other life-threatening disease or condition and (1) the study is approved or funded by one or more of the following: the National Institutes of Health, the Centers for Disease Control and Prevention, the Agency for Health Care Research and Quality, the Centers for Medicare and Medicaid Services, the U.S. Department of Defense, the U.S. Department of Veterans Affairs, or the U.S. Department of Energy, or (2) the study or investigation is conducted under an investigational new drug application reviewed by the Food and Drug Administration, or (3) the study or investigation is a drug trial this is exempt from having such an investigational new drug application. If You qualify, Alliant cannot deny Your participation in an approved clinical trial. Alliant cannot deny, limit or place conditions on its coverage of Your routine patient costs associated with Your participation in an approved clinical trial for which You qualify. You will not be denied or excluded from any Covered Services based on Your health condition or participation in a clinical trial. The cost of the medication or treatment that is the subject of the clinical trial is specifically excluded from coverage. For Covered Services related to an approved clinical trial, cost sharing (i.e., Deductible, Coinsurance and Copayments) will apply the same as if the service was not specifically related to an approved clinical trial. In other words, You will pay the cost sharing You would pay if the services were not related to a clinical trial. COLORECTAL CANCER EXAMINATIONS AND LABORATORY TESTS Alliant follows the recommendation of the United States Preventive Task force, grade A and B to determine the ages for preventive colorectal screenings. Covered Services include colorectal cancer screening examinations and laboratory tests specified in the current American Cancer Society guidelines for colorectal cancer screening (which are not considered investigational). COMPLICATIONS OF PREGNANCY Benefits are provided for complications of pregnancy resulting from conditions requiring Hospital confinement when the pregnancy is not terminated and whose diagnoses are distinct from pregnancy but are adversely affected by pregnancy or are caused by pregnancy. Benefits for a normal or difficult delivery are not covered under this provision. Such benefits are determined solely by the Maternity Care section of this Contract. In-Network cost- sharing applies accordingly. CONSULTATION SERVICES Covered when the special skill and knowledge of a consulting Physician is required for the diagnosis or treatment of an illness or Injury. DIABETES We cover Medically Necessary equipment, supplies, pharmacological agents, and outpatient self- management training and education, including nutritional therapy for individuals with insulin- dependent diabetes, insulin-using diabetes, gestational diabetes, and non-insulin-using diabetes as prescribed by the Physician. Covered Services for outpatient self-management training and education must be provided by a certified, registered or licensed health care professional with expertise in diabetes. DIALYSIS TREATMENT Dialysis treatment is a Covered Service. DURABLE MEDICAL EQUIPMENT Your plan will pay the rental charge up to the lesser of the purchase price of the equipment or twelve (12) months of rental charges. In addition to meeting criteria for Medical Necessity, the equipment must also be used to improve the functions of a malformed part of the body or to prevent or slow further decline of the Member’s medical condition. The equipment must be ordered and/or prescribed by a Physician and be appropriate for in-home use. The equipment must meet the following criteria: • It can stand repeated use; • It is manufactured solely to serve a medical purpose; • It is not merely for comfort or convenience; • It is normally not useful to a person not ill or injured; • It is ordered by a Provider; • The Provider certifies in writing the Medical Necessity for the equipment. ° The Provider also states the length of time the equipment will be required; ° We may require proof at any time of the continuing Medical Necessity of any item; • It is related to the patient’s physical disorder. EMERGENCY ROOM SERVICES/EMERGENCY MEDICAL SERVICES Coverage is provided for Hospital emergency room care for initial services rendered for the onset of symptoms for an emergency medical condition or serious Accidental Injury which requires immediate medical care. If You require emergency care, go to the emergency room or call 911.

Autism. Autism means a developmental neurological disorder, usually appearing in the first three years of life, which affects normal brain functions and is manifested by compulsive, ritualistic behavior and severely impaired social interaction and communication skills. This Contract shall provide benefits for the diagnosis of Autism in accordance with the conditions, limitations as to type and scope of treatment authorized for neurological disorders, exclusions, cost-sharing arrangements and Copayment requirements which exist in this Contract for neurological disorders. This Contract provides for habilitative or rehabilitative services and other counseling or therapy services necessary to develop, maintain, and restore the functioning of an individual with Autism Spectrum Disorder (ASD). BREAST CANCER PATIENT CARE Covered Services include Inpatient care following a mastectomy or lymph node dissection for an appropriate length of stay as determined by the attending Physician in consultation with the Member. Follow-up visits are also included and may be conducted at home or at the Physician’s office as determined by the attending Physician in consultation with the Member. Additional charges may apply. Mastectomy bras are covered, up to 3 per calendar year. BREAST CANCER SCREENING Covered services include imaging services annually including digital mammography, breast tomosynthesis, breast x-ray and breast MRI for women aged 40 and over, or 35 and over as recommended by a physician. Diagnostic and supplemental breast cancer screening is also a covered benefit. BREAST RECONSTRUCTIVE CARE Covered Services include care following a mastectomy for reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, and prostheses and treatment of physical complications, including lymphedemas. CHIROPRACTIC CARE Your plan may include spinal manipulation and is subject to cost sharing. A calendar year visit limit may apply as outlined in the Summary of Benefits and Coverage. CLINICAL TRIAL PROGRAMS Satisfied to the requirements below, Covered Services include routine patient care costs for qualifying Members participating in approved clinical trials for cancer and/or another life- life-threatening disease or condition. You will never be enrolled in a clinical trial without Your consent. To qualify for such coverage, You must: • Be a Member; • Be diagnosed with cancer or other life-threatening disease or condition; • Be accepted into an approved clinical trial (as defined below); • Be referred by an In-Network Provider; and • Receive Prior Authorization from Alliant. An approved clinical trial means a Phase I, Phase II, Phase III or Phase IV clinical trial that is conducted in relation to the prevention, detection or treatment of cancer or other life-life- threatening disease or condition and (1) the study is approved or funded by one or more of the following: the National Institutes of Health, the Centers for Disease Control and Prevention, the Agency for Health Care Research and Quality, the Centers for Medicare and Medicaid Services, the U.S. Department of Defense, the U.S. Department of Veterans Affairs, or the U.S. Department of Energy, or (2) the study or investigation is conducted under an investigational new drug application reviewed by the Food and Drug Administration, or (3) the study or investigation is a drug trial this is exempt from having such an investigational new drug application. If You qualify, Alliant cannot deny Your participation in an approved clinical trial. Alliant cannot deny, limit or place conditions on its coverage of Your routine patient costs associated with Your participation in an approved clinical trial for which You qualify. You will not be denied or excluded from any Covered Services based on Your health condition or participation in a clinical trial. The cost of the medication or treatment that is the subject of the clinical trial is specifically excluded from coverage. For Covered Services related to an approved clinical trial, cost sharing (i.e., Deductible, Coinsurance and Copayments) will apply the same as if the service was not specifically related to an approved clinical trial. In other words, You will pay the cost sharing You would pay if the services were not related to a clinical trial. COLORECTAL CANCER EXAMINATIONS AND LABORATORY TESTS Alliant follows the recommendation of the United States Preventive Task force, grade A and B to determine the ages for preventive colorectal screenings. Covered Services include colorectal cancer screening examinations and laboratory tests specified in the current American Cancer Society guidelines for colorectal cancer screening (which are not considered investigational). COMPLICATIONS OF PREGNANCY Benefits are provided for complications of pregnancy resulting from conditions requiring Hospital confinement when the pregnancy is not terminated and whose diagnoses are distinct from pregnancy but are adversely affected by pregnancy or are caused by pregnancy. Benefits for a normal or difficult delivery are not covered under this provision. Such benefits are determined solely by the Maternity Care section of this Contract. In-Network cost- and Out-of- Network cost-sharing applies apply accordingly. CONSULTATION SERVICES Covered when the special skill and knowledge of a consulting Physician is required for the diagnosis or treatment of an illness or Injury. DIABETES We cover Medically Necessary equipment, supplies, pharmacological agents, and outpatient self- management training and education, including nutritional therapy for individuals with insulin- dependent diabetes, insulin-using diabetes, gestational diabetes, and non-insulin-using diabetes as prescribed by the Physician. Covered Services for outpatient self-management training and education must be provided by a certified, registered or licensed health care professional with expertise in diabetes. DIALYSIS TREATMENT Dialysis treatment is a Covered Service. If an Out-of-Network Provider is elected, then Out-of- Network benefits apply. DURABLE MEDICAL EQUIPMENT Your plan will pay the rental charge up to the lesser of the purchase price of the equipment or twelve (12) months of rental charges. In addition to meeting criteria for Medical Necessity, the equipment must also be used to improve the functions of a malformed part of the body or to prevent or slow further decline of the Member’s medical condition. The equipment must be ordered and/or prescribed by a Physician and be appropriate for in-home use. The equipment must meet the following criteria: • It can stand repeated use; • It is manufactured solely to serve a medical purpose; • It is not merely for comfort or convenience; • It is normally not useful to a person not ill or injured; • It is ordered by a Provider; • The Provider certifies in writing the Medical Necessity for the equipment. ° The Provider also states the length of time the equipment will be required; ° We may require proof at any time of the continuing Medical Necessity of any item; • It is related to the patient’s physical disorder. EMERGENCY ROOM SERVICES/EMERGENCY MEDICAL SERVICES Coverage is provided for Hospital emergency room care for initial services rendered for the onset of symptoms for an emergency medical condition or serious Accidental Injury which requires immediate medical care. If You require emergency care, go to the emergency room or call 911.

Autism. Autism means a developmental neurological disorder, usually appearing in the first three years of life, which affects normal brain functions and is manifested by compulsive, ritualistic behavior and severely impaired social interaction and communication skills. This Contract shall provide benefits for the diagnosis of Autism in accordance with the conditions, limitations as to type and scope of treatment authorized for neurological disorders, exclusions, cost-sharing arrangements and Copayment requirements which exist in this Contract for neurological disorders. This Contract provides for habilitative or rehabilitative services and other counseling or therapy services necessary to develop, maintain, and restore the functioning of an individual with Autism Spectrum Disorder (ASD). BREAST CANCER PATIENT CARE Covered Services include Inpatient care following a mastectomy or lymph node dissection for an appropriate length of stay as determined by the attending Physician in consultation with the Member. Follow-up visits are also included and may be conducted at home or at the Physician’s office as determined by the attending Physician in consultation with the Member. Additional charges may apply. Mastectomy bras are covered, up to 3 per calendar year. BREAST CANCER SCREENING Covered services include imaging services annually including digital mammography, breast tomosynthesis, breast x-ray and breast MRI for women aged 40 and over, or 35 and over as recommended by a physician. Diagnostic and supplemental breast cancer screening is also a covered benefit. benefit BREAST RECONSTRUCTIVE CARE Covered Services include care following a mastectomy for reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, and prostheses and treatment of physical complications, including lymphedemas. CHIROPRACTIC CARE Your plan may include spinal manipulation and is subject to cost sharing. A calendar year visit limit may apply as outlined in the Summary of Benefits and Coverage. CLINICAL TRIAL PROGRAMS FOR TREATMENT OF CHILDREN’S CANCER Covered Services include routine patient care costs incurred in connection with the provision of goods, services, and benefits to Members who are Dependent children in connection with approved clinical trial programs for the treatment of children’s cancer. “Routine patient care costs” means those Prior Authorized as Medically Necessary costs as provided in Georgia law (OCGA 33-24-59.1). CLINICAL TRIAL PROGRAMS REQUIRED BY PPACA Satisfied to the requirements below, Covered Services include routine patient care costs for qualifying Members participating in approved clinical trials for cancer and/or another life- life-threatening disease or condition. You will never be enrolled in a clinical trial without Your consent. To qualify for such coverage, You must: • Be a Member; • Be diagnosed with cancer or other life-threatening disease or condition; • Be accepted into an approved clinical trial (as defined below); • Be referred by an In-Network Provider; and • Receive Prior Authorization from Alliant. Alliant An approved clinical trial means a Phase I, Phase II, Phase III or Phase IV clinical trial that is conducted in relation to the prevention, detection or treatment of cancer or other life-threatening disease or condition and (1) the study is approved or funded by one or more of the following: the National Institutes of Health, the Centers for Disease Control and Prevention, the Agency for Health Care Research and Quality, the Centers for Medicare and Medicaid Services, the U.S. Department of Defense, the U.S. Department of Veterans Affairs, or the U.S. Department of Energy, or (2) the study or investigation is conducted under an investigational new drug application reviewed by the Food and Drug Administration, or (3) the study or investigation is a drug trial this is exempt from having such an investigational new drug application. If You qualify, Alliant cannot deny Your participation in an approved clinical trial. Alliant cannot deny, limit or place conditions on its coverage of Your routine patient costs associated with Your participation in an approved clinical trial for which You qualify. You will not be denied or excluded from any Covered Services based on Your health condition or participation in a clinical trial. The cost of the medication or treatment that is the subject of the clinical trial is specifically excluded from coverage. For Covered Services related to an approved clinical trial, cost sharing (i.e., Deductible, Coinsurance and Copayments) will apply the same as if the service was not specifically related to an approved clinical trial. In other words, You will pay the cost sharing You would pay if the services were not related to a clinical trial. COLORECTAL CANCER EXAMINATIONS AND LABORATORY TESTS Alliant follows the recommendation of the United States Preventive Task force, grade A and B to determine the ages for preventive colorectal screenings. Covered Services include colorectal cancer screening examinations and laboratory tests specified in the current American Cancer Society guidelines for colorectal cancer screening (which are not considered investigational). COMPLICATIONS OF PREGNANCY Benefits are provided for complications of pregnancy resulting from conditions requiring Hospital confinement when the pregnancy is not terminated and whose diagnoses are distinct from pregnancy but are adversely affected by pregnancy or are caused by pregnancy. Benefits for a normal or difficult delivery are not covered under this provision. Such benefits are determined solely by the Maternity Care section of this Contract. In-Network cost- and Out-of-Network cost-sharing applies apply accordingly. CONSULTATION SERVICES Covered when the special skill and knowledge of a consulting Physician is required for the diagnosis or treatment of an illness or Injuryinjury. DIABETES We cover Medically Necessary equipment, supplies, pharmacological agents, and outpatient self- management training and education, including nutritional therapy for individuals with insulin- dependent diabetes, insulin-using diabetes, gestational diabetes, and non-insulin-using diabetes as prescribed by the Physician. Covered Services for outpatient self-management training and education must be provided by a certified, registered or licensed health care professional with expertise in diabetes. DIALYSIS TREATMENT Dialysis treatment is a Covered Service. If an Out-of-Network Provider is elected, then Out-of-Network benefits apply. DURABLE MEDICAL EQUIPMENT Your plan will pay the rental charge up to the lesser of the purchase price of the equipment or twelve (12) months of rental charges. In addition to meeting criteria for Medical Necessity, the equipment must also be used to improve the functions of a malformed part of the body or to prevent or slow further decline of the Member’s medical condition. The equipment must be ordered and/or prescribed by a Physician and be appropriate for in-home use. The equipment must meet the following criteria: • It can stand repeated use; • It is manufactured solely to serve a medical purpose; • It is not merely for comfort or convenience; • It is normally not useful to a person not ill or injured; • It is ordered by a Provider; • The Provider certifies in writing the Medical Necessity for the equipment. ° The Provider also states the length of time the equipment will be required; ° We may require proof at any time of the continuing Medical Necessity of any item; • It is related to the patient’s physical disorder. EMERGENCY ROOM SERVICES/EMERGENCY MEDICAL SERVICES Coverage is provided for Hospital emergency room care for initial services rendered for the onset of symptoms for an emergency medical condition or serious Accidental Injury which requires immediate medical care. If You require emergency care, go to the emergency room or call 911.