Medical Benefits and Exclusions. Subject to the terms, conditions, definitions and exclusions specified in this Agreement and subject to the payment by Members of the applicable Cost-Sharing Amounts, if any, Members shall be entitled to receive the coverage for the Benefits listed below. Services will be covered by Keystone: a) only if they are Medically Necessary; and b) only if they are appropriately referred or preauthorized (as applicable) by Keystone and/or its designee; and c) only if the Member is actively enrolled at the time of the service. This Agreement provides all Essential Health Benefits, as that term is defined by PPACA. It is important to refer to the Summary of Cost Sharing and Benefits to determine the amounts Members are responsible for paying to Providers, to determine whether any benefit limitations/maximums apply to this coverage. Certain services require Preauthorization by Keystone or its designee. Please consult the Preauthorization Program attachment to determine which services require Preauthorization.
Medical Benefits and Exclusions
