OTHER COVERED SERVICES. The services listed in this section are covered as shown on the Summary of Your Costs.
OTHER COVERED SERVICES. 1. Diabetic Equipment and Supplies We will pay for the following equipment and supplies for the treatment of diabetes which are Medically Necessary and prescribed or recommended by your PCP or other Participating Provider legally authorized to prescribe under Title 8 of the New York State Education Law: • Blood glucose monitors; • Blood glucose monitors for visually impaired; • Data management systems; • Test strips for monitors and visual reading; • Urine test strips; • Injection aids; • Cartridges for visually impaired; • Insulin; • Syringes; • Insulin pumps and appurtenances thereto; • Insulin infusion devices; • Oral agents; and • Additional equipment and supplies designated by the Commissioner of Health as appropriate for the treatment of diabetes.
OTHER COVERED SERVICES. Acupuncture Limited to 12 visits per calendar year, except for chemical dependency treatment Deductible, then 20% coinsurance Deductible, then 50% coinsurance Allergy Testing and Treatment Deductible, then 20% coinsurance Deductible, then 50% coinsurance YOUR COSTS OF THE ALLOWED AMOUNT IN-NETWORK PROVIDERS OUT-OF-NETWORK PROVIDERS Chemotherapy, Radiation Therapy and Kidney Dialysis Deductible, then 20% coinsurance Deductible, then 50% coinsurance Clinical Trials Covered as any other service Covered as ay other service Dental Accidents Covered as any other service Covered as any other service Dental Anesthesia When medically necessary Deductible, then 20% coinsurance Deductible, then 50% coinsurance Foot Care Routine care that is medically necessary for the treatment of diabetes Deductible, then 20% coinsurance Deductible, then 50% coinsurance Infusion Therapy Deductible, then 20% coinsurance Deductible, then 50% coinsurance Mastectomy and Breast Reconstruction Deductible, then 20% coinsurance Deductible, then 50% coinsurance Medical Foods Deductible, then 20% coinsurance Deductible, then 50% coinsurance Spinal or Other Manipulative Treatment Limited to 10 visits per calendar year Deductible, then 20% coinsurance Deductible, then 50% coinsurance Temporomandibular Joint (TMJ) Disorders • Office visits • Inpatient facility fees • Other professional services Deductible, then 20% coinsurance Deductible, then 20% coinsurance Deductible, then 20% coinsurance Deductible, then 50% coinsurance Deductible, then 50% coinsurance Deductible, then 50% coinsurance Therapeutic Injections Deductible, then 20% coinsurance Deductible, then 50% coinsurance Transplants • Office visits • Inpatient facility fees • Other professional and facility services, including donor search and harvest expenses • Travel and lodging. $5,000 limit per transplant. *All approved transplant centers covered at in-network benefit level Deductible, then 20% coinsurance Deductible, then 20% coinsurance Deductible, then 20% coinsurance Deductible, then 0% coinsurance Not covered* Not covered* Not covered* Deductible, then 0% coinsurance IMPORTANT PLAN INFORMATION
OTHER COVERED SERVICES. 4.9.1 Alcohol/drug detoxification services, subject to the benefit limitations as listed in Exhibit 2 of this Agreement. Services for substance abuse and chemical dependency, when required in the treatment of a mental illness, will be provided at the same benefit level as other medical or surgical conditions.
OTHER COVERED SERVICES. 1. Federally Qualified Health Center (FQHC) Services FQHC services include physician services, services and supplies covered under SSA §1861(s)(2) (A). Services include primary health, referral for supplemental health services, health education, patient case management, including outreach, counseling, referral and follow-up services (see 42 USC §254c(a) & (b)). APPENDIX K January 1,2005
OTHER COVERED SERVICES. (This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services.)
OTHER COVERED SERVICES. Mastectomy and Reconstructive Mammoplasty MCS Life will cover mastectomy-related services for both men and women, including all stages or reconstruction and surgery to achieve breast symmetry, prosthesis and complications that may arise from a mastectomy, Cancer Rights Act of 1998. Requires pre-authorization from MCS Life. Lymphedema therapy requires pre-authorization from MCS Life Clinical Affairs, and copayment or coinsurance for physical therapy applies. Mammoplasties or plastic reconstruction for breast reduction or augmentation are not covered (except for reconstruction after mastectomy for breast cancer. Initial deductible applies/No initial deductible applies. Annual Physical Exam MCS Life will cover an annual physical exam, provided it is for preventive purposes. Excluded are physical exams and lab tests for medical certificates ordered by the employer or for other purpose that is not prevention, except as otherwise provided under Law No. 296 of September 1, 2000, known as the Children and Adolescents Health Conservation Act of Puerto Rico, as amended. A comprehensive annual health evaluation performed by health professionals may include diagnostic tests, among others, according . Initial deductible applies/No initial deductible applies. Acquired Immunodeficiency Syndrome (AIDS/HIV) Covered as any other condition, in accordance with Law No. 349 of September 2, 2000, as amended. Initial deductible applies/No initial deductible applies. Autism According to Law No. 220-2012 approved on September 4, 2012, better known as BIDA Act (Spanish acronym for the Act for the Wellbeing, Integration, and Development of Persons with Autism), treatments for autism disorders, as defined in the Diagnostic and Statistical Manual of Mental Disorders, will be covered without limits, after a medical necessity has been established under this certificate. Covered services include, but are not limited to, genetics, neurology, immunology, gastroenterology, nutrition, speech and language therapies, psychological, occupational and physical services, and will include medical visits and medically necessary tests. Initial deductible applies/No initial deductible applies. Down Syndrome Services for insureds with Down Syndrome will be covered without limits, in accordance with Law No. 97 of May 15, 2018. Services include tests, without limiting to, genetics, neurology, immunology, gastroenterology and nutrition; in addition, medical visits and medically referred tests and therapeut...
OTHER COVERED SERVICES. (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.) • Bariatric surgery • Coverage provided outside the United States. • Non-Emergency care when traveling outside the U.S • Chiropractic Care See xxxx://xxxxxxxx.xxxx.xxx • If you are also covered by an account-type plan such as an integrated health flexible spending arrangement (FSA), health reimbursement arrangement (HRA), and/or a health savings account (HSA), then you may have access to additional funds to help cover certain out-of-pocket expenses – like the deductible, co-payments, or co-insurance, or benefits not otherwise covered • Private Duty Nursing If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at the number on the back of your BCBSM ID card. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 0-000-000-0000 or xxx.xxx.xxx/xxxx, or the U.S. Department of Health and Human Services at 0-000-000-0000 x00000 or xxx.xxxxx.xxx.xxx.
OTHER COVERED SERVICES. 1. Diabetic Equipment and Supplies. We will pay for the following equipment and supplies for the treatment of diabetes which are Medically Necessary and prescribed or recommended by your PCP or other Participating Provider legally authorized to prescribe under Title VIII of the New York State Education Law:
OTHER COVERED SERVICES. (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.) • Bariatric surgery • Chiropractic Care • Coverage provided outside the United States. See xxxx://xxxxxxxx.xxxx.xxx • If you are also covered by an account-type plan such as an integrated health flexible spending arrangement (FSA), health reimbursement arrangement (HRA), and/or a health savings account (HSA), then you may have access to additional funds to help cover certain out-of-pocket expenses – like the deductible, co-payments, or co-insurance, or benefits not otherwise covered • Non-Emergency care when traveling outside the U.S • Private Duty Nursing
