Common use of Outpatient Infusion Therapy Services Clause in Contracts

Outpatient Infusion Therapy Services. Services must be arranged by a PCP and approved through Prior Authorization by HMO. Some outpatient Infusion Therapy services for routine maintenance drugs have been identified as capable of being safely administered, outside of a Hospital. Your out-of-pocket expenses may be lower when these Covered Services are provided in an Infusion Suite, a home or an office instead of an Outpatient Hospital setting. Non-maintenance outpatient Infusion Therapy services will be covered the same as any other illness. The Schedule of Copayments and Benefit Limits describes payment for Infusion Therapy services. Outpatient Laboratory and X-Ray Services Laboratory and radiographic procedures, services and materials, including (but not limited to) diagnostic x-rays, x- ray therapy, chemotherapy, fluoroscopy, electrocardiograms, laboratory tests and therapeutic radiology services must be ordered, authorized or arranged by the PCP and provided through a Participating facility. Prior Authorization may be required. Rehabilitation Services and Habilitation Services Rehabilitation Services and physical, speech and occupational therapies that in the opinion of a Physician are Medically Necessary and meet or exceed Your treatment goals are provided when Prior Authorization is obtained or prescribed by Your PCP or Specialist. For a physically disabled person, treatment goals may include maintenance of functioning or prevention or slowing of further deterioration. Rehabilitation Services and Habilitation Services may be provided in the Provider’s office, in a Hospital as an inpatient, in an outpatient facility, or as home health care visits. Rehabilitation Services and Habilitation Services, including coverage for chiropractic services, are available from a Participating Provider when Prior Authorization is obtained or prescribed by Your PCP. Benefits are provided for Habilitation Services provided for a Member with a disabling condition when both of the following conditions are met: • the treatment is administered by one of the following Participating Providers: a licensed speech language pathologist, licensed audiologist, licensed occupational therapist, licensed physical therapist, Physician, licensed nutritionist, licensed social worker or licensed psychologist. • the initial or continued treatment must be proven and not Experimental/Investigational. Benefits for Habilitation Services do not apply to those services that are solely educational in nature or otherwise paid under state or federal law for purely educational services. Custodial Care, respite care, day care, therapeutic recreation, vocational training and residential treatment are not Habilitation Services. A service that does not help the Member to meet functional goals in a treatment plan within a prescribed time frame is not a Habilitation Service. Benefits for Durable Medical Equipment and prosthetic devices, when used as a component of Habilitation Services are described under Durable Medical Equipment and Prosthetic Appliances and Orthotic Devices. Treatment of Acquired Brain Injury will be covered the same as any other physical condition. Cognitive Rehabilitation therapy, cognitive communication therapy, neurocognitive therapy and Rehabilitation; neurobehavioral, neurophysiological, neuropsychological and psychophysiological testing or treatment; neurofeedback therapy, remediation, post-acute transition services and community reintegration services, including outpatient day treatment services, or any other post-acute treatment services are covered, if such services are necessary as a result of and related to an Acquired Brain Injury. To ensure that appropriate post-acute care treatment is provided, HMO includes coverage for periodic reevaluation for a Member who: (1) has incurred an Acquired Brain Injury; (2) has been unresponsive to treatment; and (3) becomes responsive to treatment at a later date. Services may be provided at a Hospital, an acute or post-acute Rehabilitation Hospital, an assisted living facility or any other facility at which appropriate services or therapies may be provided. Benefits for Autism Spectrum Disorder will not apply towards and are not subject to any Rehabilitation services and Habilitation services visits maximum indicated on Your Schedule of Copayments and Benefit Limits.

Outpatient Infusion Therapy Services. Services must be arranged by a PCP and approved through Prior Authorization by HMO. Some outpatient Infusion Therapy services for routine maintenance drugs have been identified as capable of being safely administered, outside of a Hospital. Your out-of-pocket expenses may be lower when these Covered Services are provided in an Infusion Suite, a home or an office instead of an Outpatient Hospital setting. Non-maintenance outpatient Infusion Therapy services will be covered the same as any other illness. The Schedule of Copayments and Benefit Limits SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS describes payment for Infusion Therapy services. Outpatient Laboratory and X-Ray Services Laboratory and radiographic procedures, services and materials, including (but not limited to) diagnostic x-rays, x- ray therapy, chemotherapy, fluoroscopy, electrocardiograms, laboratory tests and therapeutic radiology services must be ordered, authorized or arranged by the PCP and provided through a Participating facility. Prior Authorization may be required. Rehabilitation Services and Habilitation Services Rehabilitation Services and physical, speech and occupational therapies that in the opinion of a Physician are Medically Necessary and meet or exceed Your treatment goals are provided when Prior Authorization is obtained or prescribed by Your PCP or Specialist. For a physically disabled person, treatment goals may include maintenance of functioning or prevention or slowing of further deterioration. Rehabilitation Services and Habilitation Services may be provided in the Provider’s office, in a Hospital as an inpatient, in an outpatient facility, or as home health care visits. Rehabilitation Services and Habilitation Services, including coverage for chiropractic services, are available from a Participating Provider when Prior Authorization is obtained or prescribed by Your PCP. Benefits are provided for Habilitation Services provided for a Member with a disabling condition when both of the following conditions are met: • the treatment is administered by one of the following Participating Providers: a licensed speech language pathologist, licensed audiologist, licensed occupational therapist, licensed physical therapist, Physician, licensed nutritionist, licensed social worker or licensed psychologist. • the initial or continued treatment must be proven and not Experimental/Investigational. Benefits for Habilitation Services do not apply to those services that are solely educational in nature or otherwise paid under state or federal law for purely educational services. Custodial Care, respite care, day care, therapeutic recreation, vocational training and residential treatment are not Habilitation Services. A service that does not help the Member to meet functional goals in a treatment plan within a prescribed time frame is not a Habilitation Service. Benefits for Durable Medical Equipment and prosthetic devices, when used as a component of Habilitation Services are described under Durable Medical Equipment and Prosthetic Appliances and Orthotic Devices. Treatment of Acquired Brain Injury will be covered the same as any other physical condition. Cognitive Rehabilitation therapy, cognitive communication therapy, neurocognitive therapy and Rehabilitation; neurobehavioral, neurophysiological, neuropsychological and psychophysiological testing or treatment; neurofeedback therapy, remediation, post-acute transition services and community reintegration services, including outpatient day treatment services, or any other post-acute treatment services are covered, if such services are necessary as a result of and related to an Acquired Brain Injury. To ensure that appropriate post-acute care treatment is provided, HMO includes coverage for periodic reevaluation for a Member who: (1) has incurred an Acquired Brain Injury; (2) has been unresponsive to treatment; and (3) becomes responsive to treatment at a later date. Services may be provided at a Hospital, an acute or post-acute Rehabilitation Hospital, an assisted living facility or any other facility at which appropriate services or therapies may be provided. Benefits for Autism Spectrum Disorder will not apply towards and are not subject to any Rehabilitation services and Habilitation services visits maximum indicated on Your Schedule SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS. Maternity Care and Family Planning Services Maternity Care. HMO provides coverage for inpatient care for the mother and the newborn in a Hospital for a minimum of Copayments and Benefit Limits.forty-eight (48) hours following an uncomplicated vaginal delivery, or ninety-six (96) hours following an uncomplicated delivery by cesarean section. Prior Authorization is not required. Upon request, the length-of- stay may be extended if HMO determines that an extension is Medically Necessary. Covered Services, which may require Prior Authorization, include:

Outpatient Infusion Therapy Services. Services must be arranged by a PCP and approved through Prior Authorization by HMO. Some outpatient Infusion Therapy services for routine maintenance drugs have been identified as capable of being safely administered, outside of a Hospital. Your out-of-pocket expenses may be lower when these Covered Services are provided in an Infusion Suite, a home or an office instead of an Outpatient Hospital setting. Non-maintenance outpatient Infusion Therapy services will be covered the same as any other illness. The Schedule of Copayments and Benefit Benefits Limits describes payment for Infusion Therapy services. Outpatient Laboratory and X-Ray Services Laboratory and radiographic procedures, services and materials, including (but not limited to) diagnostic x-rays, x- ray therapy, chemotherapy, fluoroscopy, electrocardiograms, laboratory tests and therapeutic radiology services must be ordered, authorized or arranged by the PCP and provided through a Participating facility. Prior Authorization may be required. Rehabilitation Services and Habilitation Services Rehabilitation Services and physical, speech and occupational therapies that in the opinion of a Physician are Medically Necessary and meet or exceed Your treatment goals are provided when Prior Authorization is obtained or prescribed by Your PCP or Specialist. For a physically disabled person, treatment goals may include maintenance of functioning or prevention or slowing of further deterioration. Rehabilitation Services and Habilitation Services may be provided in the Provider’s office, in a Hospital as an inpatient, in an outpatient facility, or as home health care visits. Rehabilitation Services and Habilitation Services, including coverage for chiropractic services, are available from a Participating Provider when Prior Authorization is obtained or prescribed by Your PCP. Benefits are provided for Habilitation Services provided for a Member with a disabling condition when both of the following conditions are met: • the treatment is administered by one of the following Participating Providers: a licensed speech language pathologist, licensed audiologist, licensed occupational therapist, licensed physical therapist, Physician, licensed nutritionist, licensed social worker or licensed psychologist. • the initial or continued treatment must be proven and not Experimental/Investigational. Benefits for Habilitation Services do not apply to those services that are solely educational in nature or otherwise paid under state or federal law for purely educational services. Custodial Care, respite care, day care, therapeutic recreation, vocational training and residential treatment are not Habilitation Services. A service that does not help the Member to meet functional goals in a treatment plan within a prescribed time frame is not a Habilitation Service. Benefits for Durable Medical Equipment and prosthetic devices, when used as a component of Habilitation Services are described under Durable Medical Equipment and Prosthetic Appliances and Orthotic Devices. Treatment of Acquired Brain Injury will be covered the same as any other physical condition. Cognitive Rehabilitation therapy, cognitive communication therapy, neurocognitive therapy and Rehabilitation; neurobehavioral, neurophysiological, neuropsychological and psychophysiological testing or treatment; neurofeedback therapy, remediation, post-acute transition services and community reintegration services, including outpatient day treatment services, or any other post-acute treatment services are covered, if such services are necessary as a result of and related to an Acquired Brain Injury. To ensure that appropriate post-acute care treatment is provided, HMO includes coverage for periodic reevaluation for a Member who: (1) has incurred an Acquired Brain Injury; (2) has been unresponsive to treatment; and (3) becomes responsive to treatment at a later date. Services may be provided at a Hospital, an acute or post-acute Rehabilitation Hospital, an assisted living facility or any other facility at which appropriate services or therapies may be provided. Benefits for Autism Spectrum Disorder will not apply towards and are not subject to any Rehabilitation services and Habilitation services visits maximum indicated on Your Schedule of Copayments and Benefit Limits.

Outpatient Infusion Therapy Services. Services must be arranged by a PCP and approved through Prior Authorization Preauthorized by HMO. Some outpatient Infusion Therapy services for routine maintenance drugs have been identified as capable of being safely administered, outside of a Hospital. Your out-of-pocket expenses may be lower when these Covered Services are provided in an Infusion Suite, a home or an office instead of an Outpatient Hospital setting. Non-maintenance outpatient Infusion Therapy services will be covered the same as any other illness. The Schedule of Copayments and Benefit Limits describes payment for Infusion Therapy services. Outpatient Laboratory and X-Ray Services Laboratory and radiographic procedures, services and materials, including (but not limited to) diagnostic x-rays, x- ray therapy, chemotherapy, fluoroscopy, electrocardiograms, laboratory tests and therapeutic radiology services must be ordered, authorized or arranged by the PCP and provided through a Participating facility. Prior Authorization Preauthorization may be required. Rehabilitation Services and Habilitation Services Rehabilitation Services and physical, speech and occupational therapies that in the opinion of a Physician are Medically Necessary and meet or exceed Your treatment goals are provided when Prior Authorization is obtained preauthorized or prescribed by Your PCP or Specialist. For a physically disabled person, treatment goals may include maintenance of functioning or prevention or slowing of further deterioration. Rehabilitation Services and Habilitation Services may be provided in the Provider’s 's office, in a Hospital as an inpatient, in an outpatient facility, or as home health care visits. Rehabilitation Services and Habilitation Services, including coverage for chiropractic services, are available from a Participating Provider when Prior Authorization is obtained Preauthorized or prescribed by Your PCP. Benefits are provided for Habilitation Services provided for a Member with a disabling condition when both of the following conditions are met: • the The treatment is administered by one of the following Participating Providers: a licensed speech language pathologist, licensed audiologist, licensed occupational therapist, licensed physical therapist, Physician, licensed nutritionist, licensed social worker or licensed psychologist. • the The initial or continued treatment must be proven and not Experimental/Investigational. Benefits for Habilitation Services do not apply to those services that are solely educational in nature or otherwise paid under state or federal law for purely educational services. Custodial Care, respite care, day care, therapeutic recreation, vocational training and residential treatment are not Habilitation Services. A service that does not help the Member to meet functional goals in a treatment plan within a prescribed time frame is not a Habilitation Service. Benefits for Durable Medical Equipment and prosthetic devices, when used as a component of Habilitation Services are described under Durable Medical Equipment and Prosthetic Appliances and Orthotic Devices. Treatment of Acquired Brain Injury will be covered the same as any other physical condition. Cognitive Rehabilitation rehabilitation therapy, cognitive communication therapy, neurocognitive therapy and Rehabilitationrehabilitation; neurobehavioral, neurophysiological, neuropsychological and psychophysiological testing or treatment; neurofeedback therapy, remediation, post-acute transition services and community reintegration services, including outpatient day treatment services, or any other post-acute treatment services are covered, if such services are necessary as a result of and related to an Acquired Brain Injury. To ensure that appropriate post-acute care treatment is provided, HMO includes coverage for periodic reevaluation for a Member who: (1) has incurred an Acquired Brain Injury; (2) has been unresponsive to treatment; and (3) becomes responsive to treatment at a later date. Services may be provided at a Hospital, an acute or post-acute Rehabilitation Hospitalrehabilitation hospital, an assisted living facility or any other facility at which appropriate services or therapies may be provided. Benefits Maternity Care and Family Planning Services Maternity Care. HMO provides coverage for Autism Spectrum Disorder will inpatient care for the mother and the newborn in a Hospital for a minimum of forty-eight (48) hours following an uncomplicated vaginal delivery, or ninety-six (96) hours following an uncomplicated delivery by cesarean section. Preauthorization is not apply towards and are not subject to any Rehabilitation services and Habilitation services visits maximum indicated on Your Schedule of Copayments and Benefit Limits.required. Upon request, the length-of-stay may be extended if HMO determines that an extension is Medically Necessary. Covered Services, which may require Preauthorization, include:

Outpatient Infusion Therapy Services. Services must be arranged by a PCP and approved through Prior Authorization Preauthorized by HMO. Some outpatient Infusion Therapy services for routine maintenance drugs have been identified as capable of being safely administered, outside of a Hospital. Your out-of-pocket expenses may be lower when these Covered Services are provided in an Infusion Suite, a home or an office instead of an Outpatient Hospital setting. Non-maintenance outpatient Infusion Therapy services will be covered the same as any other illness. The Schedule of Copayments and Benefit Limits describes payment for Infusion Therapy services. Outpatient Laboratory and X-Ray Services Laboratory and radiographic procedures, services and materials, including (but not limited to) diagnostic x-rays, x- ray therapy, chemotherapy, fluoroscopy, electrocardiograms, laboratory tests and therapeutic radiology services must be ordered, authorized or arranged by the PCP and provided through a Participating facility. Prior Authorization Preauthorization may be required. Rehabilitation Services and Habilitation Services Rehabilitation Services and physical, speech and occupational therapies that in the opinion of a Physician are Medically Necessary and meet or exceed Your treatment goals are provided when Prior Authorization is obtained preauthorized or prescribed by Your PCP or Specialist. For a physically disabled person, treatment goals may include maintenance of functioning or prevention or slowing of further deterioration. Rehabilitation Services and Habilitation Services may be provided in the Provider’s office, in a Hospital as an inpatient, in an outpatient facility, or as home health care visits. Rehabilitation Services and Habilitation Services, including coverage for chiropractic services, are available from a Participating Provider when Prior Authorization is obtained Preauthorized or prescribed by Your PCP. Benefits are provided for Habilitation Services provided for a Member with a disabling condition when both of the following conditions are met: • the The treatment is administered by one of the following Participating Providers: a licensed speech language pathologist, licensed audiologist, licensed occupational therapist, licensed physical therapist, Physician, licensed nutritionist, licensed social worker or licensed psychologist. • the The initial or continued treatment must be proven and not Experimental/Investigational. Benefits for Habilitation Services do not apply to those services that are solely educational in nature or otherwise paid under state or federal law for purely educational services. Custodial Care, respite care, day care, therapeutic recreation, vocational training and residential treatment are not Habilitation Services. A service that does not help the Member to meet functional goals in a treatment plan within a prescribed time frame is not a Habilitation Service. Benefits for Durable Medical Equipment and prosthetic devices, when used as a component of Habilitation Services are described under Durable Medical Equipment and Prosthetic Appliances and Orthotic Devices. Treatment of Acquired Brain Injury will be covered the same as any other physical condition. Cognitive Rehabilitation rehabilitation therapy, cognitive communication therapy, neurocognitive therapy and Rehabilitationrehabilitation; neurobehavioral, neurophysiological, neuropsychological and psychophysiological testing or treatment; neurofeedback therapy, remediation, post-acute transition services and community reintegration services, including outpatient day treatment services, or any other post-acute treatment services are covered, if such services are necessary as a result of and related to an Acquired Brain Injury. To ensure that appropriate post-acute care treatment is provided, HMO includes coverage for periodic reevaluation for a Member who: (1) has incurred an Acquired Brain Injury; (2) has been unresponsive to treatment; and (3) becomes responsive to treatment at a later date. Services may be provided at a Hospital, an acute or post-acute Rehabilitation Hospitalrehabilitation hospital, an assisted living facility or any other facility at which appropriate services or therapies may be provided. Benefits Maternity Care and Family Planning Services Maternity Care. HMO provides coverage for Autism Spectrum Disorder will inpatient care for the mother and the newborn in a Hospital for a minimum of forty-eight (48) hours following an uncomplicated vaginal delivery, or ninety-six (96) hours following an uncomplicated delivery by cesarean section. Preauthorization is not apply towards and are not subject to any Rehabilitation services and Habilitation services visits maximum indicated on Your Schedule of Copayments and Benefit Limits.required. Upon request, the length-of-stay may be extended if HMO determines that an extension is Medically Necessary. Covered Services, which may require Preauthorization, include:

Outpatient Infusion Therapy Services. Services must be arranged by a PCP and approved through Prior Authorization Preauthorized by HMO. Some outpatient Infusion Therapy services for routine maintenance drugs have been identified as capable of being safely administered, outside of a Hospital. Your out-of-pocket expenses may be lower when these Covered Services are provided in an Infusion Suite, a home or an office instead of an Outpatient Hospital setting. Non-Non- maintenance outpatient Infusion Therapy services will be covered the same as any other illness. The Schedule of Copayments and Benefit Benefits Limits describes payment for Infusion Therapy services. Outpatient Laboratory and X-Ray Services Laboratory and radiographic procedures, services and materials, including (but not limited to) diagnostic x-rays, x- x-ray therapy, chemotherapy, fluoroscopy, electrocardiograms, laboratory tests and therapeutic radiology services must be ordered, authorized or arranged by the PCP and provided through a Participating facility. Prior Authorization Preauthorization may be required. Rehabilitation Services and Habilitation Services Rehabilitation Services and physical, speech and occupational therapies that in the opinion of a Physician are Medically Necessary and meet or exceed Your treatment goals are provided when Prior Authorization is obtained preauthorized or prescribed by Your PCP or Specialist. For a physically disabled person, treatment goals may include maintenance of functioning or prevention or slowing of further deterioration. Rehabilitation Services and Habilitation Services may be provided in the Provider’s office, in a Hospital as an inpatient, in an outpatient facility, or as home health care visits. Rehabilitation Services and Habilitation Services, including coverage for chiropractic services, are available from a Participating Provider when Prior Authorization is obtained Preauthorized or prescribed by Your PCP. Benefits are provided for Habilitation Services provided for a Member with a disabling condition when both of the following conditions are met: • the The treatment is administered by one of the following Participating Providers: a licensed speech language pathologist, licensed audiologist, licensed occupational therapist, licensed physical therapist, Physician, licensed nutritionist, licensed social worker or licensed psychologist. • the The initial or continued treatment must be proven and not Experimental/Investigational. Benefits for Habilitation Services do not apply to those services that are solely educational in nature or otherwise paid under state or federal law for purely educational services. Custodial Care, respite care, day care, therapeutic recreation, vocational training and residential treatment are not Habilitation Services. A service that does not help the Member to meet functional goals in a treatment plan within a prescribed time frame is not a Habilitation Service. Benefits for Durable Medical Equipment and prosthetic devices, when used as a component of Habilitation Services are described under Durable Medical Equipment and Prosthetic Appliances and Orthotic Devices. Treatment of Acquired Brain Injury will be covered the same as any other physical condition. Cognitive Rehabilitation rehabilitation therapy, cognitive communication therapy, neurocognitive therapy and Rehabilitationrehabilitation; neurobehavioral, neurophysiological, neuropsychological and psychophysiological testing or treatment; neurofeedback therapy, remediation, post-acute transition services and community reintegration services, including outpatient day treatment services, or any other post-acute treatment services are covered, if such services are necessary as a result of and related to an Acquired Brain Injury. To ensure that appropriate post-acute care treatment is provided, HMO includes coverage for periodic reevaluation for a Member who: (1) has incurred an Acquired Brain Injury; (2) has been unresponsive to treatment; and (3) becomes responsive to treatment at a later date. Services may be provided at a Hospital, an acute or post-acute Rehabilitation Hospitalrehabilitation hospital, an assisted living facility or any other facility at which appropriate services or therapies may be provided. Benefits for Autism Spectrum Disorder will not apply towards and are not subject to any Rehabilitation rehabilitation services and Habilitation habilitation services visits maximum indicated on Your Schedule of Copayments and Benefit Limits.