Covered Services. You will receive Covered Services under the terms and conditions of this Contract only when the Covered Service is: • Medically Necessary; • Provided by a Participating Provider for in-network coverage; • Listed as a Covered Service; • Not in excess of any benefit limitations described in the Schedule of Benefits section of this Contract; and • Received while Your Contract is in force.
Covered Services. Services to be performed by Contractor under this Agreement may involve the performance of trade work covered by the provisions of Section 6.22(e) [Prevailing Wages] of the Administrative Code or Section 21C [Miscellaneous Prevailing Wage Requirements] (collectively, “Covered Services”). The provisions of Section 6.22(e) and 21C of the Administrative Code are incorporated as provisions of this Agreement as if fully set forth herein and will apply to any Covered Services performed by Contractor and its subcontractors.
Covered Services. Health care services or products for which a Covered Person is enrolled with Health Plan to receive coverage under the State Contract.
Covered Services. Health care services or products for which a Covered Person is enrolled with United to receive coverage under the State Contract.
Covered Services. Benefits for medically necessary Covered Drugs are available if the drug:
Covered Services. 1. In addition to the coverage and authorization of services requirements set forth in Article II.E.4 of this Agreement, the Contractor shall:
i. Identify, define, and specify the amount, duration, and scope of each medically necessary service that the Contractor is required to offer.
ii. Require that the medically necessary services identified be furnished in an amount, duration, and scope that is no less than the amount, duration, and scope for the same services furnished to beneficiaries under fee-for-service Medicaid, as set forth in 42 CFR 440.230.
iii. Specify the extent to which the Contractor is responsible for covering medically necessary services related to the following:
a. The prevention, diagnosis, and treatment of health impairments;
b. The ability to achieve age-appropriate growth and development; and
c. The ability to attain, maintain, or regain functional capacity.
2. The Contractor shall deliver the DMC-ODS Covered Services within a continuum of care as defined in the ASAM criteria.
3. Mandatory DMC-ODS Covered Services include:
i. Withdrawal Management (minimum one level); ii. Intensive Outpatient;
Covered Services. Coverage will be provided for Members age 19 and over for one (1) routine eye examination, including dilation, if professionally indicated, each Benefit Period. A vision examination may include, but is not limited to:
A. Case history;
B. External examination of the eye and adnexa;
C. Ophthalmoscopic examination;
D. Determination of refractive status;
E. Binocular balance testing;
F. Tonometry test for glaucoma;
Covered Services. This section describes the services this plan covers. Covered service means medically necessary services (see Definitions) and specified preventive care services you get when you are covered for that benefit. This plan provides benefits for covered services only if all of the following are true when you get the services: • The reason for the service is to prevent, diagnose or treat a covered illness, disease or injury • The service takes place in a medically necessary setting. For more information about what medically necessary means, see Definitions. • The service is not excluded • The provider is working within the scope of their license or certification This plan may exclude or limit benefits for some services. See the specific benefits in this section and the Benefits for covered services are subject to the following: • Copays • Deductibles • Coinsurance • Benefit limits • Prior Authorization. Some services must be authorized in writing before you get them. These services are identified in this section. See the Prior Authorization section for more information. • Medical and payment policies. The plan has policies that are used to administer the terms of the plan. Medical policies are generally used to further define medical necessity or investigational status for a specific procedure, drugs, biologic agents, devices, level of care or services. Payment policies define provider billing and payment rules. Our policies are based on accepted clinical practice guidelines and industry standards accepted by organizations like the American Medical Association (AMA), other professional societies and the Center for Medicare and Medicaid Services (CMS). Our policies are available to you and your provider at xxxxxxx.xxx or by calling Customer Service. If you have any questions regarding your benefits and how to use them, call Customer Service at the number listed on the back cover. The services listed in this section are covered as shown on the Summary of Your Costs. Please see the summary for your copays, deductible, coinsurance, benefit limits and if out-of-network services are covered.
Covered Services. Benefits will be provided for Prescription Drugs, including but not limited to:
A. Any self-administered contraceptive drug or device, including a contraceptive drug and device on the Preventive Drug List, that is approved by the FDA for use as a contraceptive and is obtained under a prescription written by an authorized prescriber. See Section 1.5.B, Contraceptive Methods and Counseling, for additional coverage of contraceptive drugs and devices.
B. Human growth hormones. Prior authorization is required.
C. Any drug that is approved by the FDA as an aid for the cessation of the use of tobacco products and is obtained under a prescription written by an authorized prescriber, including drugs listed in the Preventive Drug List.
Covered Services are Medically Necessary health care services, supplies and drugs that a Member is entitled to receive pursuant to the Health Services Contract and/or Evidence of Coverage applicable to the Member. Except as otherwise provided in the Member’s Health Services Contract and Evidence of Coverage, Covered Services must generally be referred and authorized in conformity with Blue Shield’s utilization management programs.
