OTHER COVERED SERVICES Sample Clauses

OTHER COVERED SERVICES. Diabetic Equipment and Supplies We will pay for the following equipment and supplies for the treatment of diabetes which are Medically Necessary and prescribed or recommended by your PCP or other Participating Provider legally authorized to prescribe under Title 8 of the New York State Education Law: • Blood glucose monitors; • Blood glucose monitors for visually impaired; • Data management systems; • Test strips for monitors and visual reading; • Urine test strips; • Injection aids; • Cartridges for visually impaired; • Insulin; • Syringes; • Insulin pumps and appurtenances thereto; • Insulin infusion devices; • Oral agents; and • Additional equipment and supplies designated by the Commissioner of Health as appropriate for the treatment of diabetes.

OTHER COVERED SERVICES. (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)

OTHER COVERED SERVICES. Acupuncture Limited to 12 visits per calendar year, except for chemical dependency treatment Deductible, then 20% coinsurance Deductible, then 50% coinsurance Allergy Testing and Treatment Deductible, then 20% coinsurance Deductible, then 50% coinsurance YOUR COSTS OF THE ALLOWED AMOUNT Chemotherapy, Radiation Therapy and Kidney Dialysis Deductible, then 20% coinsurance Deductible, then 50% coinsurance Clinical Trials Covered as any other service Covered as ay other service Dental Accidents Covered as any other service Covered as any other service Dental Anesthesia When medically necessary Deductible, then 20% coinsurance Deductible, then 50% coinsurance Foot Care Routine care that is medically necessary for the treatment of diabetes Deductible, then 20% coinsurance Deductible, then 50% coinsurance Infusion Therapy Deductible, then 20% coinsurance Deductible, then 50% coinsurance Mastectomy and Breast Reconstruction Deductible, then 20% coinsurance Deductible, then 50% coinsurance Medical Foods Deductible, then 20% coinsurance Deductible, then 50% coinsurance Spinal or Other Manipulative Treatment Limited to 10 visits per calendar year Deductible, then 20% coinsurance Deductible, then 50% coinsurance Temporomandibular Joint (TMJ) Disorders • Office visits • Inpatient facility fees • Other professional services Deductible, then 20% coinsurance Deductible, then 20% coinsurance Deductible, then 20% coinsurance Deductible, then 50% coinsurance Deductible, then 50% coinsurance Deductible, then 50% coinsurance Therapeutic Injections Deductible, then 20% coinsurance Deductible, then 50% coinsurance Transplants • Office visits • Inpatient facility fees • Other professional and facility services, including donor search and harvest expenses • Travel and lodging. $5,000 limit per transplant. *All approved transplant centers covered at in-network benefit level Deductible, then 20% coinsurance Deductible, then 20% coinsurance Deductible, then 20% coinsurance Deductible, then 0% coinsurance Not covered* Not covered* Not covered* Deductible, then 0% coinsurance

OTHER COVERED SERVICES. 4.9.1 Alcohol/drug detoxification services, subject to the benefit limitations as listed in Exhibit 2 of this Agreement. Services for substance abuse and chemical dependency, when required in the treatment of a mental illness, will be provided at the same benefit level as other medical or surgical conditions.

OTHER COVERED SERVICES. 1. Federally Qualified Health Center (FQHC) Services FQHC services include physician services, services and supplies covered under SSA §1861(s)(2) (A). Services include primary health, referral for supplemental health services, health education, patient case management, including outreach, counseling, referral and follow-up services (see 42 USC §254c(a) & (b)).

OTHER COVERED SERVICES. (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Your Rights to Continue Coverage:

OTHER COVERED SERVICES. Diabetic Equipment and Supplies. We will pay for the following equipment and supplies for the treatment of diabetes which are Medically Necessary and prescribed or recommended by your PCP or other Participating Provider legally authorized to prescribe under Title VIII of the New York State Education Law:

OTHER COVERED SERVICES. Unless otherwise specified, all covered services shall be subject to the applicable Deductible, Coinsurance, Copayments and/or other payment provisions described herein.

OTHER COVERED SERVICES. Diabetic Equipment and Supplies Diabetes Self- Management Education Durable Medical Equipment Prosthetic Appliances Orthotic Devices