Common use of Schedule of Benefits Clause in Contracts

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 cancer screening in accordance with the well care schedule established by GHC, and immunizations and vaccinations listed as covered in the GHC drug formulary (approved drug list). A fee may be charged for health education programs. The well care schedule is available in GHC clinics, by accessing GHC’s website at xxx.xxx.xxx, or upon request. Covered Services provided during a preventive care visit, which are not in accordance with the GHC well care schedule, may be subject to Cost Shares.

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 2010GHC. Preventive care includes: routine mammography screening, physical examinations and routine laboratory tests for cancer screening in accordance with the well care schedule established by GHC, and immunizations and vaccinations listed as covered in the GHC drug formulary (approved drug list). A fee may be charged for health education programs. The well care schedule is available in GHC clinics, by accessing GHC’s website at xxx.xxx.xxx, or upon request. Covered Services provided during a preventive care visit, which are not in accordance with the GHC well care schedule, may be are subject to the applicable Cost Shares.

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. Hearing aid examinations, hearing aids and fittings when authorized by a GHC Provider. Excluded: a. Replacement costs of hearing aids due to loss, breakage or theft, unless at the time of such replacement the Member is eligible under the limitation set forth in the Allowances Schedule. b. Replacement parts, replacement batteries and maintenance costs. 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 2010GHC. Preventive care includes: routine mammography screening, physical examinations and routine laboratory tests for cancer screening in accordance with the well care schedule established by GHC, and immunizations and vaccinations listed as covered in the GHC drug formulary (approved drug list). A fee may be charged for health education programs. The well care schedule is available in GHC clinics, by accessing GHC’s website at xxx.xxx.xxx, or upon request. Covered Services provided during a preventive care visit, which are not in accordance with the GHC well care schedule, may be are subject to the applicable Cost Shares.