Common use of Inpatient Services Clause in Contracts

Inpatient Services.  Hospital services which are not performed in a hospital.  Medical services of the donor that are not directly related to the organ transplant.  Services related to obtaining, storing, or other services performed for the potential future use of umbilical cord blood.  Noncadaveric small bowel transplants.  Services related to donor searches.  Donor related medical and surgical expenses when the recipient is not covered as a  Services or supplies related to an excluded transplant procedure.  Preimplantation genetic diagnosis, also known as embryo screening.  Amniocentesis or any other service when performed solely to determine gender.  Biological products for allergen immunotherapy and vaccinations.  Blood fractions.  Compound prescription drugs that are not made up of at least one legend drug.  Bulk powders and chemicals used in compound prescriptions that are not FDA approved, are not covered unless listed on our formulary.  Prescription drugs prescribed or dispensed outside of our dispensing guidelines.  Prescription drugs that have not proven effective according to the FDA.  Prescription drugs used for cosmetic purposes.  Prescription drugs purchased from a non-designated pharmacy, if a pharmacy has been designated for you through the Pharmacy Home Assignment program.  Experimental prescription drugs including those placed on notice of opportunity hearing status by the Federal Drug Efficacy Study Implementation (DESI).  Prescription drugs provided to you that are not dispensed by a network pharmacy or covered under your medical plan.  Prescription drugs and diabetic equipment and supplies purchased at a non-network pharmacy unless indicated as covered in the Summary of Pharmacy Benefits.  Prescription drug related medical supplies except for diabetic, regardless of the reason prescribed, the intended use, or medical necessity. Examples include, but are not limited to, alcohol pads, bandages, wraps or pill holders.  Off-label use of prescription drugs except as described in Experimental or Investigational Services in Section 3;  Prescribed weight-loss drugs.  Replacement of prescription drugs resulting from a lost, stolen, broken or destroyed prescription order or refill.  Therapeutic devices and appliances, including hypodermic needles and syringes except when used to administer insulin.  Prescription drugs, therapeutic equivalents, or any other pharmaceuticals used to treat sexual dysfunctions.  Vitamins, unless specifically listed as a covered healthcare service.  A prescription drug refill greater than the refill number authorized by your physician, more than a year from the date of the original prescription, or limited by law.  Long acting opioids and other controlled substances, nicotine replacement therapy, and specialty prescription drugs when purchased from a mail order pharmacy.  Prescription drugs and specialty prescription drugs when the required prescription drug preauthorization is not obtained.  Certain prescription drugs that have an over-the-counter (OTC) equivalent.  Prescriptions filled through an internet pharmacy that is not a verified internet pharmacy practice site certified by the National Association of Boards of Pharmacy.  Illegal drugs, including medical marijuana, which are dispensed in violation of state and/or federal law.  Services of a nurse's aide.  Services of a private duty nurse: o when the primary duties are limited to bathing, feeding, exercising, homemaking, giving oral medications or acting as companion or sitter; o after the caregiver or patient have demonstrated the ability to carry out the plan of care; o provided outside the home. Examples include at school, or in a nursing or assisted living facility; o that are duplication or overlap of services. Examples include when a person is receiving hospice care services or for the same hours of a skilled nursing home care visit; o that are for observation only; and o provided as part-time/intermittent and not continuous care.  Maintenance care when the condition has stabilized including routine ostomy care or tube feeding administration or if the anticipated need is indefinite.  Twenty-four (24) hour private duty nursing care for a person without an available caregiver in the home.  Respite care (e.g., care during a caregiver vacation) or private duty nursing so that the caregiver may attend work or school.  Abdominoplasty.  Brow ptosis surgery.  Cervicoplasty.  Chemical exfoliations, peels, abrasions, dermabrasions, or planing for acne, scarring, wrinkling, sun damage or other benign conditions.  Correction of variations in normal anatomy including augmentation mammoplasty, mastopexy, and correction of congenital breast asymmetry.  Dermabrasion.  Ear piercing or repair of a torn earlobe.  Excision of excess skin or subcutaneous tissue except for panniculectomy.  Genioplasty.  Hair transplants.  Hair removal including electrolysis epilation.  Inverted nipple surgery.  Laser treatment for acne and acne scars.  Osteoplasty - facial bone reduction.  Otoplasty.  Procedures to correct visual acuity including but not limited to cornea surgery or lens implants.  Removal of asymptomatic benign skin lesions.  Repeated cauterizations or electrofulguration methods used to remove growths on the skin.  Rhinoplasty.  Rhytidectomy.  Scar revision, regardless of symptoms.  Sclerotherapy for spider veins.  Skin tag removal.  Subcutaneous injection of filling material.  Suction assisted Lipectomy.  Tattooing or tattoo removal except tattooing of the nipple/areola related to a mastectomy.  Testicular prosthesis surgery.  Treatment of vitiligo.  Standby services of an assistant surgeon or anesthesiologist.  Orthodontic services related to orthognathic surgery.  Cosmetic procedures when performed primarily: o to refine or reshape body structures or dental structures that are not functionally impaired; o to improve appearance or self-esteem; or o for other psychological, psychiatric or emotional reasons.  Drugs, biological products, hospital charges, pathology, radiology fees and charges for surgeons, assistant surgeons, attending physicians and any other incidental services, which are related to cosmetic surgery.  Medically necessary surgery performed at the same time as a cosmetic procedure.

Inpatient Services.  Hospital services which are not performed in a hospital.  Medical services of the donor that are not directly related to the organ transplant.  Services related to obtaining, storing, or other services performed for the potential future use of umbilical cord blood.  Noncadaveric Non-cadaveric small bowel transplants.  Services related to donor searches.  Donor related medical and surgical expenses when the recipient is not covered as a  Services or supplies related to an excluded transplant procedure.  Preimplantation genetic diagnosis, also known as embryo screening.  Amniocentesis or any other service when performed solely to determine gender.  Biological products for allergen immunotherapy and vaccinations.  Blood fractions.  Compound prescription drugs that are not made up of at least one legend drug.  Bulk powders and chemicals used in compound prescriptions that are not FDA approved, are not covered unless listed on our formulary.  Prescription drugs prescribed or dispensed outside of our dispensing guidelines.  Prescription drugs ordered or prescribed based solely on online questionnaires, telephonic interviews, surveys, emails, or any other marketing solicitation methods, whether alone or in combination.  Prescription drugs that have not proven effective according to the FDA.  Prescription drugs used for cosmetic purposes.  Prescription drugs purchased from a non-designated pharmacy, if a pharmacy has been designated for you through the Pharmacy Home Assignment program.  Experimental prescription drugs including those placed on notice of opportunity hearing status by the Federal Drug Efficacy Study Implementation (DESI).  Prescription drugs provided to you that are not dispensed by a network pharmacy or covered under your medical plan.  Prescription drugs and diabetic equipment and supplies purchased at a non-network pharmacy unless indicated as covered in the Summary of Pharmacy Benefits.  Prescription drug related medical supplies except for diabetic, regardless of the reason prescribed, the intended use, or medical necessity. Examples include, but are not limited to, alcohol pads, bandages, wraps or pill holders.  Off-label use of prescription drugs except as described in Experimental or Investigational Services in Section 3;  Prescribed weight-loss drugs.  Replacement of prescription drugs resulting from a lost, stolen, broken or destroyed prescription order or refill.  Therapeutic devices and appliances, including hypodermic needles and syringes except when used to administer insulin.  Prescription drugs, therapeutic equivalents, or any other pharmaceuticals used to treat sexual dysfunctions.  Vitamins, unless specifically listed as a covered healthcare service.  A prescription drug refill greater than the refill number authorized by your physician, more than a year from the date of the original prescription, or limited by law.  Long acting opioids and other controlled substances, nicotine replacement therapy, and specialty prescription drugs when purchased from a mail order pharmacy.  Prescription drugs and specialty prescription drugs when the required prescription drug preauthorization is not obtained.  Certain prescription drugs that have an over-the-counter (OTC) equivalent.  Prescriptions filled through an internet pharmacy that is not a verified internet pharmacy practice site certified by the National Association of Boards of Pharmacy.  Illegal drugs, including medical marijuana, which are dispensed in violation of state and/or federal law.  Services of a nurse's aide.  Services of a private duty nurse: o when the primary duties are limited to bathing, feeding, exercising, homemaking, giving oral medications or acting as companion or sitter; o after the caregiver or patient have demonstrated the ability to carry out the plan of care; o provided outside the home. Examples include at school, or in a nursing or assisted living facility; o that are duplication or overlap of services. Examples include when a person is receiving hospice care services or for the same hours of a skilled nursing home care visit; o that are for observation only; and o provided as part-time/intermittent and not continuous care.  Maintenance care when the condition has stabilized including routine ostomy care or tube feeding administration or if the anticipated need is indefinite.  Twenty-four (24) hour private duty nursing care for a person without an available caregiver in the home.  Respite care (e.g., care during a caregiver vacation) or private duty nursing so that the caregiver may attend work or school.  Abdominoplasty.  Brow ptosis surgery.  Cervicoplasty.  Chemical exfoliations, peels, abrasions, dermabrasions, or planing for acne, scarring, wrinkling, sun damage or other benign conditions.  Correction of variations in normal anatomy including augmentation mammoplasty, mastopexy, and correction of congenital breast asymmetry.  Dermabrasion.  Ear piercing or repair of a torn earlobe.  Excision of excess skin or subcutaneous tissue except for panniculectomy.  Genioplasty.  Hair transplants.  Hair removal including electrolysis epilation.  Inverted nipple surgery.  Laser treatment for acne and acne scars.  Osteoplasty - facial bone reduction.  Otoplasty.  Procedures to correct visual acuity including but not limited to cornea surgery or lens implants.  Removal of asymptomatic benign skin lesions.  Repeated cauterizations or electrofulguration methods used to remove growths on the skin.  Rhinoplasty.  Rhytidectomy.  Scar revision, regardless of symptoms.  Sclerotherapy for spider veins.  Skin tag removal.  Subcutaneous injection of filling material.  Suction assisted Lipectomy.  Tattooing or tattoo removal except tattooing of the nipple/areola related to a mastectomy.  Testicular prosthesis surgery.  Treatment of vitiligo.  Standby services of an assistant surgeon or anesthesiologist.  Orthodontic services related to orthognathic surgery.  Cosmetic procedures when performed primarily: o to refine or reshape body structures or dental structures that are not functionally impaired; o to improve appearance or self-esteem; or o for other psychological, psychiatric or emotional reasons.  Drugs, biological products, hospital charges, pathology, radiology fees and charges for surgeons, assistant surgeons, attending physicians and any other incidental services, which are related to cosmetic surgery.  Medically necessary surgery performed at the same time as a cosmetic procedure.

Inpatient Services.  Hospital services which are not performed in a hospital.  Medical services of the donor that are not directly related to the organ transplant.  Services related to obtaining, storing, or other services performed for the potential future use of umbilical cord blood.  Noncadaveric small bowel transplants.  Services related to donor searches.  Donor related medical and surgical expenses when the recipient is not covered as a  Services or supplies related to an excluded transplant procedure.  Preimplantation genetic diagnosis, also known as embryo screening.  Amniocentesis or any other service when performed solely to determine gender.  Biological products for allergen immunotherapy and vaccinations.  Blood fractions.  Compound prescription drugs that are not made up of at least one legend drug.  Bulk powders and chemicals used in compound prescriptions that are not FDA approved, are not covered unless listed on our formulary.  Prescription drugs prescribed or dispensed outside of our dispensing guidelines.  Prescription drugs that have not proven effective according to the FDA.  Prescription drugs used for cosmetic purposes.  Prescription drugs purchased from a non-designated pharmacy, if a pharmacy has been designated for you through the Pharmacy Home Assignment program.  Experimental prescription drugs including those placed on notice of opportunity hearing status by the Federal Drug Efficacy Study Implementation (DESI).  Prescription drugs provided to you that are not dispensed by a network pharmacy or covered under your medical plan.  Prescription drugs and diabetic equipment and supplies purchased at a non-network pharmacy unless indicated as covered in the Summary of Pharmacy Benefits.  Prescription drug related medical supplies except for diabetic, regardless of the reason prescribed, the intended use, or medical necessity. Examples include, but are not limited to, alcohol pads, bandages, wraps or pill holders.  Off-label use of prescription drugs except as described in Experimental or Investigational Services in Section 3;  Prescribed weight-loss drugs.  Replacement of prescription drugs resulting from a lost, stolen, broken or destroyed prescription order or refill.  Therapeutic devices and appliances, including hypodermic needles and syringes except when used to administer insulin.  Prescription drugs, therapeutic equivalents, or any other pharmaceuticals used to treat sexual dysfunctions.  Vitamins, unless specifically listed as a covered healthcare service.  A prescription drug refill greater than the refill number authorized by your physician, more than a year from the date of the original prescription, or limited by law.  Long acting opioids and other controlled substances, nicotine replacement therapy, and specialty prescription drugs when purchased from a mail order pharmacy.  Prescription drugs and specialty prescription drugs when the required prescription drug preauthorization is not obtained.  Certain prescription drugs that have an over-the-counter (OTC) equivalent.  Prescriptions filled through an internet pharmacy that is not a verified internet pharmacy practice site certified by the National Association of Boards of Pharmacy.  Illegal drugs, including medical marijuana, which are dispensed in violation of state and/or federal law.  Services of a nurse's aide.  Services of a private duty nurse: o when the primary duties are limited to bathing, feeding, exercising, homemaking, giving oral medications or acting as companion or sitter; o after the caregiver or patient have demonstrated the ability to carry out the plan of care; o provided outside the home. Examples include at school, or in a nursing or assisted living facility; o that are duplication or overlap of services. Examples include when a person is receiving hospice care services or for the same hours of a skilled nursing home care visit; o that are for observation only; and o provided as part-time/intermittent and not continuous care.  Maintenance care when the condition has stabilized including routine ostomy care or tube feeding administration or if the anticipated need is indefinite.  Twenty-four (24) hour private duty nursing care for a person without an available caregiver in the home.  Respite care (e.g., care during a caregiver vacation) or private duty nursing so that the caregiver may attend work or school.  Abdominoplasty.  Brow ptosis surgery.  Cervicoplasty.  Chemical exfoliations, peels, abrasions, dermabrasions, or planing for acne, scarring, wrinkling, sun damage or other benign conditions.  Correction of variations in normal anatomy including augmentation mammoplasty, mastopexy, and correction of congenital breast asymmetry.  Dermabrasion.  Ear piercing or repair of a torn earlobe.  Excision of excess skin or subcutaneous tissue except for panniculectomy.  Genioplasty.  Hair transplants.  Hair removal including electrolysis epilation.  Inverted nipple surgery.  Laser treatment for acne and acne scars.  Osteoplasty - facial bone reduction.  Otoplasty.  Procedures to correct visual acuity including but not limited to cornea surgery or lens implants.  Removal of asymptomatic benign skin lesions.  Repeated cauterizations or electrofulguration methods used to remove growths on the skin.  Rhinoplasty.  Rhytidectomy.  Scar revision, regardless of symptoms.  Sclerotherapy for spider veins.  Skin tag removal.  Subcutaneous injection of filling material.  Suction assisted Lipectomy.  Tattooing or tattoo removal except tattooing of the nipple/areola related to a mastectomy.  Testicular prosthesis surgery.  Treatment of vitiligo.  Standby services of an assistant surgeon or anesthesiologist.  Orthodontic services related to orthognathic surgery.  Cosmetic procedures when performed primarily: o to refine or reshape body structures or dental structures that are not functionally impaired; o to improve appearance or self-esteem; or o for other psychological, psychiatric or emotional reasons.  Drugs, biological products, hospital charges, pathology, radiology fees and charges for surgeons, assistant surgeons, attending physicians and any other incidental services, which are related to cosmetic surgery.  Medically necessary surgery performed at the same time as a cosmetic procedure.