Surgery Services and Mastectomy Related Treatment This plan provides benefits for mastectomy surgery and mastectomy-related services in accordance with the Women’s Health and Cancer Rights Act of 1998 and Rhode Island General Law 27-20-29 et seq. For the member receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician, physician assistant, or an advance practice registered nurse and the patient, for: • all stages of reconstruction of the breast on which the mastectomy was performed; • surgery and reconstruction of the other breast to produce a symmetrical appearance; • prostheses; and • treatment of physical complications at all stages of the mastectomy, including lymphedema. See the Summary of Medical Benefits for the amount you pay.
Treatment Program Testing The Employer may request or require an employee to undergo drug and alcohol testing if the employee has been referred by the employer for chemical dependency treatment or evaluation or is participating in a chemical dependency treatment program under an employee benefit plan, in which case the employee may be requested or required to undergo drug or alcohol testing without prior notice during the evaluation or treatment period and for a period of up to two years following completion of any prescribed chemical dependency treatment program.
Infrastructure Vulnerability Scanning Supplier will scan its internal environments (e.g., servers, network devices, etc.) related to Deliverables monthly and external environments related to Deliverables weekly. Supplier will have a defined process to address any findings but will ensure that any high-risk vulnerabilities are addressed within 30 days.
Statewide HUB Program Statewide Procurement Division Note: In order for State agencies and institutions of higher education (universities) to be credited for utilizing this business as a HUB, they must award payment under the Certificate/VID Number identified above. Agencies, universities and prime contractors are encouraged to verify the company’s HUB certification prior to issuing a notice of award by accessing the Internet (xxxxx://xxxxx.xxx.xxxxx.xx.xx/tpasscmblsearch/index.jsp) or by contacting the HUB Program at 000-000-0000 or toll-free in Texas at 0-000-000-0000.
Prosthodontics We Cover prosthodontic services as follows: • Removable complete or partial dentures, for Members 15 years of age and above, including six (6) months follow-up care; • Additional services including insertion of identification slips, repairs, relines and rebases and treatment of cleft palate; and • Interim prosthesis for Members five (5) to 15 years of age. We do not Cover implants or implant related services. Fixed bridges are not Covered unless they are required: • For replacement of a single upper anterior (central/lateral incisor or cuspid) in a patient with an otherwise full complement of natural, functional and/or restored teeth; • For cleft palate stabilization; or • Due to the presence of any neurologic or physiologic condition that would preclude the placement of a removable prosthesis, as demonstrated by medical documentation.
Specialty Prescription Drugs (+ Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+): For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Tier 5: $125 Not Covered When purchased at a Retail Pharmacy (+): For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Specialty Prescription Drugs purchasedat a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% Not Covered Tier 2: 20% Not Covered Tier 3: 20% Not Covered Tier 4: 20% Not Covered When purchased at a Specialty Pharmacy (+) Tier 5: 20% Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% Not Covered Contraceptive Methods- Preventive Coverage includes barrier method (diaphragmor cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered
Consent to Transportation and Medical Treatment I consent to the use of first aid treatment and the use of generic and over-the-counter medications and treatments as directed by manufacturer labels, whether administered by the Released Parties or first aid personnel. In an emergency, I understand the Released Parties may try to contact the individual listed below as an emergency contact. If an emergency contact cannot be reached promptly, I hereby authorize the Released Parties to act as an agent for me to consent to any examination, testing, x-rays, medical, dental or surgical treatment for me as advised by a physician, dentist or other health care provider. This includes, but is not limited to, my assessment, evaluation, medical care and treatment, anesthesia, hospitalization, or other health care treatment or procedure as advised by a physician, dentist or other health care provider. I also authorize the Released Parties to arrange for transportation of me as deemed necessary and appropriate in their discretion. I, the Volunteer, do hereby release, forever discharge and hold harmless the Released Parties from any liability, claim, demand, and action whatsoever brought by me or on my behalf which arises or may hereafter arise on account of any transportation, first aid, assessment, care, treatment, response or service rendered in connection with my Activities with any of the Released Parties. If the Volunteer is less than 18 years of age, the parent(s) having legal custody and/or the legal guardian(s) of the Volunteer also hereby release, forever discharge and hold harmless the Released Parties from any liability, claim, demand and action whatsoever brought by such volunteer or on his/her behalf which arises or may hereafter arise on account of the decision by any representative or agent of the Released Parties to exercise the power to transport, administer first aid, and consent to assessment, examination, x-rays, medical, dental, surgical or other such health care treatment as set forth in the Parental Authorization for Treatment of, and Travel With, a Minor Child.
Outpatient Dental Anesthesia Services This plan covers anesthesia services received in connection with a dental service when provided in a hospital or freestanding ambulatory surgical center and: • the use of this is medically necessary; and • the setting in which the service is received is determined to be appropriate. This plan also covers facility fees associated with these services.
STATEWIDE CONTRACT MANAGEMENT SYSTEM If the maximum amount payable to Contractor under this Contract is $100,000 or greater, either on the Effective Date or at any time thereafter, this section shall apply. Contractor agrees to be governed by and comply with the provisions of §§00-000-000, 00-000-000, 00-000-000, and 00- 000-000, C.R.S. regarding the monitoring of vendor performance and the reporting of contract information in the State’s contract management system (“Contract Management System” or “CMS”). Contractor’s performance shall be subject to evaluation and review in accordance with the terms and conditions of this Contract, Colorado statutes governing CMS, and State Fiscal Rules and State Controller policies.
NATIONAL TREATMENT AND MARKET ACCESS FOR GOODS Article 201: Scope and Coverage Except as otherwise provided in this Agreement, this Chapter applies to trade in goods of a Party.
