OTHER COVERED SERVICES. The services listed in this section are covered as shown on the Summary of Your Costs.
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. 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. 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. 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. 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. Diabetic Equipment and Supplies Diabetes Self- Management Education Durable Medical Equipment Prosthetic Appliances Orthotic Devices
OTHER COVERED SERVICES. Free Trial Program • Opt-In Program (business reply cards processing of patients who have agreed to receive further correspondence from Orphan) • InSights Newsletters • Patient Surveys • Voucher Program • Relabeling of Xyrem bottles • Xyrem pallet shipments • Any other services as mutually agreed upon by the parties by completing and executing an Additional Services Request Form. [ * ] = CERTAIN CONFIDENTIAL INFORMATION CONTAINED IN THIS DOCUMENT, MARKED BY BRACKETS, HAS BEEN OMITTED AND FILED SEPARATELY WITH THE SECURITIES AND EXCHANGE COMMISSION PURSUANT TO RULE 406 OF THE SECURITIES ACT OF 1933, AS AMENDED. Base Business Non-PAP Administrative Fee* [ * ] Supplemental Business Non-PAP Administrative Fee** [ * ] PAP Administrative Fee [ * ] PAP Order Dispensing Fee [ * ] Custom and ad hoc reports [ * ] Enrollment Fee*** [ * ] Shipment Fee**** [ * ] Faxes or e-mails to Orphan’s sales force [ * ] Re-verification of Patient insurance benefits under Free Trial Program [ * ] Obtaining new prescription under Free Trial Program [ * ] Production of offer letters under Free Trial Program [ * ] Processing of Patient Business Reply Cards for opting-in to Patient correspondence from Orphan [ * ] Processing and mailing of “inSIGHTS” Patient newsletters for new patients [ * ] Processing and mailing of “inSIGHTS” Patient newsletters for pending/approved Patients [ * ] Patient surveys [ * ] Bottle re-labelling of [ * ]***** [ * ] Bottle re-labelling of [ * ] [ * ] Shipment of Xyrem pallets [ * ] Preparation of Reimbursement letters to Patients (sent via Fed Ex) [ * ] Preparation of Pharmacy letters to Patients (sent via Fed Ex) [ * ] Orphan shall reimburse SDS for all [ * ], on a pass-through basis, meaning that Orphan shall reimburse SDS for the actual amount billed to SDS by its [ * ]. If the [ * ] cost is related to an SDS error (e.g., [ * ]), Orphan will not be responsible for [ * ] related to such errors. Orphan shall pay SDS for any Additional Services as mutually agreed upon in an Additional Services Request Form executed by both parties. *Payable on first [ * ] bottles of Product shipped by SDS per calendar year on Non-PAP Orders [ * ] = CERTAIN CONFIDENTIAL INFORMATION CONTAINED IN THIS DOCUMENT, MARKED BY BRACKETS, HAS BEEN OMITTED AND FILED SEPARATELY WITH THE SECURITIES AND EXCHANGE COMMISSION PURSUANT TO RULE 406 OF THE SECURITIES ACT OF 1933, AS AMENDED. **Payable on bottles of Product shipped by SDS per calendar year on Non-PAP Orders in excess of [ * ] bo...
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. Tooth whitening, Adult orthodontia, Implants, veneers, and Adult services noted as Not Covered on the Dental Schedule and Limitations Table in the EOC are not covered services. This plan is compliant with requirements of the pediatric dental EHB benchmark plan, including coverage of services in circumstances of Medical Necessity as defined in the Early Periodic Screening, Diagnosis and Treatment (EPSDT) benefit. Plans may be modified to ensure compliance with State and Federal requirements. Your interest in the Blue Shield Family Dental HMO Plan is appreciated. Blue Shield has been serving Californians for over 75 years, and we look forward to serving your dental care needs. The Blue Shield Family Dental HMO Plan offers you a dental Plan with a wide choice of Plan Dental Providers. All Covered Services will be provided by or arranged through your Dental Center. You will have the opportunity to be an active participant in your own dental care. Blue Shield of California Family Dental HMO Plan will help you make a personal commitment to main- taining and, where possible, improving your dental health sta- tus. Like you, we believe that maintaining a healthy lifestyle and preventing dental illness are as important as caring for your needs when dental problems arise. Please review this booklet which summarizes the coverage and general provisions of the Blue Shield Family Dental HMO Plan. Blue Shield’s dental plans are administered by a Dental Plan Administrator (DPA), which is an entity that contracts with Blue Shield to administer the delivery of dental services through a network of Participating Dentists. A DPA also con- tracts with Blue Shield to serve as a claims administrator for the processing of claims for services received from Non-Par- ticipating Dentists. This plan has separate Benefits for Pediatric Members and Adult Members. Pediatric dental Benefits are available for Members through the end of the month in which the Member turns 19. Adult dental Benefits are available for ages 19 and older. This dental Plan is offered through Covered California. For more information about Covered California, please visit xxx.xxxxxxxxx.xxx or call 0-000-000-0000. If you have any questions regarding the information in this booklet, need assis- tance, or have any problems, you may contact your Dental Plan Member Services Department at: [Family Dental Customer Service]. This section explains eligibility and enrollment for this plan. It also describes the terms of your c...
