Related Exclusion. This agreement does NOT cover ground ambulance transportation to a physician’s office. Air and Water Ambulance Medically necessary air and water ambulance services are covered as listed in the Summary of Medical Benefits. Medically necessary air and water ambulance services are covered up to the maximum benefit limit as shown in the Summary of Medical Benefits. When you receive services from a network provider, you are responsible to pay the copayment, and the difference between our allowance and the maximum benefit limit. You are responsible to pay up to the total charge when a non- network provider renders air or water ambulance services. Air ambulance service means transportation by a helicopter or fixed wing plane. The aircraft must be a certified ambulance. The crew, maintenance support crew, and aircraft must meet the certification requirements and hold a certificate for air ambulance operators under Part 135 of the Federal Aviation Administration (FAA) regulations. Water ambulance means transportation by a boat. The boat must be specially designed and equipped for transporting the sick or injured. It must also have such other safety and lifesaving equipment per state or local regulation. Use of an air or water ambulance is medically necessary when the time needed to move a patient by land, or the instability of transportation by land, may threaten a patient’s condition or survival. It is also medically necessary if the proper equipment needed to treat the patient is not available on a ground ambulance. The patient must be transported for treatment to the nearest facility that can provide a level of care for the patient’s illness. It must have available the type of physician or physician specialist needed to treat the patient’s condition. We will only cover air and water ambulance services originating and ending in the United States and its territories. Our allowance for the air or water ambulance includes the services rendered by an emergency medical technician or paramedic, drugs, supplies and cardiac monitoring.
Related Exclusion. Vision care services covered under other plans are not considered an allowable expense for purposes of coordination of benefits. See Section 6.0 - How We Coordinate Your Benefits When You Are Covered By More Than One Plan for further information.
Related Exclusion. This agreement does NOT cover ground ambulance transportation to a physician’s office. Air and Water Ambulance Medically necessary air and water ambulance services are covered up to the maximum benefit limit and the level of coverage shown in the Summary of Medical Benefits. When you receive services from a network provider you are responsible to pay the copayment, and the difference between our allowance and the maximum benefit limit. You are responsible to pay up to the total charge when a non-network provider renders air or water ambulance services. Air ambulance service means transportation by a helicopter or fixed wing plane. The aircraft must be a certified ambulance. The crew, maintenance support crew and aircraft must meet the certification requirements and hold a certificate for air ambulance operators under Part 135 of the Federal Aviation Administration (FAA) regulations. Water ambulance means transportation by a boat. The boat must be specially designed and equipped for transporting the sick or injured. It must also have such other safety and lifesaving equipment per state or local regulation. Use of an air or water ambulance is medically necessary when the time needed to move a patient by land, or the instability of transportation by land, may threaten a patient’s condition or survival. It is also medically necessary if the proper equipment needed to treat the patient is not available on a ground ambulance. The patient must be transported for treatment to the nearest facility that can provide a level of care for the patient’s illness. It must have available the type of physician or physician specialist needed to treat the patient’s condition. We will only cover air and water ambulance services originating and ending in the United States and its territories. Our allowance for the air or water ambulance includes the services rendered by an emergency medical technician or paramedic, drugs, supplies and cardiac monitoring.
Related Exclusion. This agreement does not cover: • vision hardware for a member aged nineteen (19) and older; • vision hardware purchased from a non-network provider; and • non-collection vision hardware. Vision care services covered under other plans are not considered an allowable expense for purposes of coordination of benefits. See Section 6.0 - How We Coordinate Your Benefits When You Are Covered By More Than One Plan for further information.
