Schedule of Benefits. The Schedule of Benefits lists your expected Out-of-Pocket costs for Benefits and Prescription Drugs covered under the Plan.
Schedule of Benefits. Hospital Care
Schedule of Benefits. The Schedule of Benefits provides a list of the Covered Medical Expenses as described in this Policy. It outlines what percentage of those Covered Medical Expenses will be provided when services are incurred by an Insured to the extent those charges exceed any Deductible and/or Copay and/or Coinsurance amounts.
Schedule of Benefits. The Schedule of Benefits referred to in this policy wording is the Schedule of Benefits used in this policy wording and in the marketing material. The policy wording is to be read in conjunction with the Schedule of Benefits and vice versa.
Schedule of Benefits. In respect of Full Time Members of the armed forces police fire or prison services please see Endorsement A Age of Insured Person on the date of the accident Benefit 16 years and over Under 16 years 1 Death £50,000 £20,000 2 Loss of two or more Limbs or Loss of both Eyes or one of each or Loss of Hearing in both ears £100,000 £100,000
Schedule of Benefits. The section of this Contract that describes the Copayments, Deductibles, Coinsurance, Out-of-Pocket Limits, Preauthorization Requirements, and other limits on Covered Services. Service Area: The geographical area, designated by Us and approved by the State of New York, in which We provide coverage. Our Service Area consists of Albany, Clinton, Columbia, Essex, Xxxxxx, Xxxxxx, Xxxxxxxxxx, Rensselaer, Saratoga, Schenectady, Schoharie, Xxxxxx, and Washington.
Schedule of Benefits. The section of this Contract that describes the Copayments, Deductibles, Coinsurance, Out-of-Pocket Limits, Preauthorization requirements, Referral requirements, and other limits on Covered Services.
Schedule of Benefits. If there is a conflict between this Schedule of Benefits and any summaries provided to you, this Schedule of Benefits will control. Care Management There may be additional services that are available to you, such as disease management programs, discharge planning, health education, and patient advocacy. When you seek prior authorization for a Covered Health Care Service as required or are otherwise identified as meeting eligibility requirements for a care management program, we will work with you to engage in the care management process and to provide you with information about these additional services. Does Prior Authorization Apply We require prior authorization for certain Covered Health Care Services. Your Primary Care Physician and other Network providers are responsible for obtaining prior authorization before they provide these services to you. Please note that prior authorization is required even if you have an electronic referral submitted online to UnitedHealthcare by your Primary Care Physician to seek care from another Network Physician. We recommend that you confirm with us that all Covered Health Care Services have been prior authorized as required. Before receiving these services from a Network provider, you may want to call us to verify that the Hospital, Physician and other providers are Network providers and that they have obtained the required prior authorization. Network facilities and Network providers cannot bill you for services they do not prior authorize as required. You can call us at the telephone number on your ID card. What Will You Pay for Covered Health Care Services? Benefits for Covered Health Care Services are described in the tables below. Payment Information Annual Deductibles are calculated on a calendar year basis. Out-of-Pocket Limits are calculated on a calendar year basis. Benefit limits are calculated on a calendar year basis unless otherwise specifically stated. SAMPLE NOTE: When Covered Health Care Services are provided by an Indian Health Service provider, your cost share may be reduced. Payment Term And Description Amounts Annual Deductible The amount you pay for Covered Health Care Services per year before you are eligible to receive Benefits. The Annual Deductible applies to Covered Health Care Services under the Policy as indicated in this Schedule of Benefits including Covered Health Care Services provided under the Outpatient Prescription Drug Section. The Annual Deductible applies to Covered Health Care ...
Schedule of Benefits. The section of this Contract that describes the Copayments, Deductibles, Coinsurance, Out-of-Pocket Limits, Preauthorization Requirements, and other limits on Covered Services. Service Area: The geographical area, designated by Us and approved by the State of New York, in which We provide coverage. Our Service Area consists of Allegany, Chautauqua, Cattaraugus, Erie, Genesee, Niagara, Orleans and Wyoming.
Schedule of Benefits. Benefits are subject to all provisions of the Group Medical Coverage Agreement, including, without limitation, the Accessing Care provisions and General Exclusions. Members must refer to Section II., the Allowances Schedule, for Cost Shares and specific benefit limits that apply to benefits listed in this Schedule of Benefits. Members are entitled to receive only benefits and services that are Medically Necessary and clinically appropriate for the treatment of a Medical Condition as determined by GHC's Medical Director, or his/her designee, and as described herein. All Covered Services are subject to case management and utilization review at the discretion of GHC.
A. Hospital Care
1. Room and board, including private room when prescribed, and general nursing services.
2. Hospital services (including use of operating room, anesthesia, oxygen, x-ray, laboratory and radiotherapy services).
3. Alternative care arrangements may be covered as a cost-effective alternative in lieu of otherwise covered Medically Necessary hospitalization, or other covered Medically Necessary institutional care. Alternative care arrangements in lieu of covered hospital or other institutional care must be determined to be appropriate and Medically Necessary based upon the Member’s Medical Condition. Coverage must be authorized in advance by GHC as appropriate and Medically Necessary. Such care will be covered to the same extent the replaced Hospital Care is covered under the Agreement.
4. Drugs and medications administered during confinement.
5. Special duty nursing, when prescribed as Medically Necessary. If a Member is hospitalized in a non-GHC Facility, GHC reserves the right to require transfer of the Member to a GHC Facility, upon consultation between a GHC Provider and the attending physician. If the Member refuses to transfer, all further costs incurred during the hospitalization are the responsibility of the Member.
B. Medical and Surgical Care
1. Surgical services.
2. Diagnostic x-ray, nuclear medicine, ultrasound and laboratory services.
3. Family planning counseling services.
4. Hearing examinations to determine hearing loss.
5. Blood and blood derivatives and their administration.
6. Preventive care (well care) services for health maintenance in accordance with the well care schedule established by GHC and the Patient Protection and Affordable Care Act of 2010. Preventive care includes: routine mammography screening, physical examinations and routine laboratory tests for ...
