Common use of List of Benefits Clause in Contracts

List of Benefits. The following benefits are covered by the Health Plan. Benefits are listed alphabetically for your convenience. Some benefits are subject to benefit-specific limitations and/or exclusions, which are listed, when applicable, directly below each benefit. A broader list of exclusions that apply to all benefits, regardless of whether they are Medically Necessary, is provided under Exclusions in this section. Accidental Dental Injury Services We cover restorative Services necessary to promptly repair, but not replace, sound natural teeth that have been injured as the result of an external force. Coverage is provided when all of the following conditions have been met: 1. The accident has been reported to your primary care Plan Physician within seventy-two (72) hours of the accident. 2. A Plan Provider provides the restorative dental Services; 3. The injury occurred as the result of an external force that is defined as violent contact with an external object; not force incurred while chewing; 4. The injury was sustained to sound natural teeth; 5. The covered Services must be requested within sixty (60) days of the injury; and 6. The covered Services are provided during the twelve (12) consecutive month period commencing from the date that treatment for the injury occurred. Coverage under this benefit is provided for the most cost-effective procedure available that, in the opinion of the Plan Provider, would produce the most satisfactory result. For the purposes of this benefit, sound natural teeth are defined as a tooth or teeth that have not been: 1. Weakened by existing dental pathology such as decay or periodontal disease, or 2. Previously restored by a crown, inlay, onlay, porcelain restoration, or treatment by endodontics. See the benefit-specific exclusions immediately below for additional information. Benefit-Specific Exclusions: 1. Services provided by non-Plan Providers. 2. Services provided after twelve (12) months from the date the injury occurred. 3. Services for teeth that have been avulsed (knocked out) or that have been so severely damaged that, in the opinion of the Plan Provider, restoration is impossible. Allergy Services We cover the following allergy Services: 1. Evaluations and treatment; and 2. Injections and serum. Ambulance Services We cover licensed ambulance Services only if your medical condition requires: 1. The basic life support, advanced life support, or critical care life support capabilities of an ambulance for inter-facility or home transfer; or 2. The ambulance transportation has been ordered by a Plan Provider. Coverage is also provided for Medically Necessary transportation or Services including Medically Necessary air ambulance transport to the nearest hospital able to provide needed Services, rendered as the result of a 911 call. Your Cost Share will apply to each encounter, whether or not transport was required. Ambulance transportation from an emergency room to a Plan Facility or from a hospital to a Plan Facility that is both Medically Necessary and ordered by a Plan Provider is covered at no charge. We also cover medically appropriate ambulette (non-emergent transportation) Services provided by select transport carriers when ordered by a Plan Provider at no charge. We cover licensed ambulance and ambulette (non-emergent transportation) Services ordered by a Plan Provider only inside our Service Area, except as covered under Emergency Services. See the benefit-specific exclusions immediately below for additional information.

List of Benefits. The following benefits are covered by the Health Plan. Benefits are listed alphabetically for your convenience. Some benefits are subject to benefit-specific limitations and/or exclusions, which are listed, when applicable, directly below each benefit. A broader list of exclusions that apply to all benefits, regardless of whether they are Medically Necessary, is provided under Exclusions in this section. Accidental Dental Injury Services We cover restorative Services necessary Medically Necessary dental services to promptly repair, but not replacetreat injuries to the jaw, sound natural teeth that have been injured teeth, mouth or face as the a result of an external forceaccident. Dental appliances required to diagnose or treat an accidental injury to the teeth, and the repair of dental appliances damaged as a result of accidental injury to the jaw, mouth or face, are also covered. Coverage is provided when all of the following conditions have been metsatisfied: 1. The accident has been reported to your primary care Primary Care Plan Physician within seventy-two (72) hours of the accident. ; 2. A Plan Provider provides the restorative dental Services; 3. The injury occurred as the result of an external force that is defined as violent contact with an external object; , not force incurred while chewing; 4. The injury was sustained to sound natural teeth; 5. The covered Services must be requested within sixty (60) days of the injury; and 6. The covered Services are provided during the twelve (12) consecutive month period commencing from the date that treatment for the injury occurred. Coverage under this benefit is provided for the most cost-effective procedure available that, in the opinion of the Plan Provider, would produce the most satisfactory result. For the purposes of this benefit, sound natural teeth are defined as a tooth or teeth that have not beenthat: 1. Weakened Have not been weakened by existing dental pathology such as decay or periodontal disease, ; or 2. Previously Have not been previously restored by a crown, inlay, onlay, porcelain restoration, restoration or treatment by endodontics. Note: An injury that results from chewing or biting is not considered an Accidental Injury under this Plan. See the benefit-specific exclusions exclusion(s) immediately below for additional information. Benefit-Specific Exclusions: Exclusion(s): 1. Services provided by non-Plan Providers. 2. Services provided after twelve (12) months from the date the injury occurred. 3. Services for teeth that have been avulsed (knocked out) or that have been so severely damaged that, that in the opinion of the Plan Provider, restoration is impossible. Allergy Services We cover the following allergy Services: 1. Evaluations and treatment; and 2. Injections Injection Visits and serum. Ambulance Services We cover licensed ambulance Services only if your medical condition requires: 1. The basic life support, advanced life support, or critical care life support capabilities of an ambulance for inter-facility or home transfer; or and 2. The ambulance transportation has been ordered by a Plan Provider. Coverage is also provided for Medically Necessary transportation or Services Services, including Medically Necessary air ambulance transport to the nearest hospital able to provide needed Services, rendered as the result of a 911 call. Your Cost Share will apply to each encounter, whether or not transport was required. Ambulance transportation from an emergency room to a Plan Facility or from a hospital to a Plan Facility that is both Medically Necessary and ordered by a Plan Provider is covered at no charge. We also cover medically appropriate ambulette (nonCoverage for Air Ambulance Services, as defined in the section Important Terms You Should Know, when Services are received from a Non-emergent transportation) Services provided by select transport carriers when ordered by a Plan Participating Provider at no charge. We cover licensed ambulance and ambulette (non-emergent transportation) Services ordered by a Plan Provider only inside our Service Area, except as covered under Emergency of Air Ambulance Services. See the benefit-specific exclusions immediately below for additional information.: