Orthodontic Services limitations a. Orthodontic services are payable for Eligible Persons under age 19.
Orthodontic Services limitations Sample Clauses
Related to Orthodontic Services limitations
Cosmetic Services We do not Cover cosmetic services or surgery unless otherwise specified, except that cosmetic surgery shall not include reconstructive surgery when such service is incidental to or follows surgery resulting from trauma, infection or diseases of the involved part, and reconstructive surgery because of congenital disease or anomaly of a covered Child which has resulted in a functional defect , except for cosmetic orthodontics as described in the Dental Care sections of this Contract. Cosmetic surgery does not include surgery determined to be Medically Necessary. If a claim for a procedure listed in 11 NYCRR 56 (e.g., certain plastic surgery and dermatology procedures) is submitted retrospectively and without medical information, any denial will not be subject to the Utilization Review process in the Utilization Review and External Appeal sections of this Contract unless medical information is submitted.
Infertility Services This plan covers the following services, in accordance with R.I. General Law §27-20-20. • Services for the diagnosis and treatment of infertility if you are:
Diagnostic Services Procedures ordered by a recognized Provider because of specific symptoms to diagnose a specific condition or disease. Some examples include, but are not limited to:
Chiropractic Services This plan covers chiropractic visits up to the benefit limit shown in the Summary of Medical Benefits. The benefit limit applies to any visit for the purposes of chiropractic treatment or diagnosis.
Pharmacy Services The Contractor shall establish a network of pharmacies. The Contractor or its PBM must provide at least two (2) pharmacy providers within thirty (30) miles or thirty (30) minutes from a member’s residence in each county, as well as at least two (2) durable medical equipment providers in each county or contiguous county.
Pharmacy Benefits - Prescription Drugs and Diabetic Equipment or Supplies from a Pharmacy This plan covers prescription drugs listed on our formulary and diabetic equipment or supplies bought from a pharmacy as a pharmacy benefit. These benefits are administered by our Pharmacy Benefit Manager (PBM). Our formulary includes a tiered copayment structure and indicates that certain prescription drugs require preauthorization. If a prescription drug is not on our formulary, it is not covered. For specific coverage information or a copy of the most current formulary, please visit our website or call our Customer Service Department. Prescription drugs and diabetic equipment or supplies are covered when dispensed using the following guidelines: • the prescription must be medically necessary, consistent with the physician’s diagnosis, ordered by a physician whose license allows him or her to order it, filled at a pharmacy whose license allows such a prescription to be filled, and filled according to state and federal laws; • the prescription must consist of legend drugs that require a physician’s prescription under law, or compound medications made up of at least one legend drug requiring a physician’s prescription under law; • the prescription must be dispensed at the proper place of service as determined by our Pharmacy and Therapeutics Committee. For example, certain prescription drugs may only be covered when obtained from a specialty pharmacy; and • the prescription is limited to the quantities authorized by your physician not to exceed the quantity listed in the Summary of Pharmacy Benefits. Prescription drugs are subject to the benefit limits and the amount you pay shown in the Summary of Pharmacy Benefits.
LIMITATIONS OF COVERED MEDICAL SERVICES In order to be covered, the Member’s Attending Physician must specifically prescribe such services and such services must be consequent to treatment of the cleft lip or cleft palate.
Mastectomy Services Inpatient This plan provides coverage for a minimum of forty-eight (48) hours in a hospital following a mastectomy and a minimum of twenty-four (24) hours in a hospital following an axillary node dissection. Any decision to shorten these minimum coverages shall be made by the attending physician in consultation with and upon agreement with you. If you participate in an early discharge, defined as inpatient care following a mastectomy that is less than forty-eight (48) hours and inpatient care following an axillary node dissection that is less than twenty-four (24) hours, coverage shall include a minimum of one (1) home visit conducted by a physician or registered nurse.
Routing for Operator Services and Directory Assistance Traffic For a Verizon Telecommunications Service dial tone line purchased by MLTC for resale pursuant to the Resale Attachment, upon request by MLTC, Verizon will establish an arrangement that will permit MLTC to route the MLTC Customer’s calls for operator and directory assistance services to a provider of operator and directory assistance services selected by MLTC. Verizon will provide this routing arrangement in accordance with, but only to the extent required by, Applicable Law. Verizon will provide this routing arrangement pursuant to an appropriate written request submitted by MLTC and a mutually agreed-upon schedule. This routing arrangement will be implemented at MLTC's expense, with charges determined on an individual case basis. In addition to charges for initially establishing the routing arrangement, MLTC will be responsible for ongoing monthly and/or usage charges for the routing arrangement. MLTC shall arrange, at its own expense, the trunking and other facilities required to transport traffic to MLTC’s selected provider of operator and directory assistance services.
PREGNANCY LEAVE BENEFITS Common Central Provisions a) The Employer shall provide for permanent and long-term occasional teachers and teachers hired into a term position who access such leaves, a SEB plan to top up their E.I.
