Our Right to Approve Alternative Benefits Sample Clauses

Our Right to Approve Alternative Benefits. We may in our sole discretion cover benefits not listed in this agreement or benefits that are excluded (not covered). This is our right to approve alternative benefits. Alternative benefits are health service specific and time-limited authorizations which must be pre-approved by us for each person. Alternative benefits are only offered on an individual, case-by-case basis when approved by us. We approve alternative benefits based upon information that a covered health care service may be less effective than a requested alternative benefit. We get this information from your treating physician. We determine whether covering the alternative benefit will not only be helpful to you, but be more cost effective than a covered alternative. This review takes place in our Case Management Department. It includes the review of a Medical Director. The determination by us of whether to cover an alternative benefit is solely for the purpose of claims payment and the administration of health benefits under this agreement. Your treatment remains a decision made by you with your doctor. Any decision to cover or not to cover alternative benefits is within our sole discretion. Any decision not to approve alternative benefits made by us in good faith is binding upon you. If we approve an alternative benefit, you must verbally agree to our specific terms and conditions. You must sign a letter of agreement acknowledging acceptance of the specific terms and conditions of the alternative benefits. We do not make alternative benefits available to all members. We do not make them available to any member a second time without additional approval. Alternative benefits must be consistent with our goals to offer cost-effective health care benefits. Copayments and deductibles for alternative benefits will be applied based on how copayments and deductibles would be applied for similar covered health care services.

Our Right to Approve Alternative Benefits. We have the right to cover benefits not listed in this agreement as alternatives to covered benefits. We must pre-approve all alternatives for each individual. We do not make alternatives available to all members or to any member a second time without additional approval. Alternatives must be consistent with our goals to offer cost-effective health care benefits. Any decisions to cover or not to cover alternative benefits are within our sole discretion, and any decision not to approve alternative benefits made by us in good faith is binding upon you.