Scans in an Outpatient Setting. Positron Emission Tomography (PET) is a noninvasive diagnostic imaging procedure that quantifies biochemical processes in living tissue. Positron Emission Tomography (PET) scans in an outpatient setting require Prior Authorization. Practitioner/Provider Services This benefit has one or more exclusions as specified in the Exclusions Section. Practitioner/Provider services are those services that are reasonably required to maintain good health. Practitioner/Provider services include, but are not limited to, periodic examinations and office visits by: • A licensed Practitioner/Provider • Specialist services provided by other Health Care Professionals who are licensed to practice, are certified, and practicing as authorized by applicable law or authority • A medical group • An independent practice association • Other authority authorized by applicable state law Some Practitioner/Provider services require Prior Authorization. Refer to the Prior Authorization Section for Prior Authorization requirements. This Benefit includes, but not limited to, consultation and Health Care Services and supplies provided by your Practitioner/Provider as shown below: • Office visits/telemedicine visits provided by a qualified Practitioner/Provider. • Video Visits provided online between a designated Practitioner/Provider and patient about non-urgent healthcare matters. • Outpatient surgery and Inpatient surgery including necessary anesthesia services. Anesthesia may include hypnotherapy. • Hospital and Skilled Nursing Facility visits as part of continued supervision of Covered care • Allergy Services, including testing and serum • Sterilization procedures • Student Health Centers: Dependent Students attending school either in New Mexico or outside New Mexico may receive care through their Primary Care Physician or at the Student Health Center. A Prior Authorization is not needed prior to receiving care from the Student Health Center. Services provided outside of the Student Health Center are limited to Medically Necessary Covered services for the initial care or treatment of an Emergency Health Care Service or Urgent Care situation. • Second medical opinions. Cost Sharing will apply when you or your Practitioner/Provider requests the second medical opinion. Cost Sharing will not apply if we require a second medical opinion to evaluate the medical appropriateness of a diagnosis or service. Prescription Drugs/Medications This benefit has one or more exclusions as specified in th...
Scans in an Outpatient Setting. Positron Emission Tomography (PET) is a noninvasive diagnostic imaging procedure that quantifies biochemical processes in living tissue. Positron Emission Tomography (PET) scans in an outpatient setting require Prior Authorization. Practitioner/Provider Services Services provided by an Excluded Provider are not Covered. Any benefit or service, including pharmaceuticals, provided by an Excluded Provider as defined and maintained by the following regulatory agencies: Department of Health and Human Services; Office of the Inspector General (OIG); U.S. Department of Health; the General Services Administration; and the Office of Personnel Management, Office of Inspector General, which includes, but is not limited to, the: • Excluded Parties Lists System (EPLS), • List of Excluded Individuals/Entities (LEIE), • Office of Personnel Management (OPM). Office Visits, listed below, are not Covered. • Get acquainted visits without physical assessment or diagnostic or therapeutic intervention provided are not Covered. Infertility services, listed below, are not Covered. • Prescription Drugs and Injections • Reversal of voluntary sterilization is not Covered. • Donor sperm is not Covered. • In-vitro, Gamete Intra Fallopian Transfer (GIFT) and zygote intrafallopian transfer (ZIFT) fertilization are not Covered. • Storage or banking of sperm, ova (human eggs), embryos, zygotes or other human tissue is not Covered. Prescription Drugs/Medications • Prescription Drugs/Medications that require a Prior Authorization when Prior Authorization was not obtained are not Covered. • New Prescription Drugs/Medications for which the determination of criteria for Coverage has not yet been established by our Pharmacy and Therapeutics Committee are not Covered. • Prescription Drugs/Medications purchased outside the United States are not Covered. • Prescription Drugs/Medications, medicines, treatments, procedures, or devices that we determine are Experimental or Investigational are not Covered. • Prescription Drugs/Medications that have not been approved by the FDA are not Covered. • Prescription Drugs/Medications that are identified by Drug Efficacy Study Implementation (DESI) as Less than Effective (LTE) DESI drugs are not Covered. • Replacement Prescription Drugs/Medications resulting from loss, theft, or destruction are not Covered. • Disposable medical supplies, except when provided in a Hospital or a Practitioner’s/Provider’s office or by a home health professional, are not Covered. ...
