OTHER PROGRAM PROVISIONS. Should the Member, on his or her own accord, choose a Brand Name Drug over a Generic Drug, regardless of whether a Generic equivalent is available and even if the Physician orders the drug to be “dispensed as written,” the Member will pay the Copayment for the Generic Drug as outlined in the Summary of Benefits and Coverage’s, PLUS the difference in the cost of the two drugs. The difference you will be charged between the two drug costs will not exceed $200 per prescription, not including the copayment. The following are not Covered Services under this Contract: Prescription drug products for any amount dispensed which exceeds the FDA clinically recommended dosing schedule; Prescription Drugs received through an Internet pharmacy provider or mail order provider except for our designated mail order provider; Newly approved FDA drugs that have not been approved for at least 180-days. Non-legend vitamins; Over-the-counter items; Cosmetic drugs; Appetite suppressants; Weight loss products; Diet supplements; Syringes (for use other than insulin) except when in coordination with an approved injectable; Non-contraceptive injectables (except with pre-certification); The administration or injection of any Prescription Drug or any drugs or medicines; Prescription Drugs which are entirely consumed or administered at the time and place where the prescription order is issued; Prescription refills in excess of the number specified by the Physician, or any refill dispensed after one year from the date of the prescription order; Prescription Drugs for which there is no charge; Charges for items such as therapeutic devices, artificial appliances, or similar devices, regardless of their intended use; Prescription Drugs for use as an Inpatient or outpatient of a Hospital and Prescription Drugs provided for use in a convalescent care facility or nursing home which are ordinarily furnished by such facility for the care and treatment of Inpatients; Charges for delivery of any Prescription Drugs; Drugs and medicines which do not require a prescription order and which are not Prescription Drugs (except insulin); Prescription Drugs provided by a Physician whether or not a charge is made for such Prescription Drugs; Prescription Drugs which are not Medically Necessary or which we determine are not consistent with the diagnosis (See Off-Label Drugs for exceptions); Prescription Drugs which we determine are not provided in accordance with accepted professional medical standards in the United States; Any services or supplies, which are not specifically listed as covered under this Prescription Drug program; Prescription Drugs which are Experimental or Investigational in nature as explained in the “Limitations and Exclusions” section; Prescription medicine for nail fungus except for immunocompromised or diabetic patients; Non-formulary drugs except as described in this Prescription Drug Program section. Pediatric Vision Benefits This section describes the services and supplies available to Covered Persons under age 19 only. These services and supplies must be provided and billed by Providers and must be Medically Necessary unless otherwise specified. The following Routine Vision Care Services are covered: Vision Examinations - Alliant will cover comprehensive examination components as follows: • a case history • general patient observation • clinical and diagnostic testing and evaluation • inspection of conjunctivae and sclera • examination of orbits • test visual acuity • gross visual field testing • ocular motility • binocular testing • examination of irises, cornea(s), lenses, and anterior xxxxxxxx • examination of pupils • measurement of intraocular pressure (tonometry) • ophthalmoscopic examinations • determination of refract status • color vision testing • stereopsis testing • case presentation including summary findings and recommendations including prescribing Lenses Lenses and Frames - Alliant will cover the following services only when performed to obtain prescribed Lenses and Frames: • facial measurements and determination of interpupillary distance • assistance in choosing Frames • verification of Lenses as prescribed • after-care for a reasonable period of time for fitting and adjustment. Contact Lens Evaluations and Follow-up - Alliant will cover contact lens compatibility tests, diagnostic evaluations, and diagnostic lens analysis to determine a patient's suitability for contact lenses or a change in contact lenses. Appropriate follow-up care is also covered. Pediatric Vision Coverage is not provided for (in addition to those non-covered items listed in the "Exclusions" section of this Certificate):
Appears in 1 contract
Samples: www.alliantplans.com
OTHER PROGRAM PROVISIONS. Should the Member, on his or her own accord, choose a Brand Name Drug over a Generic Druggeneric drug, regardless of whether a Generic generic equivalent is available and even if the Physician orders the drug to be “dispensed as written,” the Member will pay the Copayment for the Generic Brand Drug as outlined in the Summary of Benefits and Coverage’s, PLUS the difference in the cost of the two drugs. The difference you will be charged between the two drug costs will not exceed $200 per prescription, not including the copayment. The following are not Covered Services under this ContractOUTPATIENT PRESCRIPTION DRUG BENEFITS DO NOT INCLUDE THE FOLLOWING: • Prescription drug Drug products for any amount dispensed which exceeds the FDA clinically recommended dosing schedule; • Prescription Drugs received through an Internet pharmacy provider or mail mail-order provider except for our Our designated mail order provider; • Newly approved FDA drugs that have not been approved for at least 180-180 days. ; • Non-legend vitamins; • Over-the-counter items; • Cosmetic drugs; • Appetite suppressants; • Weight loss products; • Diet supplements; • Syringes (for use other than insulin) except when in coordination with an approved injectable; Non-contraceptive injectables • Injectables (except with pre-certificationPrior Authorization as required); • The administration or injection of any Prescription Drug or any drugs or medicines; • Prescription Drugs which are entirely consumed or administered at the time and place where the prescription order is issued; • Prescription refills in excess of the number specified by the Physician, or any refill dispensed after one year from the date of the prescription order; • Prescription Drugs for which there is no charge; • Charges for items such as therapeutic devices, artificial appliances, or similar devices, regardless of their intended use; • Prescription Drugs for use as while an Inpatient or outpatient Outpatient of a Hospital and Hospital; • Prescription Drugs provided for use in a convalescent care facility or nursing home which are ordinarily furnished by such facility for the care and treatment of Inpatients; • Charges for delivery of any Prescription Drugs; • Drugs and medicines which do not require a prescription order prescription, and which are not Prescription Drugs (except insulin)Drugs; • Prescription Drugs provided by a Physician whether or not a charge is made for such Prescription Drugs; • Prescription Drugs which are not Medically Necessary or which we We determine are not consistent with the diagnosis (See the Off-Label Drugs section for exceptions); • Prescription Drugs which we We determine are not provided in accordance with accepted professional medical standards in the United States; • Any services or supplies, which are not specifically listed as covered under this Prescription Drug program; • Prescription Drugs which are Experimental or Investigational in nature as explained in the “General Limitations and Exclusions” Exclusions section; • Prescription medicine for nail fungus except for immunocompromised or diabetic patients; • Non-formulary drugs except as described in this Prescription Drug Program section. Pediatric Vision Benefits PEDIATRIC VISION BENEFITS This section describes the services and supplies available to Covered Persons under covered persons up to but not including the age 19 onlyof 19. These services and supplies must be provided and billed by Providers and must be Medically Necessary unless otherwise specified. The following Routine Vision Care Services are covered: Vision Examinations - – Alliant will cover comprehensive examination components as follows: • a case history • general patient observation • clinical and diagnostic testing and evaluation • inspection of conjunctivae and sclera • examination of orbits • test visual acuity • gross visual field testing • ocular motility • binocular testing • examination of irises, cornea(s), lenses, and anterior xxxxxxxx • examination of pupils • measurement of intraocular pressure (tonometry) • ophthalmoscopic examinations • determination of refract status • color vision testing • stereopsis testing • case presentation including summary findings and recommendations including prescribing Lenses Lenses and Frames - – Alliant will cover prescribed Lenses and Frames; see limitations below. Alliant will cover the following services only when performed to obtain prescribed Lenses and Frames: • facial measurements and determination of interpupillary distance • assistance in choosing Frames • verification of Lenses as prescribed • after-care for a reasonable period of time for fitting and adjustment. adjustment Contact Lens Evaluations and Follow-up - – Alliant will cover contact lens compatibility tests, diagnostic evaluations, and diagnostic lens analysis to determine a patient's suitability for contact lenses or a change in contact lenses. Appropriate follow-up care is also covered. Pediatric Vision Coverage is not provided for (in contact lenses. In addition to those non-covered items listed in the "Exclusions" General Limitations and Exclusions section of this Certificate):, Pediatric Vision Coverage is not provided for: • An eye examination or materials ordered as a result of an eye examination prior to Your Effective Date; • Lenses which are not prescribed; • The replacement of Lenses or Frames except as specified in the Summary of Benefits and Coverage; • Safety glass, safety goggles and sports glasses; • Services that Alliant determines are special or unusual; such as orthoptics, vision training and low vision aids; • Tints other than Number One or Two; • Tints with photosensitive or antireflective properties; • Progressive Lenses; • Spectacle lens treatments or "add-ons", except for tints Number One or Two; • Any surgical procedure for the correction of a visual refractive problem including, but not limited to, radial keratotomy and LASIK (laser in situ keratomileusis); • Non-Covered Services or services specifically excluded in the text of this Certificate. PEDIATRIC ORAL (DENTAL) BENEFITS Pediatric dental benefits are available for covered members, up to but not including, the age of 19. This pediatric coverage includes services for evaluations, preventive treatments and dental radiology. This benefit is subject to the member’s Deductible and Coinsurance. Listed below are the Covered Services and any applicable limitations.
Appears in 1 contract
Samples: alliantplans.com
OTHER PROGRAM PROVISIONS. Should the Member, on his or her own accord, choose a Brand Name Drug over a Generic Druggeneric drug, regardless of whether a Generic generic equivalent is available and even if the Physician orders the drug to be “dispensed as written,” the Member will pay the Copayment for the Generic Brand Drug as outlined in the Summary of Benefits and Coverage’s, PLUS the difference in the cost of the two drugs. The difference you will be charged between the two drug costs will not exceed $200 per prescription, not including the copayment. The following are not Covered Services under this ContractOUTPATIENT PRESCRIPTION DRUG BENEFITS DO NOT INCLUDE THE FOLLOWING: • Prescription drug Drug products for any amount dispensed which exceeds the FDA clinically recommended dosing schedule; • Prescription Drugs received through an Internet pharmacy provider or mail mail-order provider except for our designated mail order provider; • Newly approved FDA drugs that have not been approved for at least 180-180 days. ; • Non-legend vitamins; • Over-the-counter items; • Cosmetic drugs; • Appetite suppressants; • Weight loss products; • Diet supplements; • Syringes (for use other than insulin) except when in coordination with an approved injectable; Non-contraceptive injectables • Injectables (except with pre-certificationPrior Authorization as required); • The administration or injection of any Prescription Drug or any drugs or medicines; • Prescription Drugs which are entirely consumed or administered at the time and place where the prescription order is issued; • Prescription refills in excess of the number specified by the Physician, or any refill dispensed after one year from the date of the prescription order; • Prescription Drugs for which there is no charge; • Charges for items such as therapeutic devices, artificial appliances, or similar devices, regardless of their intended use; • Prescription Drugs for use as while an Inpatient or outpatient Outpatient of a Hospital and Hospital; • Prescription Drugs provided for use in a convalescent care facility or nursing home which are ordinarily furnished by such facility for the care and treatment of Inpatients; • Charges for delivery of any Prescription Drugs; • Drugs and medicines which do not require a prescription order prescription, and which are not Prescription Drugs (except insulin)Drugs; • Prescription Drugs provided by a Physician whether or not a charge is made for such Prescription Drugs; • Prescription Drugs which are not Medically Necessary or which we determine are not consistent with the diagnosis (See the Off-Label Drugs section for exceptions); • Prescription Drugs which we determine are not provided in accordance with accepted professional medical standards in the United States; • Any services or supplies, which are not specifically listed as covered under this Prescription Drug program; • Prescription Drugs which are Experimental or Investigational in nature as explained in the “General Limitations and Exclusions” Exclusions section; • Prescription medicine for nail fungus except for immunocompromised or diabetic patients; • Non-formulary drugs except as described in this Prescription Drug Program section. Pediatric Vision Benefits PEDIATRIC VISION BENEFITS This section describes the services and supplies available to Covered Persons under covered persons up to but not including the age 19 onlyof 19. These services and supplies must be provided and billed by Providers and must be Medically Necessary unless otherwise specifiedotherwisespecified. The following Routine Vision Care Services are covered: Vision Examinations - – Alliant will cover comprehensive examination components as follows: • a case history • general patient observation • clinical and diagnostic testing and evaluation • inspection of conjunctivae and sclera • examination of orbits • test visual acuity • gross visual field testing • ocular motility • binocular testing • examination of irises, cornea(s), lenses, and anterior xxxxxxxx • examination of pupils • measurement of intraocular pressure (tonometry) • ophthalmoscopic examinations ophthalmoscopicexaminations • determination of refract status • color vision testing • stereopsis testing • case presentation including summary findings and recommendations including prescribing Lenses Lenses and Frames - – Alliant will cover prescribed Lenses and Frames; see limitations below. Alliant will cover the following services only when performed to obtain prescribed Lenses and Frames: • facial measurements and determination of interpupillary distance • assistance in choosing Frames • verification of Lenses as prescribed • after-care for a reasonable period of time for fitting and adjustment. adjustment Contact Lens Evaluations and Follow-up - – Alliant will cover contact lens compatibility tests, diagnostic evaluations, and diagnostic lens analysis to determine a patient's suitability for contact lenses or a change in contact lenses. Appropriate follow-up care is also covered. Pediatric Vision Coverage is not provided for (in contact lenses. In addition to those non-covered items listed in the "Exclusions" General Limitations and Exclusions section of this Certificate):, Pediatric Vision Coverage is not provided for: • An eye examination or materials ordered as a result of an eye examination prior to your Effective Date; • Lenses which are not prescribed; • The replacement of Lenses or Frames except as specified in the Summary of Benefits and Coverage; • Safety glass, safety goggles and sports glasses; • Services that Alliant determines are special or unusual; such as orthoptics, vision training and low vision aids; • Tints other than Number One or Two; • Tints with photosensitive or antireflective properties; • Progressive Lenses; • Spectacle lens treatments or "add-ons", except for tints Number One or Two; • Any surgical procedure for the correction of a visual refractive problem including, but not limited to, radial keratotomy and LASIK (laser in situ keratomileusis); • Non-Covered Services or services specifically excluded in the text of this Certificate. PEDIATRIC ORAL (DENTAL) BENEFITS Pediatric dental benefits are available for covered members, up to but not including, the age of 19. This pediatric coverage includes services for evaluations, preventive treatments and dental radiology. This benefit is subject to the member’s Deductible and Coinsurance. Listed below are the Covered Services and any applicable limitations. Clinical Oral Evaluation Combined limit of 2 evaluations per year (all limits are on a calendar year basis) Periodic oral evaluation. Limited to 2 per year; with a minimum of 6 months apart. Benefit is only allowed for a covered person showing signs or symptoms of periodontal disease and for patients with risk factors such as smoking, diabetes or related health issues. No benefit is payable when performed with a cleaning (prophylaxis). Benefit is not available when comprehensive oral evaluation is performed. Limited oral evaluation – problem focused Limited to 2 per year; with a minimum of 6 months apart. Oral evaluation for a patient under 3 years of age and counseling with primary caregiver Limited to 2 per year; with a minimum of 6 months apart. Comprehensive oral evaluation Limited to 2 per year; with a minimum of 6 months apart. Comprehensive periodontal evaluation. Limited to 2 per year; with a minimum of 6 months apart. Benefit is only allowed for a covered person showing signs or symptoms of periodontal disease and for patients with risk factors such as smoking, diabetes or related health issues. No benefit is payable when performed with a cleaning (prophylaxis). Benefit is not available when comprehensive oral evaluation is performed. Palliative treatment of dental pain Emergency basis Dental Radiology Intraoral – complete series (including bitewings) Limited to 1 every 5 years. A complete series is a least 14 films, including bitewings. Intraoral – periapical first film Limited to 2 sets per year* Intraoral – periapical, each additional film Limited to 2 sets per year* Intraoral – occlusal film Limited to x-rays necessary to diagnose a specific treatment. Bitewings – single film Limited to 2 sets per year* Bitewings – 2 films Limited to 2 sets per year* Bitewings – 4 films Limited to 2 sets per year* Vertical bitewings – 7-8 films Limited to 2 sets per year* Panoramic film Limited to 1 every 5 years Cephalometric x-ray Limited to x-rays necessary to diagnose a specific treatment. Oral/Facial Photographic Images Limited to x-rays necessary to diagnose a specific treatment. Preventive Treatment Prophylaxis – adult (to age 19), including all scaling and polishing procedures. Limited to 2 per year; with a minimum of 6 months apart. Prophylaxis – child, including all scaling and polishing procedures. Limited to 2 per year; with a minimum of 6 months apart. Topical application of fluoride varnish Limited to 2 per year; with a minimum of 6 months apart. Topical application of fluoride – excluding varnish Limited to 2 per year; with a minimum of 6 months apart. Sealant – per tooth – unrestored permanent molars Limited to 1 per tooth every 3 years. Space maintainer – fixed – unilateral Installation of initial space maintainers for retaining space when a primary tooth is prematurely lost. Benefit does not include separate adjustment expenses. Space maintainer – fixed – bilateral Installation of initial space maintainers for retaining space when a primary tooth is prematurely lost. Benefit does not include separate adjustment expenses. Space maintainer – removable Installation of initial space maintainers for retaining space when a primary tooth is prematurely lost. Benefit does not include separate adjustment expenses. Space maintainer – removable Installation of initial space maintainers for retaining space when a primary tooth is prematurely lost. Benefit does not include separate adjustment expenses. Re-cementation of space maintainer As required for fixed space maintainer GENERAL LIMITATIONS AND EXCLUSIONS WHAT IS NOT COVERED Your coverage does not provide benefits for: • Abortion and care for abortion are not covered. • Acupuncture – Acupuncture and acupressure therapy. • Allergy Services – Specific non-standard allergy services and supplies, including but not limited to, skin titration (Xxxxxx method), cytotoxicity testing (Xxxxx’x Test), treatment of non-specific candida sensitivity, and urine autoinjections. • Ambulance Service– Usage is not covered when another type of transportation can be used without endangering the Member’s health. Any ambulance usage for the convenience of the Member, family or Physician is not a Covered Service. Non-Covered Services for Ambulance include but are not limited to, trips to: A Physician’s office or clinic; a morgue or funeral home. Coverage is not available for air ambulance transport from a Hospital capable of treating the patient because the patient and/or the patient’s family prefer a specific hospital or Physician. Air ambulance services are not covered for transport to a Hospital that is not an acute care hospital, such as a nursing facility, physician’s office, or your home. • Animal Assisted Therapy • Aquatic Therapy • Aromatherapy • Beautification Procedures – Cosmetic Surgery, reconstructive surgery, pharmacological services, nutritional regimens or other services for beautification, or treatment relating to the consequences of, or as a result of, Cosmetic Surgery (including reimplantation). This exclusion includes, but is not limited to, surgery to correct gynecomastia and breast augmentation procedures, and otoplasties. Reduction mammoplasty and services for the correction of asymmetry, except when determined to be Medically Necessary by Alliant, is not covered. o This exclusion does not apply to surgery to restore function if anybody area has been altered by disease, trauma, Congenital/developmental Anomalies, or previous therapeutic processes. This exclusion does not apply to surgery to correct the results of Injuries when performed within two years of the event causing the impairment, or as a continuation of a staged reconstruction procedure, or congenital defects necessary to restore normal bodily functions, including but not limited to, cleft lip and cleft palate. • Before Coverage Begins/After Coverage Ends – Services rendered, or supplies provided before coverage begins, i.e., before a Member’s Effective Date, or after coverage ends. Such services and supplies shall include but not be limited to Inpatient Hospital admissions which begin before a Member’s Effective Date, continue after the Member’s Effective Date. • Mental health exams and services – o Rendered in connection with mental illnesses not classified in the International Classification of Diseases of the U.S. Department of Health and Human Services; or extended beyond the period necessary for evaluation and diagnosis of learning and behavioral disabilities or intellectual disabilities and developmental delay; o Psychological testing for ability, aptitude, intelligence, or interest is not covered; o Mental Health Services that are primarily educational; o Religious, marital, gender, pre-marital, and sex counseling, including services and treatment related to religious counseling, marital and pre-marital/relationship, gender counseling and sex therapy; o Court-ordered services, or those required by court order as a condition of parole or probation; o Evaluation for the purpose of maintaining employment. • Behavioral Disorders – Behavioral modification, behavioral or educational disorder services and associated expenses related to confirmation of diagnosis, progress, staging or treatment of behavioral (conduct) problems, ADD, Oppositional Defiant Disorder, learning disabilities, intellectual disabilities and or developmental delays, anoxic birth injuries, birth defects, cerebral injury, non-acute head injuries, or cerebral palsy. • Biomicroscopy – Biomicroscopy, field charting or aniseikonic investigation. • Care, Supplies, or Equipment – Care, supplies, or equipment not Medically Necessary, as determined by Alliant, for the treatment of an Injury or illness. Non-covered supplies are inclusive of but not limited to Band- Aids, tape, non-sterile gloves, thermometers, heating pads and bed boards. Other non-covered items include household supplies, including but not limited to, the purchase or rental of water purifiers, hypo-allergenic pillows, mattresses, or waterbeds, whirlpool, spa or swimming pools, exercise and massage equipment, air purifiers, central or unit air conditioners, humidifiers, dehumidifiers, escalators, elevators, ramps, stair glides, emergency alert equipment, handrails, heat appliances, improvements made to a Member’s house or place of business, and adjustments made to vehicles. Computer equipment to aid in speech or hearing loss. • Complications – Complications of non-covered procedures are not covered. • Counseling – Religious, marital and sex counseling, including services and treatment related to religious counseling, marital/relationship counseling and sex therapy.
Appears in 1 contract
Samples: alliantplans.com
OTHER PROGRAM PROVISIONS. Should the Member, on his or her own accord, choose a Brand Name Drug over a Generic Druggeneric drug, regardless of whether a Generic generic equivalent is available and even if the Physician orders the drug to be “dispensed as written,” the Member will pay the Copayment for the Generic Brand Drug as outlined in the Summary of Benefits and Coverage’s, PLUS the difference in the cost of the two drugs. The difference you will be charged between the two drug costs will not exceed $200 per prescription, not including the copayment. The following are not Covered Services under this ContractOUTPATIENT PRESCRIPTION DRUG BENEFITS DO NOT INCLUDE THE FOLLOWING: • Prescription drug Drug products for any amount dispensed which exceeds the FDA clinically recommended dosing schedule; • Prescription Drugs received through an Internet pharmacy provider or mail mail-order provider except for our designated mail order provider; • Newly approved FDA drugs that have not been approved for at least 180-180 days. ; • Non-legend vitamins; • Over-the-counter items; • Cosmetic drugs; • Appetite suppressants; • Weight loss products; • Diet supplements; • Syringes (for use other than insulin) except when in coordination with an approved injectable; Non-contraceptive injectables • Injectables (except with pre-certificationPrior Authorization as required); • The administration or injection of any Prescription Drug or any drugs or medicines; • Prescription Drugs which are entirely consumed or administered at the time and place where the prescription order is issued; • Prescription refills in excess of the number specified by the Physician, or any refill dispensed after one year from the date of the prescription order; • Prescription Drugs for which there is no charge; • Charges for items such as therapeutic devices, artificial appliances, or similar devices, regardless of their intended use; • Prescription Drugs for use as while an Inpatient or outpatient Outpatient of a Hospital and Hospital; • Prescription Drugs provided for use in a convalescent care facility or nursing home which are ordinarily furnished by such facility for the care and treatment of Inpatients; • Charges for delivery of any Prescription Drugs; • Drugs and medicines which do not require a prescription order prescription, and which are not Prescription Drugs (except insulin)Drugs; • Prescription Drugs provided by a Physician whether or not a charge is made for such Prescription Drugs; • Prescription Drugs which are not Medically Necessary or which we determine are not consistent with the diagnosis (See the Off-Label Drugs section for exceptions); • Prescription Drugs which we determine are not provided in accordance with accepted professional medical standards in the United States; • Any services or supplies, which are not specifically listed as covered under this Prescription Drug program; • Prescription Drugs which are Experimental or Investigational in nature as explained in the “General Limitations and Exclusions” Exclusions section; • Prescription medicine for nail fungus except for immunocompromised or diabetic patients; • Non-formulary drugs except as described in this Prescription Drug Program section. Pediatric Vision Benefits PEDIATRIC VISION BENEFITS This section describes the services and supplies available to Covered Persons under covered persons up to but not including the age 19 onlyof 19. These services and supplies must be provided and billed by Providers and must be Medically Necessary unless otherwise specifiedotherwisespecified. The following Routine Vision Care Services are covered: Vision Examinations - – Alliant will cover comprehensive examination components as follows: • a case history • general patient observation • clinical and diagnostic testing and evaluation • inspection of conjunctivae and sclera • examination of orbits • test visual acuity • gross visual field testing • ocular motility • binocular testing • examination of irises, cornea(s), lenses, and anterior xxxxxxxx • examination of pupils • measurement of intraocular pressure (tonometry) • ophthalmoscopic examinations ophthalmoscopicexaminations • determination of refract status • color vision testing • stereopsis testing • case presentation including summary findings and recommendations including prescribing Lenses Lenses and Frames - – Alliant will cover prescribed Lenses and Frames; see limitations below. Alliant will cover the following services only when performed to obtain prescribed Lenses and Frames: • facial measurements and determination of interpupillary distance • assistance in choosing Frames • verification of Lenses as prescribed • after-care for a reasonable period of time for fitting and adjustment. adjustment Contact Lens Evaluations and Follow-up - – Alliant will cover contact lens compatibility tests, diagnostic evaluations, and diagnostic lens analysis to determine a patient's suitability for contact lenses or a change in contact lenses. Appropriate follow-up care is also covered. Pediatric Vision Coverage is not provided for (in contact lenses. In addition to those non-covered items listed in the "Exclusions" General Limitations and Exclusions section of this Certificate):, Pediatric Vision Coverage is not provided for: • An eye examination or materials ordered as a result of an eye examination prior to your Effective Date; • Lenses which are not prescribed; • The replacement of Lenses or Frames except as specified in the Summary of Benefits and Coverage; • Safety glass, safety goggles and sports glasses; • Services that Alliant determines are special or unusual; such as orthoptics, vision training and low vision aids; • Tints other than Number One or Two; • Tints with photosensitive or antireflective properties; • Progressive Lenses; • Spectacle lens treatments or "add-ons", except for tints Number One or Two; • Any surgical procedure for the correction of a visual refractive problem including, but not limited to, radial keratotomy and LASIK (laser in situ keratomileusis); • Non-Covered Services or services specifically excluded in the text of this Certificate. PEDIATRIC ORAL (DENTAL) BENEFITS Pediatric dental benefits are available for covered members, up to but not including, the age of 19. This pediatric coverage includes services for evaluations, preventive treatments and dental radiology. This benefit is subject to the member’s Deductible and Coinsurance. Listed below are the Covered Services and any applicable limitations. Clinical Oral Evaluation Combined limit of 2 evaluations per year (all limits are on a calendar year basis) Periodic oral evaluation. Limited to 2 per year; with a minimum of 6 months apart. Benefit is only allowed for a covered person showing signs or symptoms of periodontal disease and for patients with risk factors such as smoking, diabetes or related health issues. No benefit is payable when performed with a cleaning (prophylaxis). Benefit is not available when comprehensive oral evaluation is performed. Limited oral evaluation – problem focused Limited to 2 per year; with a minimum of 6 months apart. Oral evaluation for a patient under 3 years of age and counseling with primary caregiver Limited to 2 per year; with a minimum of 6 months apart. Comprehensive oral evaluation Limited to 2 per year; with a minimum of 6 months apart. Comprehensive periodontal evaluation. Limited to 2 per year; with a minimum of 6 months apart. Benefit is only allowed for a covered person showing signs or symptoms of periodontal disease and for patients with risk factors such as smoking, diabetes or related health issues. No benefit is payable when performed with a cleaning (prophylaxis). Benefit is not available when comprehensive oral evaluation is performed. Palliative treatment of dental pain Emergency basis Dental Radiology Intraoral – complete series (including bitewings) Limited to 1 every 5 years. A complete series is a least 14 films, including bitewings. Intraoral – periapical first film Limited to 2 sets per year* Intraoral – periapical, each additional film Limited to 2 sets per year* Intraoral – occlusal film Limited to x-rays necessary to diagnose a specific treatment. Bitewings – single film Limited to 2 sets per year* Bitewings – 2 films Limited to 2 sets per year* Bitewings – 4 films Limited to 2 sets per year* Vertical bitewings – 7-8 films Limited to 2 sets per year* Panoramic film Limited to 1 every 5 years Cephalometric x-ray Limited to x-rays necessary to diagnose a specific treatment. Oral/Facial Photographic Images Limited to x-rays necessary to diagnose a specific treatment. Preventive Treatment Prophylaxis – adult (to age 19), including all scaling and polishing procedures. Limited to 2 per year; with a minimum of 6 months apart. Prophylaxis – child, including all scaling and polishing procedures. Limited to 2 per year; with a minimum of 6 months apart. Topical application of fluoride varnish Limited to 2 per year; with a minimum of 6 months apart. Topical application of fluoride – excluding varnish Limited to 2 per year; with a minimum of 6 months apart. Sealant – per tooth – unrestored permanent molars Limited to 1 per tooth every 3 years. Space maintainer – fixed – unilateral Installation of initial space maintainers for retaining space when a primary tooth is prematurely lost. Benefit does not include separate adjustment expenses. Space maintainer – fixed – bilateral Installation of initial space maintainers for retaining space when a primary tooth is prematurely lost. Benefit does not include separate adjustment expenses. Space maintainer – removable Installation of initial space maintainers for retaining space when a primary tooth is prematurely lost. Benefit does not include separate adjustment expenses. Space maintainer – removable Installation of initial space maintainers for retaining space when a primary tooth is prematurely lost. Benefit does not include separate adjustment expenses. Re-cementation of space maintainer As required for fixed space maintainer GENERAL LIMITATIONS AND EXCLUSIONS WHAT IS NOT COVERED Your coverage does not provide benefits for: • Abortion and care for abortion are not covered. • Acupuncture – Acupuncture and acupressure therapy. • Allergy Services – Specific non-standard allergy services and supplies, including but not limited to, skin titration (Xxxxxx method), cytotoxicity testing (Bryan’s Test), treatment of non-specific candida sensitivity, and urine autoinjections. • Ambulance Service– Usage is not covered when another type of transportation can be used without endangering the Member’s health. Any ambulance usage for the convenience of the Member, family or Physician is not a Covered Service. Non-Covered Services for Ambulance include but are not limited to, trips to: A Physician’s office or clinic; a morgue or funeral home. Coverage is not available for air ambulance transport from a Hospital capable of treating the patient because the patient and/or the patient’s family prefer a specific hospital or Physician. Air ambulance services are not covered for transport to a Hospital that is not an acute care hospital, such as a nursing facility, physician’s office, or your home. • Animal Assisted Therapy • Aquatic Therapy • Aromatherapy • Beautification Procedures – Cosmetic Surgery, reconstructive surgery, pharmacological services, nutritional regimens or other services for beautification, or treatment relating to the consequences of, or as a result of, Cosmetic Surgery (including reimplantation). This exclusion includes, but is not limited to, surgery to correct gynecomastia and breast augmentation procedures, and otoplasties. Reduction mammoplasty and services for the correction of asymmetry, except when determined to be Medically Necessary by Alliant, is not covered. o This exclusion does not apply to surgery to restore function if anybody area has been altered by disease, trauma, Congenital/developmental Anomalies, or previous therapeutic processes. This exclusion does not apply to surgery to correct the results of Injuries when performed within two years of the event causing the impairment, or as a continuation of a staged reconstruction procedure, or congenital defects necessary to restore normal bodily functions, including but not limited to, cleft lip and cleft palate. • Before Coverage Begins/After Coverage Ends – Services rendered, or supplies provided before coverage begins, i.e., before a Member’s Effective Date, or after coverage ends. Such services and supplies shall include but not be limited to Inpatient Hospital admissions which begin before a Member’s Effective Date, continue after the Member’s Effective Date. • Mental health exams and services – o Rendered in connection with mental illnesses not classified in the International Classification of Diseases of the U.S. Department of Health and Human Services; or extended beyond the period necessary for evaluation and diagnosis of learning and behavioral disabilities or intellectual disabilities and developmental delay; o Psychological testing for ability, aptitude, intelligence, or interest is not covered; o Mental Health Services that are primarily educational; o Religious, marital, gender, pre-marital, and sex counseling, including services and treatment related to religious counseling, marital and pre-marital/relationship, gender counseling and sex therapy; o Court-ordered services, or those required by court order as a condition of parole or probation; o Evaluation for the purpose of maintaining employment. • Behavioral Disorders – Behavioral modification, behavioral or educational disorder services and associated expenses related to confirmation of diagnosis, progress, staging or treatment of behavioral (conduct) problems, ADD, Oppositional Defiant Disorder, learning disabilities, intellectual disabilities and or developmental delays, anoxic birth injuries, birth defects, cerebral injury, non-acute head injuries, or cerebral palsy. • Biomicroscopy – Biomicroscopy, field charting or aniseikonic investigation. • Care, Supplies, or Equipment – Care, supplies, or equipment not Medically Necessary, as determined by Alliant, for the treatment of an Injury or illness. Non-covered supplies are inclusive of but not limited to Band- Aids, tape, non-sterile gloves, thermometers, heating pads and bed boards. Other non-covered items include household supplies, including but not limited to, the purchase or rental of water purifiers, hypo-allergenic pillows, mattresses, or waterbeds, whirlpool, spa or swimming pools, exercise and massage equipment, air purifiers, central or unit air conditioners, humidifiers, dehumidifiers, escalators, elevators, ramps, stair glides, emergency alert equipment, handrails, heat appliances, improvements made to a Member’s house or place of business, and adjustments made to vehicles. Computer equipment to aid in speech or hearing loss. • Complications – Complications of non-covered procedures are not covered. • Counseling – Religious, marital and sex counseling, including services and treatment related to religious counseling, marital/relationship counseling and sex therapy.
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Samples: alliantplans.com
OTHER PROGRAM PROVISIONS. Should the Member, on his or her own accord, choose a Brand Name Drug over a Generic Drug, regardless of whether a Generic equivalent is available and even if the Physician orders the drug to be “dispensed as written,” the Member will pay the Copayment for the Generic Drug as outlined in the Summary of Benefits and Coverage’s, PLUS the difference in the cost of the two drugs. The difference you will be charged between the two drug costs will not exceed $200 per prescription, not including the copayment. The following are not Covered Services under this Contract: Prescription drug products for any amount dispensed which exceeds the FDA clinically recommended dosing schedule; Prescription Drugs received through an Internet pharmacy provider or mail order provider except for our designated mail order provider; Newly approved FDA drugs that have not been approved for at least 180-days. Non-legend vitamins; Over-the-counter items; Cosmetic drugs; Appetite suppressants; Weight loss products; Diet supplements; Syringes (for use other than insulin) except when in coordination with an approved injectable; Non-contraceptive injectables injectable (except with pre-certificationPrior Authorization); The administration or injection of any Prescription Drug or any drugs or medicines; Prescription Drugs which are entirely consumed or administered at the time and place where the prescription order is issued; Prescription refills in excess of the number specified by the Physician, or any refill dispensed after one year from the date of the prescription order; Prescription Drugs for which there is no charge; Charges for items such as therapeutic devices, artificial appliances, or similar devices, regardless of their intended use; Prescription Drugs for use as an Inpatient or outpatient of a Hospital and Prescription Drugs provided for use in a convalescent care facility or nursing home which are ordinarily furnished by such facility for the care and treatment of Inpatients; Charges for delivery of any Prescription Drugs; Drugs and medicines which do not require a prescription order and which are not Prescription Drugs (except insulin); Prescription Drugs provided by a Physician whether or not a charge is made for such Prescription Drugs; Prescription Drugs which are not Medically Necessary or which we determine are not consistent with the diagnosis (See Off-Label Drugs for exceptions); Prescription Drugs which we determine are not provided in accordance with accepted professional medical standards in the United States; Any services or supplies, which are not specifically listed as covered under this Prescription Drug program; Prescription Drugs which are Experimental or Investigational in nature as explained in the “Limitations and Exclusions” section; Prescription medicine for nail fungus except for immunocompromised or diabetic patients; Non-formulary drugs except as described in this Prescription Drug Program section. Pediatric Vision Benefits This section describes the services and supplies available to Covered Persons under up to but not including the age 19 onlyof 19. These services and supplies must be provided and billed by Providers and must be Medically Necessary unless otherwise specified. The following Routine Vision Care Services are covered: Vision Examinations - Alliant will cover comprehensive examination components as follows: • a case history • general patient observation • clinical and diagnostic testing and evaluation • inspection of conjunctivae and sclera • examination of orbits • test visual acuity • gross visual field testing • ocular motility • binocular testing • examination of irises, cornea(s), lenses, and anterior xxxxxxxx • examination of pupils • measurement of intraocular pressure (tonometry) • ophthalmoscopic examinations • determination of refract status • color vision testing • stereopsis testing • case presentation including summary findings and recommendations including prescribing Lenses Lenses and Frames - Alliant will cover the following services only when performed to obtain prescribed Lenses and Frames: • facial measurements and determination of interpupillary distance • assistance in choosing Frames • verification of Lenses as prescribed • after-care for a reasonable period of time for fitting and adjustment. Contact Lens Evaluations and Follow-up - Alliant will cover contact lens compatibility tests, diagnostic evaluations, and diagnostic lens analysis to determine a patient's suitability for contact lenses or a change in contact lenses. Appropriate follow-up care is also covered. Pediatric Vision Coverage is not provided for (in addition to those non-covered items listed in the "Exclusions" section of this Certificate):
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Samples: alliantplans.com
OTHER PROGRAM PROVISIONS. Should the Member, on his or her own accord, choose a Brand Name Drug over a Generic Drug, regardless of whether a Generic equivalent is available and even if the Physician orders the drug to be “dispensed as written,” the Member will pay the Copayment for the Generic Drug as outlined in the Summary of Benefits and Coverage’s, PLUS the difference in the cost of the two drugs. The difference you will be charged between the two drug costs will not exceed $200 per prescription, not including the copayment. The following are not Covered Services under this Contract: • Prescription drug products for any amount dispensed which exceeds the FDA clinically recommended dosing schedule; • Prescription Drugs received through an Internet pharmacy provider or mail order provider except for our designated mail order provider; • Newly approved FDA drugs that have not been approved for at least 180-days. • Non-legend vitamins; • Over-the-counter items; • Cosmetic drugs; • Appetite suppressants; • Weight loss products; • Diet supplements; • Syringes (for use other than insulin) except when in coordination with an approved injectable; • Non-contraceptive injectables (except with pre-certification); • The administration or injection of any Prescription Drug or any drugs or medicines; • Prescription Drugs which are entirely consumed or administered at the time and place where the prescription order is issued; • Prescription refills in excess of the number specified by the Physician, or any refill dispensed after one year from the date of the prescription order; • Prescription Drugs for which there is no charge; • Charges for items such as therapeutic devices, artificial appliances, or similar devices, regardless of their intended use; • Prescription Drugs for use as an Inpatient or outpatient of a Hospital and Prescription Drugs provided for use in a convalescent care facility or nursing home which are ordinarily furnished by such facility for the care and treatment of Inpatients; • Charges for delivery of any Prescription Drugs; • Drugs and medicines which do not require a prescription order and which are not Prescription Drugs (except insulin); • Prescription Drugs provided by a Physician whether or not a charge is made for such Prescription Drugs; • Prescription Drugs which are not Medically Necessary or which we determine are not consistent with the diagnosis (See Off-Label Drugs for exceptions); • Prescription Drugs which we determine are not provided in accordance with accepted professional medical standards in the United States; • Any services or supplies, which are not specifically listed as covered under this Prescription Drug program; • Prescription Drugs which are Experimental or Investigational in nature as explained in the “Limitations and Exclusions” section; • Prescription medicine for nail fungus except for immunocompromised or diabetic patients; • Non-formulary drugs except as described in this Prescription Drug Program section. Pediatric Vision Benefits Benefits This section describes the services and supplies available to Covered Persons under age 19 only. These services and supplies must be provided and billed by Providers and must be Medically Necessary unless otherwise specified. The following Routine Vision Care Services are covered: Vision Examinations - Alliant will cover comprehensive examination components as follows: • a case history • general patient observation • clinical and diagnostic testing and evaluation • inspection of conjunctivae and sclera • examination of orbits • test visual acuity • gross visual field testing • ocular motility • binocular testing • examination of irises, cornea(s), lenses, and anterior xxxxxxxx • examination of pupils • measurement of intraocular pressure (tonometry) • ophthalmoscopic examinations • determination of refract status • color vision testing • stereopsis testing • case presentation including summary findings and recommendations including prescribing Lenses Lenses and Frames - Alliant will cover the following services only when performed to obtain prescribed Lenses and Frames: • facial measurements and determination of interpupillary distance • assistance in choosing Frames • verification of Lenses as prescribed • after-care for a reasonable period of time for fitting and adjustment. Contact Lens Evaluations and Follow-up - Alliant will cover contact lens compatibility tests, diagnostic evaluations, and diagnostic lens analysis to determine a patient's suitability for contact lenses or a change in contact lenses. Appropriate follow-up care is also covered. Pediatric Vision Coverage is not provided for (in addition to those non-covered items listed in the "Exclusions" section of this Certificate):
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Samples: www.alliantplans.com
OTHER PROGRAM PROVISIONS. Should the Member, on his or her own accord, choose a Brand Name Drug over a Generic Druggeneric drug, regardless of whether a Generic generic equivalent is available and even if the Physician orders the drug to be “dispensed as written,” the Member will pay the Copayment for the Generic Brand Drug as outlined in the Summary of Benefits and Coverage’s, PLUS the difference in the cost of the two drugs. The difference you will be charged between the two drug costs will not exceed $200 per prescription, not including the copayment. The following are not Covered Services under this ContractOUTPATIENT PRESCRIPTION DRUG BENEFITS DO NOT INCLUDE THE FOLLOWING: • Prescription drug Drug products for any amount dispensed which exceeds the FDA clinically recommended dosing schedule; • Prescription Drugs received through an Internet pharmacy provider or mail mail-order provider except for our designated mail order provider; • Newly approved FDA drugs that have not been approved for at least 180-180 days. ; • Non-legend vitamins; • Over-the-counter items; • Cosmetic drugs; • Appetite suppressants; • Weight loss products; • Diet supplements; • Syringes (for use other than insulin) except when in coordination with an approved injectable; Non-contraceptive injectables • Injectables (except with pre-certificationPrior Authorization as required); • The administration or injection of any Prescription Drug or any drugs or medicines; • Prescription Drugs which are entirely consumed or administered at the time and place where the prescription order is issued; • Prescription refills in excess of the number specified by the Physician, or any refill dispensed after one year from the date of the prescription order; • Prescription Drugs for which there is no charge; • Charges for items such as therapeutic devices, artificial appliances, or similar devices, regardless of their intended use; • Prescription Drugs for use as while an Inpatient or outpatient Outpatient of a Hospital and Hospital; • Prescription Drugs provided for use in a convalescent care facility or nursing home which are ordinarily furnished by such facility for the care and treatment of Inpatients; • Charges for delivery of any Prescription Drugs; • Drugs and medicines which do not require a prescription order prescription, and which are not Prescription Drugs (except insulin)Drugs; • Prescription Drugs provided by a Physician whether or not a charge is made for such Prescription Drugs; • Prescription Drugs which are not Medically Necessary or which we determine are not consistent with the diagnosis (See the Off-Label Drugs section for exceptions); • Prescription Drugs which we determine are not provided in accordance with accepted professional medical standards in the United States; • Any services or supplies, which are not specifically listed as covered under this Prescription Drug program; • Prescription Drugs which are Experimental or Investigational in nature as explained in the “General Limitations and Exclusions” Exclusions section; • Prescription medicine for nail fungus except for immunocompromised or diabetic patientsdiabeticpatients; • Non-formulary drugs except as described in this Prescription Drug Program section. Pediatric Vision Benefits PEDIATRIC VISION BENEFITS This section describes the services and supplies available to Covered Persons under covered persons up to but not including the age 19 onlyof 19. These services and supplies must be provided and billed by Providers and must be Medically Necessary unless otherwise specified. The following Routine Vision Care Services are covered: Vision Examinations - – Alliant will cover comprehensive examination components as follows: • a case history • general patient observation • clinical and diagnostic testing and evaluation • inspection of conjunctivae and sclera • examination of orbits • test visual acuity • gross visual field testing • ocular motility • binocular testing • examination of irises, cornea(s), lenses, and anterior xxxxxxxx • examination of pupils • measurement of intraocular pressure (tonometry) • ophthalmoscopic examinations • determination of refract status • color vision testing • stereopsis testing • case presentation including summary findings and recommendations including prescribing Lenses Lenses and Frames - – Alliant will cover prescribed Lenses and Frames; see limitations below. Alliant will cover the following services only when performed to obtain prescribed Lenses and Frames: • facial measurements and determination of interpupillary distance • assistance in choosing Frames • verification of Lenses as prescribed • after-care for a reasonable period of time for fitting and adjustment. adjustment Contact Lens Evaluations and Follow-up - – Alliant will cover contact lens compatibility tests, diagnostic evaluations, and diagnostic lens analysis to determine a patient's suitability for contact lenses or a change in contact lenses. Appropriate follow-up care is also covered. Pediatric Vision Coverage is not provided for (in contact lenses. In addition to those non-covered items listed in the "Exclusions" General Limitations and Exclusions section of this Certificate):, Pediatric Vision Coverage is not provided for: • An eye examination or materials ordered as a result of an eye examination prior to your EffectiveDate; • Lenses which are not prescribed; • The replacement of Lenses or Frames except as specified in the Summary of Benefits and Coverage; • Safety glass, safety goggles and sports glasses; • Services that Alliant determines are special or unusual; such as orthoptics, vision training and low vision aids; • Tints other than Number One or Two; • Tints with photosensitive or antireflective properties; • Progressive Lenses; • Spectacle lens treatments or "add-ons", except for tints Number One or Two; • Any surgical procedure for the correction of a visual refractive problem including, but not limited to, radial keratotomy and LASIK (laser in situ keratomileusis); • Non-Covered Services or services specifically excluded in the text of this Certificate. PEDIATRIC ORAL (DENTAL) BENEFITS Pediatric dental benefits are available for covered members, up to but not including, the age of 19. This pediatric coverage includes services for evaluations, preventive treatments and dental radiology. This benefit is subject to the member’s Deductible and Coinsurance. Listed below are the Covered Services and any applicable limitations. Clinical Oral Evaluation Combined limit of 2 evaluations per year (all limits are on a calendar year basis) Periodic oral evaluation. Limited to 2 per year; with a minimum of 6 months apart. Benefit is only allowed for a covered person showing signs or symptoms of periodontal disease and for patients with risk factors such as smoking, diabetes or related health issues. No benefit is payable when performed with a cleaning (prophylaxis). Benefit is not available when comprehensive oral evaluation is performed. Limited oral evaluation – problem focused Limited to 2 per year; with a minimum of 6 months apart. Oral evaluation for a patient under 3 years of age and counseling with primary caregiver Limited to 2 per year; with a minimum of 6 months apart. Comprehensive oral evaluation Limited to 2 per year; with a minimum of 6 months apart. Comprehensive periodontal evaluation. Limited to 2 per year; with a minimum of 6 months apart. Benefit is only allowed for a covered person showing signs or symptoms of periodontal disease and for patients with risk factors such as smoking, diabetes or related health issues. No benefit is payable when performed with a cleaning (prophylaxis). Benefit is not available when comprehensive oral evaluation is performed. Palliative treatment of dental pain Emergency basis Dental Radiology Intraoral – complete series (including bitewings) Limited to 1 every 5 years. A complete series is a least 14 films, including bitewings. Intraoral – periapical first film Limited to 2 sets per year* Intraoral – periapical, each additional film Limited to 2 sets per year* Intraoral – occlusal film Limited to x-rays necessary to diagnose a specific treatment. Bitewings – single film Limited to 2 sets per year* Bitewings – 2 films Limited to 2 sets per year* Bitewings – 4 films Limited to 2 sets per year* Vertical bitewings – 7-8 films Limited to 2 sets per year* Panoramic film Limited to 1 every 5 years Cephalometric x-ray Limited to x-rays necessary to diagnose a specific treatment. Oral/Facial Photographic Images Limited to x-rays necessary to diagnose a specific treatment. Preventive Treatment Prophylaxis – adult (to age 19), including all scaling and polishing procedures. Limited to 2 per year; with a minimum of 6 months apart. Prophylaxis – child, including all scaling and polishing procedures. Limited to 2 per year; with a minimum of 6 months apart. Topical application of fluoride varnish Limited to 2 per year; with a minimum of 6 months apart. Topical application of fluoride – excluding varnish Limited to 2 per year; with a minimum of 6 months apart. Sealant – per tooth – unrestored permanent molars Limited to 1 per tooth every 3 years. Space maintainer – fixed – unilateral Installation of initial space maintainers for retaining space when a primary tooth is prematurely lost. Benefit does not include separate adjustment expenses. Space maintainer – fixed – bilateral Installation of initial space maintainers for retaining space when a primary tooth is prematurely lost. Benefit does not include separate adjustment expenses. Space maintainer – removable Installation of initial space maintainers for retaining space when a primary tooth is prematurely lost. Benefit does not include separate adjustment expenses. Space maintainer – removable Installation of initial space maintainers for retaining space when a primary tooth is prematurely lost. Benefit does not include separate adjustment expenses. Re-cementation of space maintainer As required for fixed space maintainer GENERAL LIMITATIONS AND EXCLUSIONS WHAT IS NOT COVERED Your coverage does not provide benefits for: • Abortion and care for abortion are not covered. • Acupuncture – Acupuncture and acupressure therapy. • Allergy Services – Specific non-standard allergy services and supplies, including but not limited to, skin titration (Xxxxxx method), cytotoxicity testing (Bryan’s Test), treatment of non-specific candida sensitivity, and urine autoinjections. • Ambulance Service– Usage is not covered when another type of transportation can be used without endangering the Member’s health. Any ambulance usage for the convenience of the Member, family or Physician is not a Covered Service. Non-Covered Services for Ambulance include but are not limited to, trips to: A Physician’s office or clinic; a morgue or funeral home. Coverage is not available for air ambulance transport from a Hospital capable of treating the patient because the patient and/or the patient’s family prefer a specific hospital or Physician. Air ambulance services are not covered for transport to a Hospital that is not an acute care hospital, such as a nursing facility, physician’s office, or your home. • Animal Assisted Therapy • Aquatic Therapy • Aromatherapy • Beautification Procedures – Cosmetic Surgery, reconstructive surgery, pharmacological services, nutritional regimens or other services for beautification, or treatment relating to the consequences of, or as a result of, Cosmetic Surgery (including reimplantation). This exclusion includes, but is not limited to, surgery to correct gynecomastia and breast augmentation procedures, and otoplasties. Reduction mammoplasty and services for the correction of asymmetry, except when determined to be Medically Necessary by Alliant, is not covered. o This exclusion does not apply to surgery to restore function if anybody area has been altered by disease, trauma, Congenital/developmental Anomalies, or previous therapeutic processes. This exclusion does not apply to surgery to correct the results of Injuries when performed within two years of the event causing the impairment, or as a continuation of a staged reconstruction procedure, or congenital defects necessary to restore normal bodily functions, including but not limited to, cleft lip and cleft palate. • Before Coverage Begins/After Coverage Ends – Services rendered, or supplies provided before coverage begins, i.e., before a Member’s Effective Date, or after coverage ends. Such services and supplies shall include but not be limited to Inpatient Hospital admissions which begin before a Member’s Effective Date, continue after the Member’s Effective Date. • Biomicroscopy – Biomicroscopy, field charting or aniseikonic investigation. • Care, Supplies, or Equipment – Care, supplies, or equipment not Medically Necessary, as determined by Alliant, for the treatment of an Injury or illness. Non-covered supplies are inclusive of but not limited to Band- Aids, tape, non-sterile gloves, thermometers, heating pads and bed boards. Other non-covered items include household supplies, including but not limited to, the purchase or rental of water purifiers, hypo-allergenic pillows, mattresses, or waterbeds, whirlpool, spa or swimming pools, exercise and massage equipment, air purifiers, central or unit air conditioners, humidifiers, dehumidifiers, escalators, elevators, ramps, stair glides, emergency alert equipment, handrails, heat appliances, improvements made to a Member’s house or place of business, and adjustments made to vehicles. Computer equipment to aid in speech or hearing loss. • Complications – Complications of non-covered procedures are not covered. • Counseling – Religious, marital and sex counseling, including services and treatment related to religious counseling, marital/relationship counseling and sex therapy.
Appears in 1 contract
Samples: alliantplans.com
OTHER PROGRAM PROVISIONS. Should the Member, on his or her own accord, choose a Brand Name Drug over a Generic Drug, regardless of whether a Generic equivalent is available and even if the Physician orders the drug to be “dispensed as written,” the Member will pay the Copayment for the Generic Brand Drug as outlined in the Summary of Benefits and Coverage’s, PLUS the difference in the cost of the two drugs. The difference you will be charged between the two drug costs will not exceed $200 per prescription, not including the copayment. The following are not Covered Services under this ContractOUTPATIENT PRESCRIPTION DRUG BENEFITS DO NOT INCLUDE THE FOLLOWING: • Prescription drug Drug products for any amount dispensed which exceeds the FDA clinically recommended dosing schedule; • Prescription Drugs received through an Internet pharmacy provider or mail mail-order provider except for our Our designated mail order provider; • Newly approved FDA drugs that have not been approved for at least 180-180 days. ; • Non-legend vitamins; • Over-the-counter items; • Cosmetic drugs; • Appetite suppressants; • Weight loss products; • Diet supplements; • Syringes (for use other than insulin) except when in coordination with an approved injectable; Non-contraceptive injectables • Injectables (except with pre-certificationPrior Authorization as required); • The administration or injection of any Prescription Drug or any drugs or medicines; • Prescription Drugs which are entirely consumed or administered at the time and place where the prescription order is issued; • Prescription refills in excess of the number specified by the Physician, or any refill dispensed after one year from the date of the prescription order; • Prescription Drugs for which there is no charge; • Charges for items such as therapeutic devices, artificial appliances, or similar devices, regardless of their intended use; • Prescription Drugs for use as while an Inpatient or outpatient Outpatient of a Hospital and Hospital; • Prescription Drugs provided for use in a convalescent care facility or nursing home which are ordinarily furnished by such facility for the care and treatment of Inpatients; • Charges for delivery of any Prescription Drugs; • Drugs and medicines which do not require a prescription order prescription, and which are not Prescription Drugs (except insulin)Drugs; • Prescription Drugs provided by a Physician whether or not a charge is made for such Prescription Drugs; • Prescription Drugs which are not Medically Necessary or which we We determine are not consistent with the diagnosis (See the Off-Label Drugs section for exceptions); • Prescription Drugs which we We determine are not provided in accordance with accepted professional medical standards in the United States; • Any services or supplies, which are not specifically listed as covered under this Prescription Drug program; • Prescription Drugs which are Experimental or Investigational in nature as explained in the “General Limitations and Exclusions” Exclusions section; • Prescription medicine for nail fungus except for immunocompromised or diabetic patients; • Non-formulary drugs except as described in this Prescription Drug Program section. Pediatric Vision Benefits PEDIATRIC VISION BENEFITS (Be aware that this benefit is only covered for Members with Small Group Metal plans.) This section describes the services theservices and supplies available to Covered Persons under covered persons up to but not including the age 19 onlyof 19. These services and supplies must be provided and billed by Providers and must be Medically Necessary unless otherwise specified. The following Routine Vision Care Services routine vision care services are coveredcovered subject to the calendar year limitations outlined in the Summary of Benefits and Coverage: Vision Examinations - – Alliant will cover comprehensive examination components as follows: • a case history history; • general patient observation observation; • clinical and diagnostic testing and evaluation evaluation; • inspection of conjunctivae and sclera sclera; • examination of orbits orbits; • test visual acuity acuity; • gross visual field testing testing; • ocular motility motility; • binocular testing testing; • examination of irises, cornea(s), lenses, and anterior xxxxxxxx xxxxxxxx; • examination of pupils pupils; • measurement of intraocular pressure (tonometry) ); • ophthalmoscopic examinations examination; • determination of refract status status; • color vision testing testing; • stereopsis testing testing; • case presentation including summary findings and recommendations including prescribing Lenses Lenses. Lenses and Frames - – Alliant will cover prescribed Lenses and Frames; see limitations below. Alliant will cover the following services only when performed to obtain prescribed Lenses and Frames: • facial measurements and determination of interpupillary distance distance. • assistance in choosing Frames Frames. • verification of Lenses as prescribed prescribed. • after-care for a reasonable period of time for fitting and adjustment. Contact Lens Evaluations and Follow-up - – Alliant will cover contact lens compatibility tests, diagnostic evaluations, and diagnostic lens analysis to determine a patient's suitability for contact lenses or a change in contact lenses. Appropriate follow-up care is also covered. Pediatric Vision Coverage is not provided for (in contact lenses. In addition to those non-covered items listed in the "Exclusions" General Limitations and Exclusions section of this Certificate):, Pediatric Vision Coverage is not provided for: • An eye examination or materials ordered as a result of an eye examination prior to Your Effective Date; • Lenses which are not prescribed; • The replacement of Lenses or Frames except as specified in the Summary of Benefits and Coverage; • Safety glass, safety goggles, and sports glasses; • Services that Alliant determines are special or unusual; such as orthoptics, vision training and low vision aids; • Tints other than number one or two; • Tints with photosensitive or anti-reflective properties; • Progressive Lenses; • Spectacle lens treatments or "add-ons," except for tints Number One or Two; • Any surgical procedure for the correction of a visual refractive problem including, but not limited to, radial keratotomy and LASIK (laser in situ keratomileusis); • Non-Covered Services or services specifically excluded in the text of this Certificate. PEDIATRIC ORAL (DENTAL) BENEFITS (Be aware that this benefit is only covered for Members with Small Group Metal plans.) Pediatric dental benefits are available for covered Members, up to but not including, the age of 19. This pediatric coverage includes services for evaluations, preventive treatments and dental radiology. This benefit is subject to the Member’s Deductible and Coinsurance. Listed below are the Covered Services and any applicable limitations. DIAGNOSTIC AND PREVENTATIVE CARE Periodic and comprehensive oral evaluations - Limited to 2 per year. Limited, problem focused oral evaluations - Limited to 2 per year Periodontal Evaluations – Limit two per year. Service covered for Members who have symptoms of periodontal disease and for patients who have risk factors such as smoking, diabetes, or other issues. Not payable when prophylaxis or comprehensive oral evaluation is performed. Radiographs – The following radiographs are covered: • Bitewing X-Rays: Limit 2 per year • Full Mouth X-Rays: Limit 1 series per 3 years • Panoramic X-Rays: Limit 1 series per 5 years • Other X-Rays (intra-oral periapical and occlusal and extra-oral x-rays): As needed to diagnose specific treatment. Dental Cleaning (prophylaxis) – Limit 2 per year. Includes scaling and polishing procedures to remove plaque, tartar, and stain. Covered as child prophylaxis for Members 13 and Xxxxxxx and covered as adult prophylaxis for Members 14 and older. Fluoride Treatment – Topical Fluoride limited to two per year. Sealants or Preventive Resin Restorations – Limit one per tooth per 3 years. Service is for application of sealants to occlusal surface of permanent molars that are free of decay and restoration. Installation of initial space maintainers for retaining space when a primary tooth is lost – Does not include separate adjustment expenses. Recementation of space maintainers Removal of fixed space maintainers Emergency Treatment – Service covered for infection or temporary pain relief only if no other services outside of the exam and x-rays were performed on the same date of service. Out-of-Network emergency palliative care is covered at the same Member cost share as an In-Network Dentist BASIC AND RESTORATIVE SERVICES Fillings (restorations) – covered for primary or permanent teeth. Two types are covered: • Composite restorations are covered for anterior teeth only. Molar or Bicuspid teeth restorations will be alternative services and paid up to the maximum allowed for an Amalgam filling. Any remaining expenses incurred is the Member’s responsibility. One surface having multiple restorations is counted as one restoration. • Amalgam restorations are a mixture of metals formed to fill cavities that resulted from tooth decay; also known as “silver fillings”. One surface having multiple restorations is counted as one restoration. Pin Retention – Limit 1 time per 5 years. Covered as an addition to a restoration that is not combined with core build-up. Endodontic Therapy and Services – Covered on primary or permanent teeth. Limit once per tooth/root per lifetime. • Root Canal therapy and retreatment: includes treatment and fillings. Tests, labs, x-rays, intraoperative, tests, or other follow-up care is considered fundamental to the therapy; • Periradicular surgical procedures: refers to surgery to the external root surface and includes root amputation, tooth reimplementation, apicoectomy, and/or surgical isolation; • Partial pulpotomy for apexogenesis; • Vital pulpotomy; • Pulp debridement, pulp therapy; • Apexification/recalcification. MAJOR AND COMPLEX SERVICES Pre-fabricated Stainless Steel Crowns – Covered on primary or permanent teeth that cannot be restored with Composite or Amalgam restorations. Limit 1 per tooth per 5 years. Resin Based Composite Resin Crown, Anterior – Covered on primary or permanent teeth that cannot be restored with Composite or Amalgam restorations. Limit 1 per tooth per 5 years. Initial placements for permanent teeth: Covered when tooth cannot be repaired with direct placement filling material as a result of decay or injury. Includes onlays, crowns, veneers, core build-ups and posts and implant supported crowns and abutments. Limit to 1 per tooth per 5 years. Replacement of inlays, onlays, crowns or other restorations of permanent teeth – Treatment covered if: • 5 years have passed since initial placement and is not/cannot be made serviceable. • Accidental injury has caused damage beyond repair while restoration was in the oral cavity o Or • Extraction of functioning teeth (with the exception of third molars or teeth not in full occlusion with an opposing tooth or prosthesis requires replacement).
Appears in 1 contract
Samples: alliantplans.com
OTHER PROGRAM PROVISIONS. Should the Member, on his or her own accord, choose a Brand Name Drug over a Generic Drug, regardless of whether a Generic equivalent is available and even if the Physician orders the drug to be “dispensed as written,” the Member will pay the Copayment for the Generic Brand Drug as outlined in the Summary of Benefits and Coverage’s, PLUS the difference in the cost of the two drugs. The difference you will be charged between the two drug costs will not exceed $200 per prescription, not including the copayment. The following are not Covered Services under this ContractOUTPATIENT PRESCRIPTION DRUG BENEFITS DO NOT INCLUDE THE FOLLOWING: • Prescription drug Drug products for any amount dispensed which exceeds the FDA clinically recommended dosing schedule; • Prescription Drugs received through an Internet pharmacy provider or mail mail-order provider except for our designated mail order provider; • Newly approved FDA drugs that have not been approved for at least 180-180 days. ; • Non-legend vitamins; • Over-the-counter items; • Cosmetic drugs; • Appetite suppressants; • Weight loss products; • Diet supplements; • Syringes (for use other than insulin) except when in coordination with an approved injectable; Non-contraceptive injectables • Injectables (except with pre-certificationPrior Authorization as required); • The administration or injection of any Prescription Drug or any drugs or medicines; • Prescription Drugs which are entirely consumed or administered at the time and place where the prescription order is issued; • Prescription refills in excess of the number specified by the Physician, or any refill dispensed after one year from the date of the prescription order; • Prescription Drugs for which there is no charge; • Charges for items such as therapeutic devices, artificial appliances, or similar devices, regardless of their intended use; • Prescription Drugs for use as while an Inpatient or outpatient Outpatient of a Hospital and Hospital; • Prescription Drugs provided for use in a convalescent care facility or nursing home which are ordinarily furnished by such facility for the care and treatment of Inpatients; • Charges for delivery of any Prescription Drugs; • Drugs and medicines which do not require a prescription order prescription, and which are not Prescription Drugs (except insulin)Drugs; • Prescription Drugs provided by a Physician whether or not a charge is made for such Prescription Drugs; • Prescription Drugs which are not Medically Necessary or which we determine are not consistent with the diagnosis (See the Off-Label Drugs section for exceptions); • Prescription Drugs which we determine are not provided in accordance with accepted professional medical standards in the United States; • Any services or supplies, which are not specifically listed as covered under this Prescription Drug program; • Prescription Drugs which are Experimental or Investigational in nature as explained in the “General Limitations and Exclusions” Exclusions section; • Prescription medicine for nail fungus except for immunocompromised or diabetic patientsdiabeticpatients; • Non-formulary drugs except as described in this Prescription Drug Program section. Pediatric Vision Benefits PEDIATRIC VISION BENEFITS (Be aware that this benefit is only covered for members with Small Group Metal plans.) This section describes the services and supplies available to Covered Persons under covered persons up to but not including the age 19 onlyof 19. These services and supplies must be provided and billed by Providers and must be Medically Necessary unless otherwise specified. The following Routine Vision Care Services routine vision care services are coveredcovered subject to the calendar year limitations outlined in the Summary of Benefits and Coverage: Vision Examinations - – Alliant will cover comprehensive examination components as follows: • a case history • general patient observation • clinical and diagnostic testing and evaluation • inspection of conjunctivae and sclera • examination of orbits • test visual acuity • gross visual field testing • ocular motility • binocular testing • examination of irises, cornea(s), lenses, and anterior xxxxxxxx • examination of pupils • measurement of intraocular pressure (tonometry) • ophthalmoscopic examinations examination • determination of refract status • color vision testing • stereopsis testing • case presentation including summary findings and recommendations including prescribing Lenses Lenses and Frames - – Alliant will cover prescribed Lenses and Frames; see limitations below. Alliant will cover the following services only when performed to obtain prescribed Lenses and Frames: • facial measurements and determination of interpupillary distance distance. • assistance in choosing Frames Frames. • verification of Lenses as prescribed prescribed. • after-care for a reasonable period of time for fitting and adjustment. Contact Lens Evaluations and Follow-up - – Alliant will cover contact lens compatibility tests, diagnostic evaluations, and diagnostic lens analysis to determine a patient's suitability for contact lenses or a change in contact lenses. Appropriate follow-up care is also covered. Pediatric Vision Coverage is not provided for (in contact lenses. In addition to those non-covered items listed in the "Exclusions" General Limitations and Exclusions section of this Certificate):, Pediatric Vision Coverage is not provided for: • An eye examination or materials ordered as a result of an eye examination prior to your EffectiveDate; • Lenses which are not prescribed; • The replacement of Lenses or Frames except as specified in the Summary of Benefits andCoverage; • Safety glass, safety goggles and sports glasses; • Services that Alliant determines are special or unusual; such as orthoptics, vision training and low vision aids; • Tints other than number one or two; • Tints with photosensitive or antireflective properties; • Progressive Lenses; • Spectacle lens treatments or "add-ons", except for tints Number One or Two; • Any surgical procedure for the correction of a visual refractive problem including, but not limited to, radial keratotomy and LASIK (laser in situ keratomileusis); • Non-Covered Services or services specifically excluded in the text of this Certificate. PEDIATRIC ORAL (DENTAL) BENEFITS (Be aware that this benefit is only covered for members with Small Group Metal plans.) Pediatric dental benefits are available for covered Members, up to but not including, the age of 19. This pediatric coverage includes services for evaluations, preventive treatments and dental radiology. This benefit is subject to the Member’s Deductible and Coinsurance. Listed below are the Covered Services and any applicable limitations. Clinical Oral Evaluation Combined limit of 2 evaluations per year (all limits are on a calendar year basis) Periodic oral evaluation Limited to 2 per year; with a minimum of 6 months apart. Benefit is only allowed for a covered person showing signs or symptoms of periodontal disease and for patients with risk factors such as smoking, diabetes or related health issues. No benefit is payable when performed with a cleaning (prophylaxis). Benefit is not available when comprehensive oral evaluation is performed. Limited oral evaluation – problem focused Limited to 2 per year; with a minimum of 6 months apart. Oral evaluation for a patient under 3 years of age and counseling with primary caregiver Limited to 2 per year; with a minimum of 6 months apart. Comprehensive oral evaluation Limited to 2 per year; with a minimum of 6 months apart. Comprehensive periodontal evaluation Limited to 2 per year; with a minimum of 6 months apart. Benefit is only allowed for a covered person showing signs or symptoms of periodontal disease and for patients with risk factors such as smoking, diabetes or related health issues. No benefit is payable when performed with a cleaning (prophylaxis). Benefit is not available when comprehensive oral evaluation is performed. Palliative treatment of dental pain Emergency basis Dental Radiology Intraoral – complete series (including bitewings) Limited to 1 every 5 years. A complete series is a least 14 films, including bitewings. Intraoral – periapical first film Limited to 2 sets per year* Intraoral – periapical, each additional film Limited to 2 sets per year* Intraoral – occlusal film Limited to x-rays necessary to diagnose a specific treatment. Bitewings – single film Limited to 2 sets per year* Bitewings – 2 films Limited to 2 sets per year* Bitewings – 4 films Limited to 2 sets per year* Vertical bitewings – 7-8 films Limited to 2 sets per year* Panoramic film Limited to 1 every 5 years. Cephalometric x-ray Limited to x-rays necessary to diagnose a specific treatment. Oral/Facial Photographic Images Limited to x-rays necessary to diagnose a specific treatment. Preventive Treatment Prophylaxis – adult (to age 19), including all scaling and polishing procedures. Limited to 2 per year; with a minimum of 6 months apart. Prophylaxis – child, including all scaling and polishing procedures. Limited to 2 per year; with a minimum of 6 months apart. Topical application of fluoride varnish Limited to 2 per year; with a minimum of 6 months apart. Topical application of fluoride – excluding varnish Limited to 2 per year; with a minimum of 6 months apart. Sealant – per tooth – unrestored permanent molars Limited to 1 per tooth every 3 years. Space maintainer – fixed – unilateral Installation of initial space maintainers for retaining space when a primary tooth is prematurely lost. Benefit does not include separate adjustment expenses. Space maintainer – fixed – bilateral Installation of initial space maintainers for retaining space when a primary tooth is prematurely lost. Benefit does not include separate adjustment expenses. Space maintainer – removable Installation of initial space maintainers for retaining space when a primary tooth is prematurely lost. Benefit does not include separate adjustment expenses. Space maintainer – removable Installation of initial space maintainers for retaining space when a primary tooth is prematurely lost. Benefit does not include separate adjustment expenses. Re-cementation of space maintainer As required for fixed space maintainer GENERAL LIMITATIONS AND EXCLUSIONS WHAT IS NOT COVERED Your coverage does not provide benefits for: • Abortion and care for abortion are not covered. • Acupuncture – Acupuncture and acupressure therapy. • Allergy Services – Specific non-standard allergy services and supplies, including but not limited to, skin titration (Xxxxxx method), cytotoxicity testing (Xxxxx’x Test), treatment of non- specific candida sensitivity, and urine autoinjections. • Ambulance Service – Usage is not covered when another type of transportation can be used without endangering the Member’s health. Any ambulance usage for the convenience of the Member, family or Physician is not a Covered Service. Non-Covered Services for Ambulance include but are not limited to, trips to: A Physician’s office or clinic; a morgue or funeral home. Coverage is not available for air ambulance transport from a Hospital capable of treating the patient because the patient and/or the patient’s family prefer a specific hospital or Physician. Air ambulance services are not covered for transport to a Hospital that is not an acute care hospital, such as a nursing facility, physician’s office, or your home. • Animal Assisted Therapy • Aquatic Therapy • Aromatherapy • Beautification Procedures – Cosmetic Surgery, reconstructive surgery, pharmacological services, nutritional regimens or other services for beautification, or treatment relating to the consequences of, or as a result of, Cosmetic Surgery (including reimplantation). This exclusion includes, but is not limited to, surgery to correct gynecomastia and breast augmentation procedures, and otoplasties. Reduction mammoplasty and services for the correction of asymmetry, except when determined to be Medically Necessary by Alliant, is not covered. o This exclusion does not apply to surgery to restore function if any body area has been altered by disease, trauma, Congenital/developmental Anomalies, or previous therapeutic processes. This exclusion does not apply to surgery to correct the results of Injuries when performed within two years of the event causing the impairment, or as a continuation of a staged reconstruction procedure, or congenital defects necessary to restore normal bodily functions, including but not limited to, cleft lip and cleft palate. • Before Coverage Begins/After Coverage Ends – Services rendered, or supplies provided before coverage begins, i.e., before a Member’s Effective Date, or after coverage ends. Such services and supplies shall include but not be limited to Inpatient Hospital admissions which begin before a Member’s Effective Date, continue after the Member’s Effective Date. • Biomicroscopy – Biomicroscopy, field charting or aniseikonic investigation. • Care, Supplies, or Equipment – Care, supplies, or equipment not Medically Necessary, as determined by Alliant, for the treatment of an Injury or illness. Non-covered supplies are inclusive of but not limited to Band- Aids, tape, non-sterile gloves, thermometers, heating pads and bed boards. Other non-covered items include household supplies, including but not limited to, the purchase or rental of water purifiers, hypo-allergenic pillows, mattresses, or waterbeds, whirlpool, spa or swimming pools, exercise and massage equipment, air purifiers, central or unit air conditioners, humidifiers, dehumidifiers, escalators, elevators, ramps, stair glides, emergency alert equipment, handrails, heat appliances, improvements made to a Member’s house or place of business, and adjustments made to vehicles. Computer equipment to aid in speech or hearing loss. • Complications – Complications of non-covered procedures are not covered. • Counseling – Religious, marital and sex counseling, including services and treatment related to religious counseling, marital/relationship counseling and sex therapy.
Appears in 1 contract
Samples: alliantplans.com
OTHER PROGRAM PROVISIONS. Should the Member, on his or her own accord, choose a Brand Name Drug over a Generic Druggeneric drug, regardless of whether a Generic generic equivalent is available and even if the Physician orders the drug to be “dispensed as written,” the Member will pay the Copayment for the Generic Brand Drug as outlined in the Summary of Benefits and Coverage’s, PLUS the difference in the cost of the two drugstwodrugs. The difference you will be charged between the two drug costs will not exceed $200 per prescription, not including the copayment. The following are not Covered Services under this ContractOUTPATIENT PRESCRIPTION DRUG BENEFITS DO NOT INCLUDE THE FOLLOWING: • Prescription drug Drug products for any amount dispensed which exceeds the FDA clinically recommended dosing scheduledosingschedule; • Prescription Drugs received through an Internet pharmacy provider or mail mail-order provider except for our designated Ourdesignated mail order provider; • Newly approved FDA drugs that have not been approved for at least 180-180 days. ; • Non-legend vitamins; • Over-the-counter items; • Cosmetic drugs; • Appetite suppressants; • Weight loss products; • Diet supplements; • Syringes (for use other than insulin) except when in coordination with an approved injectable; Non-contraceptive injectables • Injectables (except with pre-certificationPrior Authorization as required); • The administration or injection of any Prescription Drug or any drugs or medicines; • Prescription Drugs which are entirely consumed or administered at the time and place where the prescription order is issued; • Prescription refills in excess of the number specified by the Physician, or any refill dispensed after one year from the date of the prescription order; • Prescription Drugs for which there is no charge; • Charges for items such as therapeutic devices, artificial appliances, or similar devices, regardless of their intended use; • Prescription Drugs for use as while an Inpatient or outpatient Outpatient of a Hospital and Hospital; • Prescription Drugs provided for use in a convalescent care facility or nursing home which are ordinarily furnished by such facility for the care and treatment of Inpatients; • Charges for delivery of any Prescription Drugs; • Drugs and medicines which do not require a prescription order prescription, and which are not Prescription Drugs (except insulin)Drugs; • Prescription Drugs provided by a Physician whether or not a charge is made for such Prescription Drugs; • Prescription Drugs which are not Medically Necessary or which we We determine are not consistent with the diagnosis (See the Off-Label Drugs for exceptionssection forexceptions); • Prescription Drugs which we We determine are not provided in accordance with accepted professional medical standards in the United States; • Any services or supplies, which are not specifically listed as covered under this Prescription Drug program; • Prescription Drugs which are Experimental or Investigational in nature as explained in the “General Limitations and Exclusions” Exclusions section; • Prescription medicine for nail fungus except for immunocompromised or diabetic patients; • Non-formulary drugs except as described in this Prescription Drug Program section. Pediatric Vision Benefits PEDIATRIC VISION BENEFITS This section describes the services theservices and supplies available to Covered Persons under covered persons up to but not including the age 19 onlyof 19. These services and supplies must be provided and billed by Providers and must be Medically Necessary unless otherwise specified. The following Routine Vision Care Services are covered: Vision Examinations - – Alliant will cover comprehensive examination components as follows: • a case history • general patient observation • clinical and diagnostic testing and evaluation • inspection of conjunctivae and sclera • examination of orbits • test visual acuity • gross visual field testing • ocular motility • binocular testing • examination of irises, cornea(s), lenses, and anterior xxxxxxxx • examination of pupils • measurement of intraocular pressure (tonometry) • ophthalmoscopic examinations • determination of refract status • color vision testing • stereopsis testing • case presentation including summary findings and recommendations including prescribing Lenses Lenses and Frames - – Alliant will cover prescribed Lenses and Frames; see limitations below. Alliant will cover the following services only when performed to obtain prescribed Lenses and Frames: • facial measurements and determination of interpupillary distance • assistance in choosing Frames • verification of Lenses as prescribed • after-care for a reasonable period of time for fitting and adjustment. adjustment Contact Lens Evaluations and Follow-up - – Alliant will cover contact lens compatibility tests, diagnostic evaluations, and diagnostic lens analysis to determine a patient's suitability for contact lenses or a change in contact lenses. Appropriate follow-up care upcare is also covered. Pediatric Vision Coverage is not provided for (in contact lenses. In addition to those non-covered items listed in the "Exclusions" General Limitations and Exclusions section of this Certificate):, PediatricVision Coverage is not provided for: • An eye examination or materials ordered as a result of an eye examination prior to Your Effective Date; • Lenses which are not prescribed; • The replacement of Lenses or Frames except as specified in the Summary of Benefits and Coverage; • Safety glass, safety goggles and sports glasses; • Services that Alliant determines are special or unusual; such as orthoptics, vision training and low vision aids; • Tints other than Number One or Two; • Tints with photosensitive or antireflective properties; • Progressive Lenses; • Spectacle lens treatments or "add-ons", except for tints Number One or Two; • Any surgical procedure for the correction of a visual refractive problem including, but not limited to, radial keratotomy and LASIK (laser in situ keratomileusis); • Non-Covered Services or services specifically excluded in the text of this Certificate. PEDIATRIC ORAL (DENTAL) BENEFITS Pediatric dental benefits are available for covered members, up to but not including, the age of 19. This pediatric coverage includes services for evaluations, preventive treatments and dental radiology. This benefit is subject to the member’s Deductibleand Coinsurance. Listed below are the Covered Services and any applicable limitations.
Appears in 1 contract
Samples: alliantplans.com
OTHER PROGRAM PROVISIONS. Should the Member, on his or her own accord, choose a Brand Name Drug over a Generic Drug, regardless of whether a Generic equivalent is available and even if the Physician orders the drug to be “dispensed as written,” the Member will pay the Copayment for the Generic Brand Drug as outlined in the Summary of Benefits and Coverage’s, PLUS the difference in the cost of the two drugs. The difference you will be charged between the two drug costs will not exceed $200 per prescription, not including the copayment. The following are not Covered Services under this ContractOUTPATIENT PRESCRIPTION DRUG BENEFITS DO NOT INCLUDE THE FOLLOWING: • Prescription drug Drug products for any amount dispensed which exceeds the FDA clinically recommended dosing schedule; • Prescription Drugs received through an Internet pharmacy provider or mail mail-order provider except for our designated mail order provider; • Newly approved FDA drugs that have not been approved for at least 180-180 days. ; • Non-legend vitamins; • Over-the-counter items; • Cosmetic drugs; • Appetite suppressants; • Weight loss products; • Diet supplements; • Syringes (for use other than insulin) except when in coordination with an approved injectable; Non-contraceptive injectables • Injectables (except with pre-certificationPrior Authorization as required); • The administration or injection of any Prescription Drug or any drugs or medicines; • Prescription Drugs which are entirely consumed or administered at the time and place where the prescription order is issued; • Prescription refills in excess of the number specified by the Physician, or any refill dispensed after one year from the date of the prescription order; • Prescription Drugs for which there is no charge; • Charges for items such as therapeutic devices, artificial appliances, or similar devices, regardless of their intended use; • Prescription Drugs for use as while an Inpatient or outpatient Outpatient of a Hospital and Hospital; • Prescription Drugs provided for use in a convalescent care facility or nursing home which are ordinarily furnished by such facility for the care and treatment of Inpatients; • Charges for delivery of any Prescription Drugs; • Drugs and medicines which do not require a prescription order prescription, and which are not Prescription Drugs (except insulin)Drugs; • Prescription Drugs provided by a Physician whether or not a charge is made for such Prescription Drugs; • Prescription Drugs which are not Medically Necessary or which we determine are not consistent with the diagnosis (See the Off-Label Drugs section for exceptions); • Prescription Drugs which we determine are not provided in accordance with accepted professional medical standards in the United States; • Any services or supplies, which are not specifically listed as covered under this Prescription Drug program; • Prescription Drugs which are Experimental or Investigational in nature as explained in the “General Limitations and Exclusions” Exclusions section; • Prescription medicine for nail fungus except for immunocompromised or diabetic patients; • Non-formulary drugs except as described in this Prescription Drug Program section. Pediatric Vision Benefits PEDIATRIC VISION BENEFITS This section describes the services and supplies available to Covered Persons under up to but not including the age 19 onlyof 19. These services and supplies must be provided and billed by Providers and must be Medically Necessary unless otherwise specified. The following Routine Vision Care Services are covered: Vision Examinations - – Alliant will cover comprehensive examination components as follows: • a case history • general patient observation • clinical and diagnostic testing and evaluation • inspection of conjunctivae and sclera • examination of orbits • test visual acuity • gross visual field testing • ocular motility • binocular testing • examination of irises, cornea(s), lenses, and anterior xxxxxxxx • examination of pupils • measurement of intraocular pressure (tonometry) • ophthalmoscopic examinations • determination of refract status • color vision testing • stereopsis testing • case presentation including summary findings and recommendations including prescribing Lenses Lenses and Frames - – Alliant will cover prescribed Lenses and Frames; see limitations below. Alliant will cover the following services only when performed to obtain prescribed Lenses and Frames: • facial measurements and determination of interpupillary distance • assistance in choosing Frames • verification of Lenses as prescribed • after-care for a reasonable period of time for fitting and adjustment. adjustment Contact Lens Evaluations and Follow-up - – Alliant will cover contact lens compatibility tests, diagnostic evaluations, and diagnostic lens analysis to determine a patient's suitability for contact lenses or a change in contact lenses. Appropriate follow-up care is also covered. Pediatric Vision Coverage is not provided for (in contact lenses. In addition to those non-covered items listed in the "Exclusions" General Limitations and Exclusions section of this Certificate):, Pediatric Vision Coverage is not provided for: • An eye examination or materials ordered as a result of an eye examination prior to your Effective Date; • Lenses which are not prescribed; • The replacement of Lenses or Frames except as specified in the Summary of Benefits and Coverage; • Safety glass, safety goggles and sports glasses; • Services that Alliant determines are special or unusual; such as orthoptics, vision training and low vision aids; • Tints other than Number One or Two; • Tints with photosensitive or antireflective properties; • Progressive Lenses; • Spectacle lens treatments or "add-ons", except for tints Number One or Two; • Any surgical procedure for the correction of a visual refractive problem including, but not limited to, radial keratotomy and LASIK (laser in situ keratomileusis); • Non-Covered Services or services specifically excluded in the text of this Certificate. PEDIATRIC ORAL (DENTAL) BENEFITS Pediatric dental benefits are available for covered members, up to but not including, the age of 19. This pediatric coverage includes services for evaluations, preventive treatments and dental radiology. This benefit is subject to the member’s Deductible and Coinsurance. Listed below are the Covered Services and any applicable limitations. Clinical Oral Evaluation Combined limit of 2 evaluations per year (all limits are on a calendar year basis) Periodic oral evaluation. Limited to 2 per year; with a minimum of 6 months apart. Benefit is only allowed for a covered person showing signs or symptoms of periodontal disease and for patients with risk factors such as smoking, diabetes or related health issues. No benefit is payable when performed with a cleaning (prophylaxis). Benefit is not available when comprehensive oral evaluation is performed. Limited oral evaluation – problem focused Limited to 2 per year; with a minimum of 6 months apart. Oral evaluation for a patient under 3 years of age and counseling with primary caregiver Limited to 2 per year; with a minimum of 6 months apart. Comprehensive oral evaluation Limited to 2 per year; with a minimum of 6 months apart. Comprehensive periodontal evaluation. Limited to 2 per year; with a minimum of 6 months apart. Benefit is only allowed for a covered person showing signs or symptoms of periodontal disease and for patients with risk factors such as smoking, diabetes or related health issues. No benefit is payable when performed with a cleaning (prophylaxis). Benefit is not available when comprehensive oral evaluation is performed. Palliative treatment of dental pain Emergency basis Dental Radiology Intraoral – complete series (including bitewings) Limited to 1 every 5 years. A complete series is a least 14 films, including bitewings. Intraoral – periapical first film Limited to 2 sets per year* Intraoral – periapical, each additional film Limited to 2 sets per year* Intraoral – occlusal film Limited to x-rays necessary to diagnose a specific treatment. Bitewings – single film Limited to 2 sets per year* Bitewings – 2 films Limited to 2 sets per year* Bitewings – 4 films Limited to 2 sets per year* Vertical bitewings – 7-8 films Limited to 2 sets per year* Panoramic film Limited to 1 every 5 years Cephalometric x-ray Limited to x-rays necessary to diagnose a specific treatment. Oral/Facial Photographic Images Limited to x-rays necessary to diagnose a specific treatment. Preventive Treatment Prophylaxis – adult (to age 19), including all scaling and polishing procedures. Limited to 2 per year; with a minimum of 6 months apart. Prophylaxis – child, including all scaling and polishing procedures. Limited to 2 per year; with a minimum of 6 months apart. Topical application of fluoride varnish Limited to 2 per year; with a minimum of 6 months apart. Topical application of fluoride – excluding varnish Limited to 2 per year; with a minimum of 6 months apart. Sealant – per tooth – unrestored permanent molars Limited to 1 per tooth every 3 years. Space maintainer – fixed – unilateral Installation of initial space maintainers for retaining space when a primary tooth is prematurely lost. Benefit does not include separate adjustment expenses. Space maintainer – fixed – bilateral Installation of initial space maintainers for retaining space when a primary tooth is prematurely lost. Benefit does not include separate adjustment expenses. Space maintainer – removable Space maintainer – removable Re-cementation of space maintainer GENERAL LIMITATIONS AND EXCLUSIONS WHAT IS NOT COVERED Your coverage does not provide benefits for: • Abortion and care for abortion are not covered. • Acupuncture – Acupuncture and acupressure therapy. • Allergy Services – Specific non-standard allergy services and supplies, including but not limited to, skin titration (Xxxxxx method), cytotoxicity testing (Bryan’s Test), treatment of non-specific candida sensitivity, and urine autoinjections. • Ambulance Service– Usage is not covered when another type of transportation can be used without endangering the Member’s health. Any ambulance usage for the convenience of the Member, family or Physician is not a Covered Service. Non-Covered Services for Ambulance include but are not limited to, trips to: A Physician’s office or clinic; a morgue or funeral home. Coverage is not available for air ambulance transport from a Hospital capable of treating the patient because the patient and/or the patient’s family prefer a specific hospital or Physician. Air ambulance services are not covered for transport to a Hospital that is not an acute care hospital, such as a nursing facility, physician’s office, or your home. • Animal Assisted Therapy • Aquatic Therapy • Aromatherapy • Beautification Procedures – Cosmetic Surgery, reconstructive surgery, pharmacological services, nutritional regimens or other services for beautification, or treatment relating to the consequences of, or as a result of, Cosmetic Surgery (including reimplantation). This exclusion includes, but is not limited to, surgery to correct gynecomastia and breast augmentation procedures, and otoplasties. Reduction mammoplasty and services for the correction of asymmetry, except when determined to be Medically Necessary by Alliant, is not covered. o This exclusion does not apply to surgery to restore function if any body area has been altered by disease, trauma, Congenital/developmental Anomalies, or previous therapeutic processes. This exclusion does not apply to surgery to correct the results of Injuries when performed within two years of the event causing the impairment, or as a continuation of a staged reconstruction procedure, or congenital defects necessary to restore normal bodily functions, including but not limited to, cleft lip and cleft palate. • Before Coverage Begins/After Coverage Ends – Services rendered, or supplies provided before coverage begins, i.e., before a Member’s Effective Date, or after coverage ends. Such services and supplies shall include but not be limited to Inpatient Hospital admissions which begin before a Member’s Effective Date, continue after the Member’s Effective Date. • Behavioral Disorders – Behavioral modification, behavioral or educational disorder services and associated expenses related to confirmation of diagnosis, progress, staging or treatment of behavioral (conduct) problems, ADD, Oppositional Defiant Disorder, learning disabilities, intellectual disabilities and or developmental delays, anoxic birth injuries, birth defects, cerebral injury, non-acute head injuries, or cerebral palsy. • Biomicroscopy – Biomicroscopy, field charting or aniseikonic investigation. • Care, Supplies, or Equipment – Care, supplies, or equipment not Medically Necessary, as determined by Alliant, for the treatment of an Injury or illness. Non-covered supplies are inclusive of but not limited to Band- Aids, tape, non-sterile gloves, thermometers, heating pads and bed boards. Other non-covered items include household supplies, including but not limited to, the purchase or rental of water purifiers, hypo-allergenic pillows, mattresses, or waterbeds, whirlpool, spa or swimming pools, exercise and massage equipment, air purifiers, central or unit air conditioners, humidifiers, dehumidifiers, escalators, elevators, ramps, stair glides, emergency alert equipment, handrails, heat appliances, improvements made to a Member’s house or place of business, and adjustments made to vehicles. Computer equipment to aid in speech or hearing loss. • Complications – Complications of non-covered procedures are not covered. • Counseling – Religious, marital and sex counseling, including services and treatment related to religious counseling, marital/relationship counseling and sex therapy.
Appears in 1 contract
Samples: alliantplans.com
OTHER PROGRAM PROVISIONS. Should the Member, on his or her own accord, choose a Brand Name Drug over a Generic Drug, regardless of whether a Generic equivalent is available and even if the Physician orders the drug to be “dispensed as written,” the Member will pay the Copayment for the Generic Drug as outlined in the Summary of Benefits and Coverage’s, PLUS the difference in the cost of the two drugs. The difference you will be charged between the two drug costs will not exceed $200 per prescription, not including the copayment. The following are not Covered Services under this Contract: • Prescription drug products for any amount dispensed which exceeds the FDA clinically recommended dosing schedule; • Prescription Drugs received through an Internet pharmacy provider or mail order provider except for our designated mail order provider; • Newly approved FDA drugs that have not been approved for at least 180-days. • Non-legend vitamins; • Over-the-counter items; • Cosmetic drugs; • Appetite suppressants; • Weight loss products; • Diet supplements; • Syringes (for use other than insulin) except when in coordination with an approved injectable; • Non-contraceptive injectables injectable (except with pre-certificationPrior Authorization); • The administration or injection of any Prescription Drug or any drugs or medicines; • Prescription Drugs which are entirely consumed or administered at the time and place where the prescription order is issued; • Prescription refills in excess of the number specified by the Physician, or any refill dispensed after one year from the date of the prescription order; • Prescription Drugs for which there is no charge; • Charges for items such as therapeutic devices, artificial appliances, or similar devices, regardless of their intended use; • Prescription Drugs for use as an Inpatient or outpatient of a Hospital and Prescription Drugs provided for use in a convalescent care facility or nursing home which are ordinarily furnished by such facility for the care and treatment of Inpatients; • Charges for delivery of any Prescription Drugs; • Drugs and medicines which do not require a prescription order and which are not Prescription Drugs (except insulin); • Prescription Drugs provided by a Physician whether or not a charge is made for such Prescription Drugs; • Prescription Drugs which are not Medically Necessary or which we determine are not consistent with the diagnosis (See Off-Label Drugs for exceptions); • Prescription Drugs which we determine are not provided in accordance with accepted professional medical standards in the United States; • Any services or supplies, which are not specifically listed as covered under this Prescription Drug program; • Prescription Drugs which are Experimental or Investigational in nature as explained in the “Limitations and Exclusions” section; • Prescription medicine for nail fungus except for immunocompromised or diabetic patients; • Non-formulary drugs except as described in this Prescription Drug Program section. Pediatric Vision Benefits This section describes the services and supplies available to Covered Persons under up to but not including the age 19 onlyof 19. These services and supplies must be provided and billed by Providers and must be Medically Necessary unless otherwise specified. The following Routine Vision Care Services are covered: Vision Examinations - Alliant will cover comprehensive examination components as follows: • a case history • general patient observation • clinical and diagnostic testing and evaluation • inspection of conjunctivae and sclera • examination of orbits • test visual acuity • gross visual field testing • ocular motility • binocular testing • examination of irises, cornea(s), lenses, and anterior xxxxxxxx • examination of pupils • measurement of intraocular pressure (tonometry) • ophthalmoscopic examinations • determination of refract status • color vision testing • stereopsis testing • case presentation including summary findings and recommendations including prescribing Lenses Lenses and Frames - Alliant will cover the following services only when performed to obtain prescribed Lenses and Frames: • facial measurements and determination of interpupillary distance • assistance in choosing Frames • verification of Lenses as prescribed • after-care for a reasonable period of time for fitting and adjustment. Contact Lens Evaluations and Follow-up - Alliant will cover contact lens compatibility tests, diagnostic evaluations, and diagnostic lens analysis to determine a patient's suitability for contact lenses or a change in contact lenses. Appropriate follow-up care is also covered. Pediatric Vision Coverage is not provided for (in addition to those non-covered items listed in the "Exclusions" section of this Certificate):
Appears in 1 contract
Samples: alliantplans.com
OTHER PROGRAM PROVISIONS. Should the Member, on his or her own accord, choose a Brand Name Drug over a Generic Drug, regardless of whether a Generic equivalent is available and even if the Physician orders the drug to be “dispensed as written,” the Member will pay the Copayment for the Generic Brand Drug as outlined in the Summary of Benefits and Coverage’s, PLUS the difference in the cost of the two drugs. The difference you will be charged between the two drug costs will not exceed $200 per prescription, not including the copayment. The following are not Covered Services under this ContractOUTPATIENT PRESCRIPTION DRUG BENEFITS DO NOT INCLUDE THE FOLLOWING: • Prescription drug Drug products for any amount dispensed which exceeds the FDA clinically recommended dosing schedule; • Prescription Drugs received through an Internet pharmacy provider or mail mail-order provider except for our designated mail order provider; • Newly approved FDA drugs that have not been approved for at least 180-180 days. ; • Non-legend vitamins; • Over-the-counter items; • Cosmetic drugs; • Appetite suppressants; • Weight loss products; • Diet supplements; • Syringes (for use other than insulin) except when in coordination with an approved injectable; Non-contraceptive injectables • Injectables (except with pre-certificationPrior Authorization as required); • The administration or injection of any Prescription Drug or any drugs or medicines; • Prescription Drugs which are entirely consumed or administered at the time and place where the prescription order is issued; • Prescription refills in excess of the number specified by the Physician, or any refill dispensed after one year from the date of the prescription order; • Prescription Drugs for which there is no charge; • Charges for items such as therapeutic devices, artificial appliances, or similar devices, regardless of their intended use; • Prescription Drugs for use as while an Inpatient or outpatient Outpatient of a Hospital and Hospital; • Prescription Drugs provided for use in a convalescent care facility or nursing home which are ordinarily furnished by such facility for the care and treatment of Inpatients; • Charges for delivery of any Prescription Drugs; • Drugs and medicines which do not require a prescription order prescription, and which are not Prescription Drugs (except insulin)Drugs; • Prescription Drugs provided by a Physician whether or not a charge is made for such Prescription Drugs; • Prescription Drugs which are not Medically Necessary or which we determine are not consistent with the diagnosis (See the Off-Label Drugs section for exceptions); • Prescription Drugs which we determine are not provided in accordance with accepted professional medical standards in the United States; • Any services or supplies, which are not specifically listed as covered under this Prescription Drug program; • Prescription Drugs which are Experimental or Investigational in nature as explained in the “General Limitations and Exclusions” Exclusions section; • Prescription medicine for nail fungus except for immunocompromised or diabetic patients; • Non-formulary drugs except as described in this Prescription Drug Program section. Pediatric Vision Benefits PEDIATRIC VISION BENEFITS (Be aware that this benefit is only covered for members with Small Group Metal plans.) This section describes the services and supplies available to Covered Persons under covered persons up to but not including the age 19 onlyof 19. These services and supplies must be provided and billed by Providers and must be Medically Necessary unless otherwise specifiedotherwisespecified. The following Routine Vision Care Services routine vision care services are coveredcovered subject to the calendar year limitations outlined in the Summary of Benefits and Coverage: Vision Examinations - – Alliant will cover comprehensive examination components as follows: • a case history • general patient observation • clinical and diagnostic testing and evaluation • inspection of conjunctivae and sclera • examination of orbits • test visual acuity • gross visual field testing • ocular motility • binocular testing • examination of irises, cornea(s), lenses, and anterior xxxxxxxx • examination of pupils • measurement of intraocular pressure (tonometry) • ophthalmoscopic examinations ophthalmoscopicexaminations • determination of refract status • color vision testing • stereopsis testing • case presentation including summary findings and recommendations including prescribing Lenses Lenses and Frames - – Alliant will cover prescribed Lenses and Frames; see limitations below. Alliant will cover the following services only when performed to obtain prescribed Lenses and Frames: • facial measurements and determination of interpupillary distance distance. • assistance in choosing Frames Frames. • verification of Lenses as prescribed prescribed. • after-care for a reasonable period of time for fitting and adjustment. Contact Lens Evaluations and Follow-up - – Alliant will cover contact lens compatibility tests, diagnostic evaluations, and diagnostic lens analysis to determine a patient's suitability for contact lenses or a change in contact lenses. Appropriate follow-up care is also covered. Pediatric Vision Coverage is not provided for (in contact lenses. In addition to those non-covered items listed in the "Exclusions" General Limitations and Exclusions section of this Certificate):, Pediatric Vision Coverage is not provided for: • An eye examination or materials ordered as a result of an eye examination prior to your Effective Date; • Lenses which are not prescribed; • The replacement of Lenses or Frames except as specified in the Summary of Benefits and Coverage; • Safety glass, safety goggles and sports glasses; • Services that Alliant determines are special or unusual; such as orthoptics, vision training and low vision aids; • Tints other than number one or two; • Tints with photosensitive or antireflective properties; • Progressive Lenses; • Spectacle lens treatments or "add-ons", except for tints Number One or Two; • Any surgical procedure for the correction of a visual refractive problem including, but not limited to, radial keratotomy and LASIK (laser in situ keratomileusis); • Non-Covered Services or services specifically excluded in the text of this Certificate. PEDIATRIC ORAL (DENTAL) BENEFITS (Be aware that this benefit is only covered for members with Small Group Metal plans.) Pediatric dental benefits are available for covered Members, up to but not including, the age of 19. This pediatric coverage includes services for evaluations, preventive treatments and dental radiology. This benefit is subject to the Member’s Deductible and Coinsurance. Listed below are the Covered Services and any applicable limitations. Clinical Oral Evaluation Combined limit of 2 evaluations per year (all limits are on a calendar year basis) Periodic oral evaluation Limited to 2 per year; with a minimum of 6 months apart. Benefit is only allowed for a covered person showing signs or symptoms of periodontal disease and for patients with risk factors such as smoking, diabetes or related health issues. No benefit is payable when performed with a cleaning (prophylaxis). Benefit is not available when comprehensive oral evaluation is performed. Limited oral evaluation – problem focused Limited to 2 per year; with a minimum of 6 months apart. Oral evaluation for a patient under 3 years of age and counseling with primary caregiver Limited to 2 per year; with a minimum of 6 months apart. Comprehensive oral evaluation Limited to 2 per year; with a minimum of 6 months apart. Comprehensive periodontal evaluation Limited to 2 per year; with a minimum of 6 months apart. Benefit is only allowed for a covered person showing signs or symptoms of periodontal disease and for patients with risk factors such as smoking, diabetes or related health issues. No benefit is payable when performed with a cleaning (prophylaxis). Benefit is not available when comprehensive oral evaluation is performed. Palliative treatment of dental pain Emergency basis Dental Radiology Intraoral – complete series (including bitewings) Limited to 1 every 5 years. A complete series is a least 14 films, including bitewings. Intraoral – periapical first film Limited to 2 sets per year* Intraoral – periapical, each additional film Limited to 2 sets per year* Intraoral – occlusal film Limited to x-rays necessary to diagnose a specific treatment. Bitewings – single film Limited to 2 sets per year* Bitewings – 2 films Limited to 2 sets per year* Bitewings – 4 films Limited to 2 sets per year* Vertical bitewings – 7-8 films Limited to 2 sets per year* Panoramic film Limited to 1 every 5 years. Cephalometric x-ray Limited to x-rays necessary to diagnose a specific treatment. Oral/Facial Photographic Images Limited to x-rays necessary to diagnose a specific treatment. Preventive Treatment Prophylaxis – adult (to age 19), including all scaling and polishing procedures. Limited to 2 per year; with a minimum of 6 months apart. Prophylaxis – child, including all scaling and polishing procedures. Limited to 2 per year; with a minimum of 6 months apart. Topical application of fluoride varnish Limited to 2 per year; with a minimum of 6 months apart. Topical application of fluoride – excluding varnish Limited to 2 per year; with a minimum of 6 months apart. Sealant – per tooth – unrestored permanent molars Limited to 1 per tooth every 3 years. Space maintainer – fixed – unilateral Installation of initial space maintainers for retaining space when a primary tooth is prematurely lost. Benefit does not include separate adjustment expenses. Space maintainer – fixed – bilateral Installation of initial space maintainers for retaining space when a primary tooth is prematurely lost. Benefit does not include separate adjustment expenses. Space maintainer – removable Installation of initial space maintainers for retaining space when a primary tooth is prematurely lost. Benefit does not include separate adjustment expenses. Space maintainer – removable Installation of initial space maintainers for retaining space when a primary tooth is prematurely lost. Benefit does not include separate adjustment expenses. Re-cementation of space maintainer As required for fixed space maintainer GENERAL LIMITATIONS AND EXCLUSIONS WHAT IS NOT COVERED Your coverage does not provide benefits for: • Abortion and care for abortion are not covered. • Acupuncture – Acupuncture and acupressure therapy. • Allergy Services – Specific non-standard allergy services and supplies, including but not limited to, skin titration (Xxxxxx method), cytotoxicity testing (Xxxxx’x Test), treatment of non- specific candida sensitivity, and urine autoinjections. • Ambulance Service – Usage is not covered when another type of transportation can be used without endangering the Member’s health. Any ambulance usage for the convenience of the Member, family or Physician is not a Covered Service. Non-Covered Services for Ambulance include but are not limited to, trips to: A Physician’s office or clinic; a morgue or funeral home. Coverage is not available for air ambulance transport from a Hospital capable of treating the patient because the patient and/or the patient’s family prefer a specific hospital or Physician. Air ambulance services are not covered for transport to a Hospital that is not an acute care hospital, such as a nursing facility, physician’s office, or your home. • Animal Assisted Therapy • Aquatic Therapy • Aromatherapy • Beautification Procedures – Cosmetic Surgery, reconstructive surgery, pharmacological services, nutritional regimens or other services for beautification, or treatment relating to the consequences of, or as a result of, Cosmetic Surgery (including reimplantation). This exclusion includes, but is not limited to, surgery to correct gynecomastia and breast augmentation procedures, and otoplasties. Reduction mammoplasty and services for the correction of asymmetry, except when determined to be Medically Necessary by Alliant, is not covered. o This exclusion does not apply to surgery to restore function if any body area has been altered by disease, trauma, Congenital/developmental Anomalies, or previous therapeutic processes. This exclusion does not apply to surgery to correct the results of Injuries when performed within two years of the event causing the impairment, or as a continuation of a staged reconstruction procedure, or congenital defects necessary to restore normal bodily functions, including but not limited to, cleft lip and cleft palate. • Before Coverage Begins/After Coverage Ends – Services rendered, or supplies provided before coverage begins, i.e., before a Member’s Effective Date, or after coverage ends. Such services and supplies shall include but not be limited to Inpatient Hospital admissions which begin before a Member’s Effective Date, continue after the Member’s Effective Date. • Mental health exams and services – o Rendered in connection with mental illnesses not classified in the International Classification of Diseases of the U.S. Department of Health and Human Services; or extended beyond the period necessary for evaluation and diagnosis of learning and behavioral disabilities or intellectual disabilities and developmental delay; o Psychological testing for ability, aptitude, intelligence, or interest is not covered; o Mental Health Services that are primarily educational; o Religious, marital, gender, pre-marital, and sex counseling, including services and treatment related to religious counseling, marital and pre-marital/relationship, gender counseling and sex therapy; o Court-ordered services, or those required by court order as a condition of parole or probation; o Evaluation for the purpose of maintaining employment. • Biomicroscopy – Biomicroscopy, field charting or aniseikonic investigation. • Care, Supplies, or Equipment – Care, supplies, or equipment not Medically Necessary, as determined by Alliant, for the treatment of an Injury or illness. Non-covered supplies are inclusive of but not limited to Band- Aids, tape, non-sterile gloves, thermometers, heating pads and bed boards. Other non-covered items include household supplies, including but not limited to, the purchase or rental of water purifiers, hypo-allergenic pillows, mattresses, or waterbeds, whirlpool, spa or swimming pools, exercise and massage equipment, air purifiers, central or unit air conditioners, humidifiers, dehumidifiers, escalators, elevators, ramps, stair glides, emergency alert equipment, handrails, heat appliances, improvements made to a Member’s house or place of business, and adjustments made to vehicles. Computer equipment to aid in speech or hearing loss. • Complications – Complications of non-covered procedures are not covered. • Counseling – Religious, marital and sex counseling, including services and treatment related to religious counseling, marital/relationship counseling and sex therapy.
Appears in 1 contract
Samples: alliantplans.com
