Common use of COVERED HEALTH CARE SERVICES Clause in Contracts

COVERED HEALTH CARE SERVICES. We agree to provide coverage for medically necessary covered health care services listed in this agreement. If a service or category of service is not specifically listed as covered, it is not covered under this agreement. Only services that we have reviewed and determined are eligible for coverage under this agreement are covered. All other services are not covered. See Section 1.4 for how we identify new services and our guidelines for reviewing and making coverage determinations. We only cover a service listed in this agreement if it is medically necessary. We review medical necessity in accordance with our medical policies and related guidelines. The term medically necessary is defined in Section 8.0 - Glossary. It does not include all medically appropriate services. The amount of coverage we provide for each health care service differs according to whether or not the service is received:  as an inpatient;  as an outpatient ;  in your home;  in a doctor’s office; or  from a pharmacy. Also coverage differs depending on whether:  the health care provider is a network provider or non-network provider;  deductibles (if any), copayments, or maximum benefit apply;  you have reached your plan year maximum out-of-pocket expense;  there are any exclusions from coverage that apply; or  our allowance for a covered health care service is less than the amount of your copayment and deductible (if any). In this case, you will be responsible to pay up to our allowance when services are rendered by a network provider. Please see the Summary of Medical Benefits to determine the benefit limits and amount that you pay for the covered health care services listed below. Please see the Summary of Pharmacy Benefits to determine the benefit limits and amount that you pay for prescription drug and diabetic equipment and supplies purchased at a pharmacy.

COVERED HEALTH CARE SERVICES. We agree to provide coverage for medically necessary covered health care services listed in this agreement. If a service or category of service is not specifically listed as covered, it is not covered under this agreement. Only services that we have reviewed and determined are eligible for coverage under this agreement are covered. All other services are not covered. See Section 1.4 for how we identify new services and our guidelines for reviewing and making coverage determinations. We only cover a service listed in this agreement if it is medically necessary. We review medical necessity in accordance with our medical policies and related guidelines. The term medically necessary is defined in Section 8.0 - Glossary. It does not include all medically appropriate services. The amount of coverage we provide for each health care service differs according to whether or not the service is received:  • as an inpatient;  • as an outpatient outpatient;  • in your home;  • in a doctor’s office; or  • from a pharmacy. Also coverage differs depending on whether:  • the health care provider is a network provider or non-network provider;  • deductibles (if any), copayments, or maximum benefit apply;  • you have reached your plan year maximum out-of-pocket expense;  • there are any exclusions from coverage that apply; or  • our allowance for a covered health care service is less than the amount of your copayment and deductible (if any). In this case, you will be responsible to pay up to our allowance when services are rendered by a network provider. Please see the Summary of Medical Benefits to determine the benefit limits and amount that you pay for the covered health care services listed below. Please see the Summary of Pharmacy Benefits to determine the benefit limits and amount that you pay for prescription drug and diabetic equipment and supplies purchased at a pharmacy.

COVERED HEALTH CARE SERVICES. We agree to provide coverage for medically necessary covered health care services listed in this agreement. If a service or category of service is not specifically listed as covered, it is not covered under this agreement. Only services that we have reviewed and determined are eligible for coverage under this agreement are covered. All other services are not covered. See Section 1.4 for how we identify new services and our guidelines for reviewing and making coverage determinations. We only cover a service listed in this agreement if it is medically necessary. We review medical necessity in accordance with our medical policies and related guidelines. The term medically necessary is defined in Section 8.0 - Glossary. It does not include all medically appropriate services. The amount of coverage we provide for each health care service differs according to whether or not the service is received:  • as an inpatient;  • as an outpatient ;  • in your home;  • in a doctor’s office; or  • from a pharmacy. Also coverage differs depending on whether:  • the health care provider is a network provider or non-network provider;  • deductibles (if any), copayments, or maximum benefit apply;  • you have reached your plan benefit year maximum out-of-pocket expense;  • there are any exclusions from coverage that apply; or  • our allowance for a covered health care service is less than the amount of your copayment and deductible (if any). In this case, you will be responsible to pay up to our allowance when services are rendered by a network provider. Please see the Summary of Medical Benefits to determine the benefit limits and amount that you pay for the covered health care services listed below. Please see the Summary of Pharmacy Benefits to determine the benefit limits and amount that you pay for prescription drug and diabetic equipment and supplies purchased at a pharmacy.

COVERED HEALTH CARE SERVICES. We agree to provide coverage for medically necessary covered health care services listed in this agreement. If a service or category of service is not specifically listed as covered, it is not covered under this agreement. Only services that we have reviewed and determined are eligible for coverage under this agreement are covered. All other services are not covered. See Section 1.4 for how we identify new services and our guidelines for reviewing and making coverage determinations. We only cover a service listed in this agreement if it is medically necessary. We review medical necessity in accordance with our medical policies and related guidelines. The term medically necessary is defined in Section 8.0 - Glossary. It does not include all medically appropriate services. The amount of coverage we provide for each health care service differs according to whether or not the service is received:  • as an inpatienthospital;  • as an outpatient outpatient;  • in your home;  • in a doctor’s office; or  • from a pharmacy. Also coverage differs depending on whether:  • the health care provider is a network provider or non-network provider;  deductibles (if any)• deductibles, copayments, or maximum benefit apply;  • you have reached your plan year maximum out-of-pocket expense;  • there are any exclusions from coverage that apply; or  • our allowance for a covered health care service is less than the amount of your copayment and deductible (if any). In this case, you will be responsible to pay up to our allowance when services are rendered by a network provider. Please see the Summary of Medical Benefits to determine the benefit limits and amount that you pay for the covered health care services listed below. Please see the Summary of Pharmacy Benefits to determine the benefit limits and amount that you pay for prescription drug and diabetic equipment and supplies purchased at a pharmacy.

COVERED HEALTH CARE SERVICES. We agree to provide coverage for medically necessary covered health care services listed in this agreement. If a service or category of service is not specifically listed as covered, it is not covered under this agreement. Only services that we have reviewed and determined are eligible for coverage under this agreement are covered. All other services are not covered. See Section 1.4 for how we identify new services and our guidelines for reviewing and making coverage determinations. We only cover a service listed in this agreement if it is medically necessary. We review medical necessity in accordance with our medical policies and related guidelines. The term medically necessary is defined in Section 8.0 - Glossary. It does not include all medically appropriate services. The amount of coverage we provide for each health care service differs according to whether or not the service is received:  as an inpatient;  as an outpatient outpatient;  in your home;  in a doctor’s office; or  from a pharmacy. Also coverage differs depending on whether:  the health care provider is a network provider or non-network provider;  deductibles (if any)deductibles, copayments, or maximum benefit apply;  you have reached your plan calendar year maximum out-of-pocket expense;  there are any exclusions from coverage that apply; or  our allowance for a covered health care service is less than the amount of your copayment and deductible (if any). In this case, you will be responsible to pay up to our allowance when services are rendered by a network provider. Please see the Summary of Medical Benefits to determine the benefit limits and amount that you pay for the covered health care services listed below. Please see the Summary of Pharmacy Benefits to determine the benefit limits and amount that you pay for prescription drug and diabetic equipment and supplies purchased at a pharmacy.

COVERED HEALTH CARE SERVICES. We agree to provide coverage for medically necessary covered health care services listed in this agreement. If a service or category of service is not specifically listed as covered, it is not covered under this agreement. Only services that we have reviewed and determined are eligible for coverage under this agreement are covered. All other services are not covered. See Section 1.4 for how we identify new services and our guidelines for reviewing and making coverage determinations. We only cover a service listed in this agreement if it is medically necessary. We review medical necessity in accordance with our medical policies and related guidelines. The term medically necessary is defined in Section 8.0 - Glossary. It does not include all medically appropriate services. The amount of coverage we provide for each health care service differs according to whether or not the service is received:  • as an inpatient;  • as an outpatient outpatient;  • in your home;  • in a doctor’s office; or  • from a pharmacy. Also coverage differs depending on whether:  • the health care provider is a network provider or non-network provider;  • deductibles (if any), copayments, or maximum benefit apply;  • you have reached your plan benefit year maximum out-of-pocket expense;  • there are any exclusions from coverage that apply; or  • our allowance for a covered health care service is less than the amount of your copayment and deductible (if any). In this case, you will be responsible to pay up to our allowance when services are rendered by a network provider. Please see the Summary of Medical Benefits to determine the benefit limits and amount that you pay for the covered health care services listed below. Please see the Summary of Pharmacy Benefits to determine the benefit limits and amount that you pay for prescription drug and diabetic equipment and supplies purchased at a pharmacy.

COVERED HEALTH CARE SERVICES. We agree to provide coverage for medically necessary covered health care services listed in this agreement. If a service or category of service is not specifically listed as covered, it is not covered under this agreement. Only services that we have reviewed and determined are eligible for coverage under this agreement are covered. All other services are not covered. See Section 1.4 for how we identify new services and our guidelines for reviewing and making coverage determinations. We only cover a service listed in this agreement if it is medically necessary. We review medical necessity in accordance with our medical policies and related guidelines. The term medically necessary is defined in Section 8.0 - Glossary. It does not include all medically appropriate services. The amount of coverage we provide for each health care service differs according to whether or not the service is received:  • as an inpatient;  • as an outpatient outpatient;  • in your home;  • in a doctor’s office; or  • from a pharmacy. Also coverage differs depending on whether:  • the health care provider is a network provider or non-network provider;  deductibles (if any)• deductibles, copayments, or maximum benefit apply;  • you have reached your plan calendar year maximum out-of-pocket expense;  • there are any exclusions from coverage that apply; or  • our allowance for a covered health care service is less than the amount of your copayment and deductible (if any). In this case, you will be responsible to pay up to our allowance when services are rendered by a network provider. Please see the Summary of Medical Benefits to determine the benefit limits and amount that you pay for the covered health care services listed below. Please see the Summary of Pharmacy Benefits to determine the benefit limits and amount that you pay for prescription drug and diabetic equipment and supplies purchased at a pharmacy.

COVERED HEALTH CARE SERVICES. We agree to provide coverage for medically necessary covered health care services listed in this agreement. If a service or category of service is not specifically listed as covered, it is not covered under this agreement. Only services that we have reviewed and determined are eligible for coverage under this agreement are covered. All other services are not covered. See Section 1.4 for how we identify new services and our guidelines for reviewing and making coverage determinations. We only cover a service listed in this agreement if it is medically necessary. We review medical necessity in accordance with our medical policies and related guidelines. The term medically necessary is defined in Section 8.0 - Glossary. It does not include all medically appropriate services. The amount of coverage we provide for each health care service differs according to whether or not the service is received:  • as an inpatient;  • as an outpatient ;  • in your home;  • in a doctor’s office; or  • from a pharmacy. Also coverage differs depending on whether:  • the health care provider is a network provider or non-network provider;  • deductibles (if any), copayments, or maximum benefit apply;  • you have reached your plan benefit year maximum out-of-pocket expense;  • there are any exclusions from coverage that apply; or  • our allowance for a covered health care service is less than the amount of your copayment and deductible (if any). In this case, you will be responsible to pay up to our allowance when services are rendered by a network provider. Please see the Summary of Medical Benefits to determine the benefit limits and amount that you pay for the covered health care services listed below. Please see the Summary of Pharmacy Benefits to determine the benefit limits and amount that you pay for prescription drug and diabetic equipment and supplies purchased at a pharmacy.

COVERED HEALTH CARE SERVICES. We agree to provide coverage for medically necessary covered health care services listed in this agreement. If a service or category of service is not specifically listed as covered, it is not covered under this agreement. Only services that we have reviewed and determined are eligible for coverage under this agreement are covered. All other services are not covered. See Section 1.4 for how we identify new services and our guidelines for reviewing and making coverage determinations. We only cover a service listed in this agreement if it is medically necessary. We review medical necessity in accordance with our medical policies and related guidelines. The term medically necessary is defined in Section 8.0 - Glossary. It does not include all medically appropriate services. The amount of coverage we provide for each health care service differs according to whether or not the service is received:  • as an inpatienthospital;  • as an outpatient outpatient;  • in your home;  • in a doctor’s office; or  • from a pharmacy. Also coverage differs depending on whether:  • the health care provider is a network provider or non-network provider;  deductibles (if any)• deductibles, copayments, or maximum benefit apply;  • you have reached your plan benefit year maximum out-of-pocket expense;  • there are any exclusions from coverage that apply; or  • our allowance for a covered health care service is less than the amount of your copayment and deductible (if any). In this case, you will be responsible to pay up to our allowance when services are rendered by a network provider. Please see the Summary of Medical Benefits to determine the benefit limits and amount that you pay for the covered health care services listed below. Please see the Summary of Pharmacy Benefits to determine the benefit limits and amount that you pay for prescription drug and diabetic equipment and supplies purchased at a pharmacy.

COVERED HEALTH CARE SERVICES. We agree to provide coverage for medically necessary covered health care services listed in this agreement. If a service or category of service is not specifically listed as covered, it is not covered under this agreement. Only services that we have reviewed and determined are eligible for coverage under this agreement are covered. All other services are not covered. See Section 1.4 1.2 for how we identify new services and our guidelines for reviewing and making coverage determinations. We only cover a service listed in this agreement if it is medically necessary. We review medical necessity in accordance with our medical policies and related guidelines. The term medically necessary is defined in Section 8.0 - Glossary. It does not include all medically appropriate services. The amount of coverage we provide for each health care service differs according to whether or not the service is received:  • as an inpatient;  • as an outpatient outpatient;  • in your home;  • in a doctor’s office; or  • from a pharmacy. Also coverage differs depending on whether:  • the health care provider is a network provider or non-network provider;  deductibles (if any)• deductibles, copayments, or maximum benefit apply;  • you have reached your plan calendar year maximum out-of-pocket expense;  • there are any exclusions from coverage that apply; or  • our allowance for a covered health care service is less than the amount of your copayment and deductible (if any). In this case, you will be responsible to pay up to our allowance when services are rendered by a network provider. Please see the Summary of Medical Benefits to determine the benefit limits and amount that you pay for the covered health care services listed below. Please see the Summary of Pharmacy Benefits to determine the benefit limits and amount that you pay for prescription drug and diabetic equipment and supplies purchased at a pharmacy.

COVERED HEALTH CARE SERVICES. We agree to provide coverage for medically necessary covered health care services listed in this agreement. If a service or category of service is not specifically listed as covered, it is not covered under this agreement. Only services that we have reviewed and determined are eligible for coverage under this agreement are covered. All other services are not covered. See Section 1.4 for how we identify new services and our guidelines for reviewing and making coverage determinations. We only cover a service listed in this agreement if it is medically necessary. We review medical necessity in accordance with our medical policies and related guidelines. The term medically necessary is defined in Section 8.0 - Glossary. It does not include all medically appropriate services. The amount of coverage we provide for each health care service differs according to whether or not the service is received:  as an inpatient;  as an outpatient outpatient;  in your home;  in a doctor’s office; or  from a pharmacy. Also coverage differs depending on whether:  the health care provider is a network provider or non-network provider;  deductibles (if any), copayments, or maximum benefit apply;  you have reached your plan benefit year maximum out-of-pocket expense;  there are any exclusions from coverage that apply; or  our allowance for a covered health care service is less than the amount of your copayment and deductible (if any). In this case, you will be responsible to pay up to our allowance when services are rendered by a network provider. Please see the Summary of Medical Benefits to determine the benefit limits and amount that you pay for the covered health care services listed below. Please see the Summary of Pharmacy Benefits to determine the benefit limits and amount that you pay for prescription drug and diabetic equipment and supplies purchased at a pharmacy.

COVERED HEALTH CARE SERVICES. We agree to provide coverage for medically necessary covered health care services listed in this agreement. If a service or category of service is not specifically listed as covered, it is not covered under this agreement. Only services that we have reviewed and determined are eligible for coverage under this agreement are covered. All other services are not covered. See Section 1.4 for how we identify new services and our guidelines for reviewing and making coverage determinations. We only cover a service listed in this agreement if it is medically necessary. We review medical necessity in accordance with our medical policies and related guidelines. The term medically necessary is defined in Section 8.0 - Glossary. It does not include all medically appropriate services. The amount of coverage we provide for each health care service differs according to whether or not the service is received:  • as an inpatient;  • as an outpatient outpatient;  • in your home;  • in a doctor’s office; or  • from a pharmacy. Also coverage differs depending on whether:  • the health care provider is a network provider or non-network provider;  deductibles (if any)• deductibles, copayments, or maximum benefit apply;  • you have reached your plan year maximum out-of-pocket expense;  • there are any exclusions from coverage that apply; or  • our allowance for a covered health care service is less than the amount of your copayment and deductible (if any). In this case, you will be responsible to pay up to our allowance when services are rendered by a network provider. Please see the Summary of Medical Benefits to determine the benefit limits and amount that you pay for the covered health care services listed below. Please see the Summary of Pharmacy Benefits to determine the benefit limits and amount that you pay for prescription drug and diabetic equipment and supplies purchased at a pharmacy.

COVERED HEALTH CARE SERVICES. We agree to provide coverage for medically necessary covered health care services listed in this agreement. If a service or category of service is not specifically listed as covered, it is not covered under this agreement. Only services that we have reviewed and determined are eligible for coverage under this agreement are covered. All other services are not covered. See Section 1.4 for how we identify new services and our guidelines for reviewing and making coverage determinations. We only cover a service listed in this agreement if it is medically necessary. We review medical necessity in accordance with our medical policies and related guidelines. The term medically necessary is defined in Section 8.0 - Glossary. It does not include all medically appropriate services. The amount of coverage we provide for each health care service differs according to whether or not the service is received:  as an inpatient;  as an outpatient outpatient;  in your home;  in a doctor’s office; or  from a pharmacy. Also coverage differs depending on whether:  the health care provider is a network provider or non-network provider;  deductibles (if any)deductibles, copayments, or maximum benefit apply;  you have reached your plan year maximum out-of-pocket expense;  there are any exclusions from coverage that apply; or  our allowance for a covered health care service is less than the amount of your copayment and deductible (if any). In this case, you will be responsible to pay up to our allowance when services are rendered by a network provider. Please see the Summary of Medical Benefits to determine the benefit limits and amount that you pay for the covered health care services listed below. Please see the Summary of Pharmacy Benefits to determine the benefit limits and amount that you pay for prescription drug and diabetic equipment and supplies purchased at a pharmacy.

COVERED HEALTH CARE SERVICES. We agree to provide coverage for medically necessary covered health care services listed in this agreement. If a service or category of service is not specifically listed as covered, it is not covered under this agreement. Only services that we have reviewed and determined are eligible for coverage under this agreement are covered. All other services are not covered. See Section 1.4 for how we identify new services and our guidelines for reviewing and making coverage determinations. We only cover a service listed in this agreement if it is medically necessary. We review medical necessity in accordance with our medical policies and related guidelines. The term medically necessary is defined in Section 8.0 - Glossary. It does not include all medically appropriate services. The amount of coverage we provide for each health care service differs according to whether or not the service is received:  • as an inpatient;  • as an outpatient outpatient;  • in your home;  • in a doctor’s office; or  • from a pharmacy. Also coverage differs depending on whether:  • the health care provider is a network provider or non-network provider;  • deductibles (if any), copayments, or maximum benefit apply;  • you have reached your plan year maximum out-of-pocket expense;  • there are any exclusions from coverage that apply; or  • our allowance for a covered health care service is less than the amount of your copayment and deductible (if any). In this case, you will be responsible to pay up to our allowance when services are rendered by a network provider. Please see the Summary of Medical Benefits to determine the benefit limits and amount that you pay for the covered health care services listed below. Please see the Summary of Pharmacy Benefits to determine the benefit limits and amount that you pay for prescription drug and diabetic equipment and supplies purchased at a pharmacy.

COVERED HEALTH CARE SERVICES. We agree to provide coverage for medically necessary covered health care services listed in this agreement. If a service or category of service is not specifically listed as covered, it is not covered under this agreement. Only services that we have reviewed and determined are eligible for coverage under this agreement are covered. All other services are not covered. See Section 1.4 1.2 for how we identify new services and our guidelines for reviewing and making coverage determinations. We only cover a service listed in this agreement if it is medically necessary. We review medical necessity in accordance with our medical policies and related guidelines. The term medically necessary is defined in Section 8.0 - Glossary. It does not include all medically appropriate services. The amount of coverage we provide for each health care service differs according to whether or not the service is received:  • as an inpatient;  • as an outpatient outpatient;  • in your home;  • in a doctor’s office; or  • from a pharmacy. Also coverage differs depending on whether:  • the health care provider is a network provider or non-network provider;  deductibles (if any)• deductibles, copayments, or maximum benefit apply;  • you have reached your plan calendar year maximum out-of-pocket expense;  • there are any exclusions from coverage that apply; or  • our allowance for a covered health care service is less than the amount of your copayment and deductible (if any). In this case, you will be responsible to pay up to our allowance when services are rendered by a network provider. Please see the Summary of Medical Benefits at the front of this agreement to determine the benefit limits and amount that you pay level of coverage we provide for the covered health care services listed below. Please see the Summary of Pharmacy Benefits to determine the benefit limits and amount that you pay for prescription drug and diabetic equipment and supplies purchased at a pharmacyin this agreement.

COVERED HEALTH CARE SERVICES. We agree to provide coverage for medically necessary covered health care services listed in this agreement. If a service or category of service is not specifically listed as covered, it is not covered under this agreement. Only services that we have reviewed and determined are eligible for coverage under this agreement are covered. All other services are not covered. See Section 1.4 1.2 for how we identify new services and our guidelines for reviewing and making coverage determinations. We only cover a service listed in this agreement if it is medically necessary. We review medical necessity in accordance with our medical policies and related guidelines. The term medically necessary is defined in Section 8.0 - Glossary. It does not include all medically appropriate services. The amount of coverage we provide for each health care service differs according to whether or not the service is received:  : (a) as an inpatient;  ; (b) as an outpatient ;  outpatient; (c) in your home;  or (d) in a doctor’s office; or  office or (e) from a pharmacy. Also coverage differs depending on whether:  whether or not: (a) the health care provider is a network provider or non-network provider;  deductibles ; (if any)b) deductibles, copayments, or and/or maximum benefit apply;  ; (c) you have reached your plan calendar year maximum out-of-pocket expense;  ; (d) there are any applicable exclusions from coverage that applycoverage; or  or (e) our allowance for a covered health care service is less than the amount of your copayment and deductible (if any)and/or deductible. In this case, you will be responsible to pay up to our allowance when services are rendered by a network provider. Please see the Summary of Medical Benefits at the front of this agreement to determine the benefit limits and amount that you pay of coverage we provide for the covered health care services listed below. Please see the Summary of Pharmacy Benefits to determine the benefit limits and amount that you pay for prescription drug and diabetic equipment and supplies purchased at a pharmacyunder this agreement.

COVERED HEALTH CARE SERVICES. We agree to provide coverage for medically necessary covered health care services listed in this agreement. If a service or category of service is not specifically listed as covered, it is not covered under this agreement. Only services that we have reviewed and determined are eligible for coverage under this agreement are covered. All other services are not covered. See Section 1.4 for how we identify new services and our guidelines for reviewing and making coverage determinations. We only cover a service listed in this agreement if it is medically necessary. We review medical necessity in accordance with our medical policies and related guidelines. The term medically necessary is defined in Section 8.0 - Glossary. It does not include all medically appropriate services. The amount of coverage we provide for each health care service differs according to whether or not the service is received:  • as an inpatient;  • as an outpatient outpatient;  • in your home;  • in a doctor’s office; or  • from a pharmacy. Also coverage differs depending on whether:  • the health care provider is a network provider or non-network provider;  • deductibles (if any), copayments, or maximum benefit apply;  • you have reached your plan benefit year maximum out-of-pocket expense;  • there are any exclusions from coverage that apply; or  • our allowance for a covered health care service is less than the amount of your copayment and deductible (if any). In this case, you will be responsible to pay up to our allowance when services are rendered by a network provider. Please see the Summary of Medical Benefits to determine the benefit limits and amount that you pay for the covered health care services listed below. Please see the Summary of Pharmacy Benefits to determine the benefit limits and amount that you pay for prescription drug and diabetic equipment and supplies purchased at a pharmacy.

COVERED HEALTH CARE SERVICES. We agree to provide coverage for medically necessary covered health care services listed in this agreement. If a service or category of service is not specifically listed as covered, it is not covered under this agreement. Only services that we have reviewed and determined are eligible for coverage under this agreement are covered. All other services are not covered. See Section 1.4 for how we identify new services and our guidelines for reviewing and making coverage determinations. We only cover a service listed in this agreement if it is medically necessary. We review medical necessity in accordance with our medical policies and related guidelines. The term medically necessary is defined in Section 8.0 - Glossary. It does not include all medically appropriate services. The amount of coverage we provide for each health care service differs according to whether or not the service is received:  as an inpatient;  as an outpatient ;  in your home;  in a doctor’s office; or  from a pharmacy. Also coverage differs depending on whether:  the health care provider is a network provider or non-network provider;  deductibles (if any), copayments, or maximum benefit apply;  you have reached your plan benefit year maximum out-of-pocket expense;  there are any exclusions from coverage that apply; or  our allowance for a covered health care service is less than the amount of your copayment and deductible (if any). In this case, you will be responsible to pay up to our allowance when services are rendered by a network provider. Please see the Summary of Medical Benefits to determine the benefit limits and amount that you pay for the covered health care services listed below. Please see the Summary of Pharmacy Benefits to determine the benefit limits and amount that you pay for prescription drug and diabetic equipment and supplies purchased at a pharmacy.

COVERED HEALTH CARE SERVICES. We agree to provide coverage for medically necessary covered health care services listed in this agreement. If a service or category of service is not specifically listed as covered, it is not covered under this agreement. Only services that we have reviewed and determined are eligible for coverage under this agreement are covered. All other services are not covered. See Section 1.4 for how we identify new services and our guidelines for reviewing and making coverage determinations. We only cover a service listed in this agreement if it is medically necessary. We review medical necessity in accordance with our medical policies and related guidelines. The term medically necessary is defined in Section 8.0 - Glossary. It does not include all medically appropriate services. The amount of coverage we provide for each health care service differs according to whether or not the service is received:  • as an inpatient;  • as an outpatient outpatient;  • in your home;  • in a doctor’s office; or  • from a pharmacy. Also coverage differs depending on whether:  • the health care provider is a network provider or non-network provider;  • deductibles (if any), copayments, or maximum benefit apply;  • you have reached your plan year maximum out-of-pocket expense;  • there are any exclusions from coverage that apply; or  • our allowance for a covered health care service is less than the amount of your copayment and deductible (if any). In this case, you will be responsible to pay up to our allowance when services are rendered by a network provider. Please see the Summary of Medical Benefits to determine the benefit limits and amount that you pay for the covered health care services listed below. Please see the Summary of Pharmacy Benefits to determine the benefit limits and amount that you pay for prescription drug and diabetic equipment and supplies purchased at a pharmacy.

COVERED HEALTH CARE SERVICES. We agree to provide coverage for medically necessary covered health care services listed in this agreement. If a service or category of service is not specifically listed as covered, it is not covered under this agreement. Only services that we have reviewed and determined are eligible for coverage under this agreement are covered. All other services are not covered. See Section 1.4 1.2 for how we identify new services and our guidelines for reviewing and making coverage determinations. We only cover a service listed in this agreement if it is medically necessary. We review medical necessity in accordance with our medical policies and related guidelines. The term medically necessary is defined in Section 8.0 - Glossary. It does not include all medically appropriate services. The amount of coverage we provide for each health care service differs according to whether or not the service is received:  as an inpatient;  as an outpatient outpatient;  in your home;  in a doctor’s office; or  from a pharmacy. Also coverage differs depending on whether:  the health care provider is a network provider or non-network provider;  deductibles (if any)deductibles, copayments, or maximum benefit apply;  you have reached your plan calendar year maximum out-of-pocket expense;  there are any exclusions from coverage that apply; or  our allowance for a covered health care service is less than the amount of your copayment and deductible (if any). In this case, you will be responsible to pay up to our allowance when services are rendered by a network provider. Please see the Summary of Medical Benefits to determine the benefit limits and amount that you pay for the covered health care services listed below. Please see the Summary of Pharmacy Benefits to determine the benefit limits and amount that you pay for prescription drug and diabetic equipment and supplies purchased at a pharmacy.

COVERED HEALTH CARE SERVICES. We agree to provide coverage for medically necessary covered health care services listed in this agreement. If a service or category of service is not specifically listed as covered, it is not covered under this agreement. Only services that we have reviewed and determined are eligible for coverage under this agreement are covered. All other services are not covered. See Section 1.4 for how we identify new services and our guidelines for reviewing and making coverage determinations. We only cover a service listed in this agreement if it is medically necessary. We review medical necessity in accordance with our medical policies and related guidelines. The term medically necessary is defined in Section 8.0 - Glossary. It does not include all medically appropriate services. The amount of coverage we provide for each health care service differs according to whether or not the service is received:  as an inpatient;  as an outpatient ;  in your home;  in a doctor’s office; or  from a pharmacy. Also coverage differs depending on whether:  the health care provider is a network provider or non-network provider;  deductibles (if any), copayments, or maximum benefit apply;  you have reached your plan benefit year maximum out-of-pocket expense;  there are any exclusions from coverage that apply; or  our allowance for a covered health care service is less than the amount of your copayment and deductible (if any). In this case, you will be responsible to pay up to our allowance when services are rendered by a network provider. Please see the Summary of Medical Benefits to determine the benefit limits and amount that you pay for the covered health care services listed below. Please see the Summary of Pharmacy Benefits to determine the benefit limits and amount that you pay for prescription drug and diabetic equipment and supplies purchased at a pharmacy.

COVERED HEALTH CARE SERVICES. We agree to provide coverage for medically necessary covered health care services listed in this agreement. If a service or category of service is not specifically listed as covered, it is not covered under this agreement. Only services that we have reviewed and determined are eligible for coverage under this agreement are covered. All other services are not covered. See Section 1.4 1.2 for how we identify new services and our guidelines for reviewing and making coverage determinations. We only cover a service listed in this agreement if it is medically necessary. We review medical necessity in accordance with our medical policies and related guidelines. The term medically necessary is defined in Section 8.0 - Glossary. It does not include all medically appropriate services. The amount of coverage we provide for each health care service differs according to whether or not the service is received:  • as an inpatient;  • as an outpatient outpatient;  • in your home;  • in a doctor’s office; or  • from a pharmacy. Also coverage differs depending on whether:  • the health care provider is a network provider or non-network provider;  deductibles (if any)• deductibles, copayments, or maximum benefit apply;  • you have reached your plan calendar year maximum out-of-pocket expense;  • there are any exclusions from coverage that apply; or  • our allowance for a covered health care service is less than the amount of your copayment and deductible (if any). In this case, you will be responsible to pay up to our allowance when services are rendered by a network provider. Please see the Summary of Medical Benefits at the front of this agreement to determine the benefit limits and amount that you pay for the covered health care services listed below. Please see the Summary of Pharmacy Benefits to determine the benefit limits and amount that you pay for prescription drug and diabetic equipment and supplies purchased at a pharmacy.