COVERED HEALTH CARE SERVICES. We agree to provide coverage for medically necessary covered health care services listed in this agreement. If a service or category of service is not specifically listed as covered, it is not covered under this agreement. Only services that we have reviewed and determined are eligible for coverage under this agreement are covered. All other services are not covered. See Section 1.4 for how we identify new services and our guidelines for reviewing and making coverage determinations. We only cover a service listed in this agreement if it is medically necessary. We review medical necessity in accordance with our medical policies and related guidelines. The term medically necessary is defined in Section 8.0 - Glossary. It does not include all medically appropriate services. The amount of coverage we provide for each health care service differs according to whether or not the service is received: • as an inpatient; • as an outpatient; • in your home; • in a doctor’s office; or • from a pharmacy. Also coverage differs depending on whether: • the health care provider is a network provider or non-network provider; • deductibles (if any), copayments, or maximum benefit apply; • you have reached your plan year maximum out-of-pocket expense; • there are any exclusions from coverage that apply; or • our allowance for a covered health care service is less than the amount of your copayment and deductible (if any). In this case, you will be responsible to pay up to our allowance when services are rendered by a network provider. Please see the Summary of Medical Benefits to determine the benefit limits and amount that you pay for the covered health care services listed below. Please see the Summary of Pharmacy Benefits to determine the benefit limits and amount that you pay for prescription drug and diabetic equipment and supplies purchased at a pharmacy.
COVERED HEALTH CARE SERVICES. Section 6.0 - How We Coordinate Your Benefits When You Are Covered By More Than One Plan; • Section 7.0 - Adverse Benefit Determinations and Appeals; and • Section 7.7 - Our Right of Subrogation and Reimbursement.
COVERED HEALTH CARE SERVICES. 16 3.1 Ambulance Services 16 3.2 Behavioral Health Services 18 A. Mental Health Services 19 B. Substance Use Disorder Treatment 21 3.3 Cardiac Rehabilitation 24 3.4 Chiropractic Medicine 24 3.5 Dental Care 25 3.6 Diabetic Equipment and Supplies 26 3.7 Dialysis Services 26 3.8 Durable Medical Equipment, Medical Supplies, Enteral Formula or Food, & Prosthetic Devices 27 3.9 Early Intervention Services (EIS) 30 3.10 Education 31 3.11 Experimental/Investigational Services 32 3.12 Hearing Services 34 3.13 Hemophilia Services 35 3.14 Home Health Care 35 3.15 Hospice Care 36 3.16 Hospital Emergency Room Services 36 3.17 Human Leukocyte Antigen Testing 37 3.18 Infertility Services 38 3.19 Infusion Therapy 38 3.20 Inpatient Hospital Services 39 3.21 Inpatient Doctors' Hospital Visits 39 3.22 Inpatient Rehabilitation Facility 40 3.23 Office Visits 40 3.24 Organ Transplants 42 3.25 Physical/Occupational Therapy 43 3.26 Pregnancy Services and Nursery Care 44 3.27 Prescription Drugs and Diabetic Equipment/Supplies 45
COVERED HEALTH CARE SERVICES. If a service or category of service is not listed as covered, it is not covered under this agreement. This agreement does NOT cover services that may otherwise be considered covered when provided with a non-covered course of service or as part of a non-covered regimen of care. This section lists many of the services or categories of services that are non-covered (excluded). In addition to this section, see Section 3.0 - Covered Health Care Services and the related exclusions. See Section 1.0 and Section 3.0 for more information about how we identify new services, review the new services, and make coverage determinations.
COVERED HEALTH CARE SERVICES. 3. Treatment of benign gynecomastia (abnormal breast enlargement in males).
COVERED HEALTH CARE SERVICES. We agree to provide coverage for medically necessary covered health care services listed in this agreement. If a service or category of service is not specifically listed as covered, it is not covered under this agreement. Only services that we have reviewed and determined are eligible for coverage under this agreement are covered. All other services are not covered.
COVERED HEALTH CARE SERVICES. This agreement does NOT cover services that may in and of themselves otherwise be considered covered, when provided attendant to a non-covered course of service or as a component of a non-covered regimen of care.
COVERED HEALTH CARE SERVICES. ▪ Required to get or maintain a license of any type.
COVERED HEALTH CARE SERVICES. SAMPLE ▪ Treatment for skin wrinkles or any treatment to improve the appearance of the skin. ▪ Treatment for spider veins. ▪ Sclerotherapy treatment of veins. ▪ Hair removal or replacement by any means.
COVERED HEALTH CARE SERVICES. ▪ Diabetic supplies for which Benefits are provided as described under Diabetes Services in Section 1: Covered Health Care Services.
