Common use of Ambulance Services Clause in Contracts

Ambulance Services. Benefits are available for ambulance services provided by a licensed ambulance or psychiatric transport van. Benefits include: • Emergency ambulance transportation (surface and air) when used to transport you from the place of illness or injury to the closest medical facility that can provide appropriate medical care; and • Non-emergency, prior-authorized ambulance transportation (surface and air) from one medical facility to another. Air ambulance services are covered at the Participating Provider Cost Share, even if you receive services from a Non-Participating Provider. Clinical trials for treatment of cancer or life-threatening diseases or conditions Benefits Benefits are available for routine patient care when you have been accepted into an approved clinical trial for treatment of cancer or a life-threatening disease or condition. A life-threatening disease or condition is a disease or condition that is likely to result in death unless its progression is interrupted. The clinical trial must have therapeutic intent and the treatment must meet one of the following requirements: • Your Participating Provider determines that your participation in the clinical trial would be appropriate based on either the trial protocol or medical and scientific information provided by you; or • You provide medical and scientific information establishing that your participation in the clinical trial would be appropriate. Coverage for routine patient care received while participating in a clinical trial requires prior authorization. Routine patient care is care that would otherwise be covered by the plan if those services were not provided in connection with an approved clinical trial. The Summary of Benefits section lists your Cost Share for Covered Services. These Cost Share amounts are the same whether or not you participate in a clinical trial. Routine patient care does not include: • The investigational item, device, or service itself; • Drugs or devices not approved by the U.S. Food and Drug Administration (FDA); • Travel, housing, companion expenses, and other non-clinical expenses; • Any item or service that is provided solely to satisfy data collection and analysis needs and that is not used in the direct clinical management of the patient; • Services that, except for the fact that they are being provided in a clinical trial, are specifically excluded under the plan; • Services normally provided by the research sponsor free for any enrollee in the trial; or • Any service that is clearly inconsistent with widely accepted and established standards of care for a particular diagnosis. Approved clinical trial means a phase I, phase II, phase III, or phase IV clinical trial conducted in relation to the prevention, detection, or treatment of cancer or other life- threatening diseases or conditions, and the study or investigation meets one of the following requirements: • It is a drug trial conducted under an investigational new drug application reviewed by the FDA; • It is a drug trial exempt under federal regulations from a new drug application; or • It is federally funded or approved by one or more of the following: o One of the National Institutes of Health; o The Centers for Disease Control and Prevention; o The Agency for Health Care Research and Quality; o The Centers for Medicare & Medicaid Services; or o A designated Agency affiliate or research entity as described in the Affordable Care Act, including the Departments of Veterans Affairs, Defense, or Energy if the study has been reviewed and approved according to Health and Human Services guidelines. Diabetes care services Benefits are available for devices, equipment, supplies, and self-management training to help manage your diabetes. Services will be covered when provided by a Physician, registered dietician, registered nurse, or other appropriately-licensed Health Care Provider who is certified as a diabetes educator. Devices, equipment, and supplies Covered diabetic devices, equipment, and supplies include: • Blood glucose monitors, including those designed to help the visually impaired; • Insulin pens, syringes, pumps, and all related necessary supplies; • Blood and urine testing strips and tablets; • Lancets and lancet puncture devices; • Podiatric footwear and devices to prevent or treat diabetes-related complications; • Medically Necessary foot care; and • Visual aids, excluding eyewear and video-assisted devices, designed to help the visually impaired with proper dosing of insulin. Your plan also covers the replacement of a covered item after the expiration of its life expectancy. Self-management training Benefits are available for outpatient training, education, and medical nutrition therapy when directed or prescribed by your Physician. These services can help you manage your diabetes and properly use the devices, equipment, and supplies available to you. With self-management training, you can learn to monitor your condition and avoid frequent hospitalizations and complications. Diagnostic X-ray, imaging, pathology, laboratory, and other testing services Benefits are available for imaging, pathology, and laboratory services for preventive screening or to diagnose or treat illness or injury. Benefits include: • Diagnostic and therapeutic imaging services, such as X-rays and ultrasounds; • Radiological and nuclear imaging, including CT, PET, and MRI scans; • Clinical pathology services; • Laboratory services; • Other areas of diagnostic testing, including respiratory, neurological, vascular, cardiological, genetic, and cerebrovascular; and • Prenatal diagnosis of genetic disorders of the fetus in cases of high-risk pregnancy. Laboratory or imaging services performed as part of a preventive health screening are covered under the Preventive Health Services Benefit.

Ambulance Services. Benefits are available for ambulance services provided by a licensed ambulance or psychiatric transport van. Benefits include: •  Emergency ambulance transportation (surface and air) when used to transport you from the place of illness or injury to the closest medical facility that can provide appropriate medical care; and •  Non-emergency, prior-authorized ambulance transportation (surface and air) from one medical facility to another. Air ambulance services are covered at the Participating Provider Cost Share, even if you receive services from a Non-Participating Provider. Clinical trials for treatment of cancer or life-threatening diseases or conditions Benefits Benefits are available for routine patient care when you have been accepted into an approved clinical trial for treatment of cancer or a life-threatening disease or condition. A life-threatening disease or condition is a disease or condition that is likely to result in death unless its progression is interrupted. The clinical trial must have therapeutic intent and the treatment must meet one of the following requirements: •  Your Participating Provider determines that your participation in the clinical trial would be appropriate based on either the trial protocol or medical and scientific information provided by you; or •  You provide medical and scientific information establishing that your participation in the clinical trial would be appropriate. Coverage for routine patient care received while participating in a clinical trial requires prior authorization. Routine patient care is care that would otherwise be covered by the plan if those services were not provided in connection with an approved clinical trial. The Summary of Benefits section lists your Cost Share for Covered Services. These Cost Share amounts are the same whether or not you participate in a clinical trial. Routine patient care does not include: •  The investigational item, device, or service itself; •  Drugs or devices not approved by the U.S. Food and Drug Administration (FDA); •  Travel, housing, companion expenses, and other non-clinical expenses; •  Any item or service that is provided solely to satisfy data collection and analysis needs and that is not used in the direct clinical management of the patient; •  Services that, except for the fact that they are being provided in a clinical trial, are specifically excluded under the plan; •  Services normally provided by the research sponsor free for any enrollee in the trial; or •  Any service that is clearly inconsistent with widely accepted and established standards of care for a particular diagnosis. Approved clinical trial means a phase I, phase II, phase III, or phase IV clinical trial conducted in relation to the prevention, detection, or treatment of cancer or other life- threatening diseases or conditions, and the study or investigation meets one of the following requirements: •  It is a drug trial conducted under an investigational new drug application reviewed by the FDA; •  It is a drug trial exempt under federal regulations from a new drug application; or •  It is federally funded or approved by one or more of the following: o One of the National Institutes of Health; o The Centers for Disease Control and Prevention; o The Agency for Health Care Research and Quality; o The Centers for Medicare & Medicaid Services; or o A designated Agency affiliate or research entity as described in the Affordable Care Act, including the Departments of Veterans Affairs, Defense, or Energy if the study has been reviewed and approved according to Health and Human Services guidelines. Diabetes care services Benefits are available for devices, equipment, supplies, and self-management training to help manage your diabetes. Services will be covered when provided by a Physician, registered dietician, registered nurse, or other appropriately-licensed Health Care Provider who is certified as a diabetes educator. Devices, equipment, and supplies Covered diabetic devices, equipment, and supplies include: •  Blood glucose monitors, including those designed to help the visually impaired; •  Insulin pens, syringes, pumps, and all related necessary supplies; •  Blood and urine testing strips and tablets; •  Lancets and lancet puncture devices; •  Podiatric footwear and devices to prevent or treat diabetes-related complications; •  Medically Necessary foot care; and •  Visual aids, excluding eyewear and video-assisted devices, designed to help the visually impaired with proper dosing of insulin. Your plan also covers the replacement of a covered item after the expiration of its life expectancy. Self-management training Benefits are available for outpatient training, education, and medical nutrition therapy when directed or prescribed by your Physician. These services can help you manage your diabetes and properly use the devices, equipment, and supplies available to you. With self-management training, you can learn to monitor your condition and avoid frequent hospitalizations and complications. Diagnostic X-ray, imaging, pathology, laboratory, and other testing services Benefits are available for imaging, pathology, and laboratory services for preventive screening or to diagnose or treat illness or injury. Benefits include: •  Diagnostic and therapeutic imaging services, such as X-rays and ultrasounds; •  Radiological and nuclear imaging, including CT, PET, and MRI scans; •  Clinical pathology services; •  Laboratory services; •  Other areas of diagnostic testing, including respiratory, neurological, vascular, cardiological, genetic, and cerebrovascular; and •  Prenatal diagnosis of genetic disorders of the fetus in cases of high-risk pregnancy. Laboratory or imaging services performed as part of a preventive health screening are covered under the Preventive Health Services Benefit.