Bone Mass Measurement and Osteoporosis. Benefits will be provided for bone mass measurement and the diagnosis and treatment of osteoporosis. Experimental/Investigational Treatment — Benefits will be provided for routine patient care in conjunction with Experimental/Investigational treatments when medically appropriate and you have cancer or a terminal condition that according to the diagnosis of your Physician is considered life threatening, if a) you are a qualified individual participating in an Approved Clinical Trial program; and b) if those services or supplies would otherwise be covered under this Certificate if not provided in connection with an Approved Clinical Trial program. You and your Physician are encouraged to call customer service at the toll‐free number on the back of your identification card in advance to obtain information about whether a particular clinical trial is qualified. Approved Clinical Trials — Benefits for Covered Services for Routine Patient Costs are provided in connection with a phase I, phase II, phase III, or phase IV clinical trial or other Life Threatening Disease or Condition and is recognized under state and/or federal law. HIV Screening and Counseling — Benefits will be provided for HIV screening and counseling and pre‐natal HIV testing ordered by your Primary Care Physician or Woman's Principal Health Care Provider, including but not limited to orders consistent with the recommendations of the American College of Obstetricians and Gynecologists or the American Academy of Pediatrics. Unless otherwise stated, benefits will be provided as described in the Preventive Care Services provision of this section of your Certificate. Infertility Treatment — Benefits will be provided for Covered Services rendered in connection with the diagnosis and/or treatment of Infertility including, but not limited to, in vitro fertilization, uterine embryo lavage, embryo transfer, artificial insemination, gamete intrafallopian tube transfer, zygote intrafallopian tube transfer, low tubal ovum transfer and intracytoplasmic sperm injection. Infertility means a disease, condition, or status characterized by 1) the inability to conceive a child or to carry a pregnancy to live birth after one year of regular unprotected sexual intercourse for a woman 35 years of age or younger, or after 6 months for a woman over 35 years of age (conceiving but having a miscarriage does not restart the 12 month or 6-month term for determining Infertility), 2) a person’s inability to reproduce either ...
Bone Mass Measurement and Osteoporosis. Benefits will be provided for bone mass measurement and the diagnosis and treatment of osteoporosis. Please refer to the SPECIAL CONDITIONS section of this Policy for benefits for Preventive Services. BENEFIT PAYMENT FOR OUTPATIENT HOSPITAL COVERED SERVICES After you have met your Deductible benefits will be provided as described below: Participating Provider When you receive Outpatient Hospital Covered Services from a Participating Provider, benefits will be provided at the Hospital payment level for Participating Providers shown on the Schedule Page. Non- Participating Provider When you receive Outpatient Hospital Covered Services from a Non- Participating Provider, benefits will be pro- vided at the Hospital payment level for Non- Participating Providers shown on the Schedule Page. Non- Plan Provider When you receive Outpatient Hospital Covered Services from a Non- Plan Provider, benefits will be provided at 50% of the Eligible Charge.
Bone Mass Measurement and Osteoporosis. Benefits will be provided for bone mass measurement and the diagnosis and treatment of osteoporosis. Chiropractic and Osteopathic Manipulations Benefits will be provided for manipulation or adjustment of osseous or articular structures, commonly referred to as chiropractic and osteopathic manipulation, when performed by a person licensed to perform such proce- dures. Your benefits for chiropractic and osteopathic manipulation will be limited to the maximum stated in your Policy. Durable Medical Equipment Benefits will be provided for such things as internal cardiac valves, internal pacemakers, mandibular reconstruc- tion devices (not used primarily to support dental prosthesis), bone screws, bolts, nails, plates and any other inter- nal and permanent devices. Benefits will also be provided for the rental (but not to exceed the total cost of equip- ment) or purchase of durable medical equipment required for temporary therapeutic use provided that this equipment is primarily and customarily used to serve a medical purpose. Amino Acid-Based Elemental Formulas Benefits will be provided for amino acid-based elemental formulas for the diagnosis and treatment of eosinophilic disorders or short-bowel syndrome, when the prescribing Physician has issued a written order stating that the amino acid-based elemental formula is medically necessary. If you purchase the formula at a Pharmacy, benefits will be provided at the benefit payment level for Other Covered Services described in the OTHER COVERED SERVICES section of this Policy. Occupational Therapy Benefits will be provided for Occupational Therapy when these services are rendered by a registered Occupation- al Therapist under the supervision of a Physician. This therapy must be furnished under a written plan established by a Physician and regularly reviewed by the therapist and Physician. The plan must be established before treat- ment is begun and must relate to the type, amount, frequency and duration of therapy and indicate the diagnosis and anticipated goals. Benefits for Outpatient Occupational Therapy will be limited to a maximum of 45 visits per calendar year. Physical Therapy Benefits will be provided for Physical Therapy when rendered by a registered professional Physical Therapist under the supervision of a Physician. The therapy must be furnished under a written plan established by a Physi- cian and regularly reviewed by the therapist and the Physician. The plan must be established before treatment is b...
