COVERED SERVICES AND BENEFITS. The Contractor must ensure that all services provided are Medically Necessary. The Contractor must submit reports related to covered services and benefits in accordance with Section 11, Reporting Requirements, and Exhibit H, Reporting Requirements, of this Contract.
COVERED SERVICES AND BENEFITS. The Evidence of Coverage describes the separate plan(s) of covered services and benefits, as well as excluded benefits, which HEALTH PLAN agrees to provide to GROUP's Enrollees, pursuant to GROUP’s choice through SHOP. GROUP understands that one Employee and his or her designated dependents may select one of these plans, and other GROUP Employees and their respective designated dependents may select the same or another of the described benefit plans, but an Employee and his or her designated dependents must all select the same benefit plan, although they may select different medical groups and primary care physicians. The SHOP plans offered pursuant to the terms of the Agreement and this Supplement are the only benefits which are covered benefits offered by HEALTH PLAN to GROUP through SHOP. HEALTH PLAN itself shall make all benefit and coverage determinations. All such determinations shall be subject to HEALTH PLAN's grievance procedures.
COVERED SERVICES AND BENEFITS. Copayments You are liable for certain Copayments to Participating Providers, which are due at the time of service. The Copayment amount for specific Covered Services, benefit limitations and out- of- pocket maximums can be found in the Schedule of Copayments and Benefit Limits. A Copayment for Basic Benefits shall not exceed fifty percent (50%) of the total cost of the services provided. Out- of- Pocket Maximums Out- of- pocket maximums paid by You or on Your behalf in a Calendar Year for Basic Benefits shall not exceed two hundred percent (200%) of the total annual Premium. HMO will determine when maximums have been reached based on information provided to HMO by You and Participating Providers to whom You have made Copayments. Once You reach the maximum, You are not required to make additional Copayments for the remainder of the Calendar Year. If You have several covered Dependents, all charges used to apply toward an individual out-of-pocket maximum will be applied towards the out-of-pocket maximum amount. When the family out-of-pocket maximum amount is reached, You are not required to make additional Copayments for Covered Services for the remainder of the Calendar Year. Note: Your Group has made the following additional benefits available. Copayments for these services do not apply to the out- of- pocket maximum amount. You will have to make Copayments under these benefits even if the out- of- pocket maximum amount has been reached: S Pharmacy Benefits Requirements All Covered Services, unless otherwise specifically described: • must be Medically Necessary; • must be performed, prescribed, directed or authorized in advance by the PCP and/or the HMO; • must be rendered by a Participating Provider; • are subject to the Copayment in the Schedule of Copayments and Benefit Limits; • may have limitations, restrictions or exclusions described in Limitations and Exclusions; • may require Preauthorization.
COVERED SERVICES AND BENEFITS. The enclosed Evidence of Coverage describes the separate plan(s) of covered services and benefits, as well as excluded benefits, which PLAN agrees to provide to GROUP's Enrollees, pursuant to GROUP’s choice through the CaliforniaChoice Program. GROUP understands that one Employee and his or her designated Dependents may select one of these plans, and other GROUP Employees and their respective designated Dependents may select the same or another of the described benefit plans but such plans shall all be within the same “metal tier” chosen by the Employer. An Employee and his or her designated Dependents must all select the same benefit plan, although they may select different primary care physicians. The Program Products offered pursuant to the terms of the Agreement and this Supplement are the only benefits which are covered benefits offered by PLAN to GROUP through the CaliforniaChoice Program. PLAN itself shall make all benefit and coverage determinations. All such determinations shall be subject to PLAN's grievance procedures.
COVERED SERVICES AND BENEFITS. All Covered Services (except in emergencies) must be provided by or through Your Participating Primary Care Physician/Practitioner, who may refer You for further treatment by Providers in the applicable network of Participating Specialists and Hospitals. Urgent Care, Retail Health Clinics, and Virtual Visits do not require Primary Care Physician/Practitioner Referral. Some services may require Prior Authorization by HMO. A Copayment for Covered Services shall not exceed fifty percent (50%) of the total cost of the services provided. Out-of-pocket maximums paid by You or on Your behalf in a Calendar Year for Covered Services shall not exceed two hundred percent (200%) of the total annual Premium. HMO will determine when maximums have been reached based on information provided to HMO by You and Participating Providers to whom You have made Copayments. Once You reach the maximum, You are not required to make additional Copayments for Covered Services or Covered Drugs for the remainder of the Calendar Year. IMPORTANT NOTE: Copayments shown below indicate the amount You are required to pay, are expressed as either a fixed dollar amount or a percentage of the Allowable Amount and will be applied for each occurrence unless otherwise indicated. Copayments and out-of-pocket maximums may be adjusted for various reasons as permitted by applicable law. Out - o f - P ocke t Maxi m ums P e r Cal e ndar Y e a r i ncl udi ng P harm ac y B ene f i t s Per Individual Member $9,100 Per Family $18,200 P r o f e s s i onal Se r v i c e s Primary Care Physician/Practitioner (“PCP”) Office or Home Visit Participating Specialist Physician (“Specialist”) Office or Home Visit $35 Copay $70 Copay
COVERED SERVICES AND BENEFITS. All Covered Services (except in emergencies) must be provided by or through Your Participating Primary Care Physician, who may refer You for further treatment by Providers in the applicable network of Participating Specialists and Hospitals. Copayment amounts will be applied for each occurrence unless otherwise indicated. IMPORTANT NOTE: Copayments are expressed as either a fixed dollar amount or a percentage of the Allowable Amount. Some services may require Preauthorization by HMO. Out- of- Pocket Maximums Per Calendar Year Per Individual Member Per Family $1,500 $3,000 Professional Services Primary Care Physician (“PCP”) Office or Home Visit Participating Specialist Physician (“Specialist”) Office or Home Visit $20 Copay $20 Copay Inpatient Hospital Services Inpatient Hospital Services, for each admission $500 Copay Outpatient Facility Services Outpatient Surgery Radiation Therapy and Chemotherapy Dialysis $200 Copay No Copay No Copay Outpatient Laboratory and X- Ray Services Arteriograms, Computerized Tomography (CT Scan), Magnetic Resonance Imaging (MRI), Electroencephalogram (EEG), Myelogram, Positron Emission Tomography (PET Scan), per procedure Other Outpatient Lab Other X- Ray Services No Copay No Copay No Copay Rehabilitation Services Rehabilitation Services and Therapies $20 Copay for PCP or $20 Copay for Specialist, $500 Copay for Inpatient Hospital Services or $20 Copay for Outpatient Facility Services, as applicable.
COVERED SERVICES AND BENEFITS. Copayments You are liable for certain Copayments to Participating Providers, which are due at the time of service. The Copayment amount for specific Covered Services, benefit limitations and out- of- pocket maximums can be found in the Schedule of Copayments and Benefit Limits. A Copayment for Basic Benefits shall not exceed fifty percent (50%) of the total cost of the services provided. Out- of- Pocket Maximums Out- of- pocket maximums paid by You or on Your behalf in a Calendar Year for Covered Services shall not exceed two hundred percent (200%) of the total annual Premium. HMO will determine when maximums have been reached based on information provided to HMO by You and Participating Providers to whom You have made Copayments. Once You reach the maximum, You are not required to make additional Copayments for the remainder of the Calendar Year. If You have several covered Dependents, all charges used to apply toward an individual out-of-pocket maximum will be applied towards the out-of-pocket maximum amount. When the family out-of-pocket maximum amount is reached, You are not required to make additional Copayments for Covered Services for the remainder of the Calendar Year. Note: Your Group has made additional pharmacy benefits available. Copayment for pharmacy benefits do not apply to the medical out- of- pocket maximum amount, but will apply to the out- of- pocket maximums for Pharmacy Benefits indicated on the Pharmacy Benefits; Schedule of Copayments and Benefit Limits.
COVERED SERVICES AND BENEFITS. The Evidence of Coverage describes the separate plan(s) of covered services and benefits, as well as excluded benefits, which Oscar Health Plan of California agrees to provide to GROUP's Enrollees, pursuant to GROUP’s choice through SHOP. GROUP understands that one Employee and his or her designated dependents may select one of these plans, and other GROUP Employees and their respective designated dependents may select the same or another of the described benefit plans, but an Employee and his or her designated dependents must all select the same benefit plan, although they may select different medical groups and primary care physicians. The SHOP plans offered pursuant to the terms of the Agreement and this Supplement are the only benefits which are covered benefits offered by Oscar Health Plan of California to GROUP through SHOP. Oscar Health Plan of California itself shall make all benefit and coverage determinations. All such determinations shall be subject to Oscar Health Plan of California's grievance procedures.
COVERED SERVICES AND BENEFITS. The Contractor must ensure that all covered services provided to Members are Medically Necessary. The Contractor must submit reports related to covered services and benefits in accordance with Section 16, Reporting Requirements, of this Contract, and the MississippiCAN and CHIP Reporting Manuals, which are incorporated into this Contract via reference. The Contractor must also supply any other reports requested by the Division in the requested time, manner, and format.
COVERED SERVICES AND BENEFITS. 84 7.1 Requirement to Make Available Covered Services 84 7.2 Medical Necessity 85 7.3 Experimental or Cosmetic Procedures 85 7.4 Covered Services and Administrative Services 85 7.5 Basic Coverage 86 7.6 Dental Services 115 7.7 Special Coverage 116 7.8 Case and Disease Management 122
