Transplant Services. If the following criteria are met, we cover stem cell rescue and transplants of organs, tissue, or bone marrow: You satisfy all medical criteria developed by Medical Group and by the facility providing the transplant; The facility is certified by Medicare; and A Plan Provider provides a written referral for care at the facility. After the referral to a transplant facility, the following applies: Unless otherwise authorized by Medical Group, transplants are covered only in our Service Area. If either Medical Group or the referral facility determines that you do not satisfy its respective criteria for transplant, we will pay only for covered Services you receive before that determination was made. Health Plan, Plan Hospitals, Medical Group and Plan Providers are not responsible for finding, furnishing, or ensuring the availability of a bone marrow or organ donor. We cover reasonable medical and hospital expenses as long as these expenses are directly related to a covered transplant for a donor, or an individual identified by Medical Group as a potential donor even if not a Member. Transplant Services Exclusions: Services related to non-human or artificial organs and their implantation. GG. Urgent Care As described below you are covered for Urgent Care Services anywhere in the world. “Urgent Care Services” are defined as Services required as the result of a sudden illness or injury, which requires prompt attention, but is not of an emergent nature.” Your Copayment or Coinsurance will be determined by the place of Service (i.e., at a Provider’s office or at an after hours urgent care center, as shown in the Summary of Services and Cost Shares section. Inside our Service Area We will cover reasonable charges for Urgent Care Services received from Plan Providers and Plan Facilities within the Service Area. If you require Urgent Care Services please call your primary care Plan Provider as follows: If your primary care Plan Physician is located at a Plan Medical Office please call: Inside the Washington, D.C. Metropolitan Area (000) 000-0000 TTY (000) 000-0000 Outside the Washington, D.C. Metropolitan Area 0-000-000-0000 TTY 0-000-000-0000 If your primary care Plan Physician is located in our network of Plan Providers, please call his or her office directly. You will find his or her telephone number on the front of your identification card. Outside our Service Area If you are injured or become ill while temporarily outside the Service Area, we will cover reasonable charges for Urgent Care Services as defined in this section. All follow-up care must be provided by a Plan Provider or Plan Facility. If you obtain prior approval from Health Plan, covered benefits include the cost of necessary ambulance or other special transportation Services medically required to transport you to a Plan Hospital or Plan Medical Office in the Service Area, or in the nearest Xxxxxx Foundation Health Plan Region for continuing or follow-up treatment. Urgent Care Limitations: We do not cover Services outside our Service Area for conditions that, before leaving the Service Area, you should have known might require Services while outside our Service Area, such as dialysis for end-stage renal disease, post-operative care following surgery, and treatment for continuing infections, unless we determine that you were temporarily outside our Service Area because of an extreme personal emergency. Urgent Care Exclusions: Urgent Care Services within our Service Area that were not provided by a Plan Provider or Plan Facility. HH. Vision Services Medical Treatment We will provide coverage for Medically Necessary treatment for diseases of or injuries to the eye. Such treatment shall be covered to the same extent as for other Medically Necessary treatments for illness or injury. Eye Exams We cover routine and necessary eye exams, including: Routine tests such as eye health and glaucoma tests; and Refraction exams to determine the need for vision correction and to provide a prescription for corrective lenses. Pediatric Eye Exams We cover the following for children under age 19 at no charge: One routine eye exam per year, including: Routine tests such as eye health and glaucoma tests; and Refraction exams to determine the need for vision correction and to provide a prescription for corrective lenses. Pediatric Lenses and Frames We cover the following for children under age 19 at no charge: One pair of lenses per year; One pair of frames per year from a select group of frames; Regular contact lenses (in lieu of lenses and frames) for the first regular supply for that contact lens per year; or Medically Necessary contact lenses up to two pair per eye per year. In addition, we cover the following Services: Eyeglass Lenses We provide a discount on the purchase of regular eyeglass lenses, including add-ons, when purchased at a Xxxxxx Permanente Optical Shop. Regular eyeglass lenses are any lenses with a refractive value. If only one eye needs correction, we also provide a balance lens for the other eye. Frames We provide a discount on the purchase of eyeglass frames, when purchased at a Xxxxxx Permanente Optical Shop. The discount includes the mounting of eyeglass lenses in the frame, original fitting of the frames, and subsequent adjustment. Contact Lenses We provide a discount on the initial fitting for contact lenses, when purchased at a Xxxxxx Permanente Optical Shop. Initial fitting means the first time you have ever been examined for contact lens wear at a Plan Facility. The discount includes the following Services: Fitting of contact lenses; Initial pair of diagnostic lenses (to assure proper fit); Insertion and removal of contact lens training; and Three (3) months of follow-up visits. You will also receive a discount on your initial purchase of contact lenses, if you choose to purchase them at the same time. Note: Additional contact lens Services are available without the discount from any Xxxxxx Permanente Optical Shop. Vision Exclusions: Industrial and athletic safety frames. Eyeglass lenses and contact lenses with no refractive value. Sunglasses without corrective lenses unless Medically Necessary. Any eye surgery solely for the purpose of correcting refractive defects of the eye, such as near-sightedness (myopia), far-sightedness (hyperopia), and astigmatism (for example, radial keratotomy, photo-refractive keratectomy, and similar procedures). Eye exercises. Contact lens Services other than the initial fitting and purchase of contact lenses as provided in this section. Replacement of lost, broken, or damaged lenses frames and contact lenses. Plano lenses. Lens adornment, such as engraving, faceting, or jewelling. Low-vision devices. Non-prescription products, such as eyeglass holders, eyeglass cases, and repair kits. Orthoptic (eye training) therapy.
Appears in 1 contract
Samples: Group Agreement
Transplant Services. If the following criteria are met, we cover stem cell rescue and transplants of organs, tissue, or bone marrow: • You satisfy all medical criteria developed by Medical Group and by the facility providing the transplant; • The facility is certified by Medicare; and • A Plan Provider provides a written referral for care at the facility. After the referral to a transplant facility, the following applies: • Unless otherwise authorized by Medical Group, transplants are covered only in our Service Area. • If either Medical Group or the referral facility determines that you do not satisfy its respective criteria for transplant, we will pay only for covered Services you receive before that determination was made. • Health Plan, Plan Hospitals, Medical Group and Plan Providers are not responsible for finding, furnishing, or ensuring the availability of a bone marrow or organ donor. • We cover reasonable medical and hospital expenses as long as these expenses are directly related to a covered transplant for a donor, or an individual identified by Medical Group as a potential donor even if not a Member. Transplant Services Exclusions: • Services related to non-human or artificial organs and their implantation. GG. Urgent Care As described below you are covered for Urgent Care Services anywhere in the world. “Urgent Care Services” are defined as Services required as the result of a sudden illness or injury, which requires prompt attention, but is not of an emergent nature.” Your Copayment or Coinsurance will be determined by the place of Service (i.e., at a Provider’s office or at an after hours urgent care center, as shown in the Summary of Services and Cost Shares section. Inside our Service Area We will cover reasonable charges for Urgent Care Services received from Plan Providers and Plan Facilities within the Service Area. If you require Urgent Care Services please call your primary care Plan Provider as follows: If your primary care Plan Physician is located at a Plan Medical Office please call: Inside the Washington, D.C. Metropolitan Area (000) 000-0000 TTY (000) 000-0000 Outside the Washington, D.C. Metropolitan Area 0-000-000-0000 TTY 0-000-000-0000 If your primary care Plan Physician is located in our network of Plan Providers, please call his or her office directly. You will find his or her telephone number on the front of your identification card. Outside our Service Area If you are injured or become ill while temporarily outside the Service Area, we will cover reasonable charges for Urgent Care Services as defined in this section. All follow-up care must be provided by a Plan Provider or Plan Facility. If you obtain prior approval from Health Plan, covered benefits include the cost of necessary ambulance or other special transportation Services medically required to transport you to a Plan Hospital or Plan Medical Office in the Service Area, or in the nearest Xxxxxx Kaiser Foundation Health Plan Region for continuing or follow-up treatment. Urgent Care Limitations: We do not cover Services outside our Service Area for conditions that, before leaving the Service Area, you should have known might require Services while outside our Service Area, such as dialysis for end-stage renal disease, post-operative care following surgery, and treatment for continuing infections, unless we determine that you were temporarily outside our Service Area because of an extreme personal emergency. Urgent Care Exclusions: • Urgent Care Services within our Service Area that were not provided by a Plan Provider or Plan Facility. HH. Vision Services Medical Treatment We will provide coverage for Medically Necessary treatment for diseases of or injuries to the eye. Such treatment shall be covered to the same extent as for other Medically Necessary treatments for illness or injury. Eye Exams We cover routine and necessary eye exams, including: • Routine tests such as eye health and glaucoma tests; and • Refraction exams to determine the need for vision correction and to provide a prescription for corrective lenses. Pediatric Eye Exams We cover the following for children under age 19 at no charge: • One routine eye exam per year, including: Routine tests such as eye health and glaucoma tests; and Refraction exams to determine the need for vision correction and to provide a prescription for corrective lenses. Pediatric Lenses and Frames We cover the following for children under age 19 at no charge: • One pair of lenses per year; • One pair of frames per year from a select group of frames; • Regular contact lenses (in lieu of lenses and frames) for the first regular supply for that contact lens per year; or • Medically Necessary contact lenses up to two pair per eye per year. In addition, we cover the following Services: Eyeglass Lenses We provide a discount on the purchase of regular eyeglass lenses, including add-ons, when purchased at a Xxxxxx Permanente Optical Shop. Regular eyeglass lenses are any lenses with a refractive value. If only one eye needs correction, we also provide a balance lens for the other eye. Frames We provide a discount on the purchase of eyeglass frames, when purchased at a Xxxxxx Permanente Optical Shop. The discount includes the mounting of eyeglass lenses in the frame, original fitting of the frames, and subsequent adjustment. Contact Lenses We provide a discount on the initial fitting for contact lenses, when purchased at a Xxxxxx Permanente Optical Shop. Initial fitting means the first time you have ever been examined for contact lens wear at a Plan Facility. The discount includes the following Services: • Fitting of contact lenses; • Initial pair of diagnostic lenses (to assure proper fit); • Insertion and removal of contact lens training; and • Three (3) months of follow-up visits. You will also receive a discount on your initial purchase of contact lenses, if you choose to purchase them at the same time. Note: Additional contact lens Services are available without the discount from any Xxxxxx Permanente Optical Shop. Vision Exclusions: • Industrial and athletic safety frames. • Eyeglass lenses and contact lenses with no refractive value. • Sunglasses without corrective lenses unless Medically Necessary. • Any eye surgery solely for the purpose of correcting refractive defects of the eye, such as near-sightedness (myopia), far-sightedness (hyperopia), and astigmatism (for example, radial keratotomy, photo-refractive keratectomy, and similar procedures). • Eye exercises. • Contact lens Services other than the initial fitting and purchase of contact lenses as provided in this section. • Replacement of lost, broken, or damaged lenses frames and contact lenses. • Plano lenses. • Lens adornment, such as engraving, faceting, or jewelling. • Low-vision devices. • Non-prescription products, such as eyeglass holders, eyeglass cases, and repair kits. • Orthoptic (eye training) therapy.
Appears in 1 contract
Samples: Group Agreement
Transplant Services. If the following criteria are met, we cover stem cell rescue and transplants of organs, tissue, or bone marrow: • You satisfy all medical criteria developed by Medical Group and by the facility providing the transplant; • The facility is certified by Medicare; and • A Plan Provider provides a written referral for care at the facility. After the referral to a transplant facility, the following applies: • Unless otherwise authorized by Medical Group, transplants are covered only in our Service Area. • If either Medical Group or the referral facility determines that you do not satisfy its respective criteria for transplant, we will pay only for covered Services you receive before that determination was made. • Health Plan, Plan Hospitals, Medical Group and Plan Providers are not responsible for finding, furnishing, or ensuring the availability of a bone marrow or organ donor. • We cover reasonable medical and hospital expenses as long as these expenses are directly related to a covered transplant for a donor, or an individual identified by Medical Group as a potential donor even if not a Member. Transplant Services Exclusions: • Services related to non-human or artificial organs and their implantation. GG. Urgent Care As described below you are covered for Urgent Care Services anywhere in the world. “Urgent Care Services” are defined as Services required as the result of a sudden illness or injury, which requires prompt attention, but is not of an emergent nature.” Your Copayment or Coinsurance will be determined by the place of Service (i.e., at a Provider’s office or at an after hours urgent care center, as shown in the Summary of Services and Cost Shares section. Inside our Service Area We will cover reasonable charges for Urgent Care Services received from Plan Providers and Plan Facilities within the Service Area. If you require Urgent Care Services please call your primary care Plan Provider as follows: If your primary care Plan Physician is located at a Plan Medical Office please call: Inside the Washington, D.C. Metropolitan Area (000) 000-0000 TTY (000) 000-0000 Outside the Washington, D.C. Metropolitan Area 0-000-000-0000 TTY 0-000-000-0000 If your primary care Plan Physician is located in our network of Plan Providers, please call his or her office directly. You will find his or her telephone number on the front of your identification card. Outside our Service Area If you are injured or become ill while temporarily outside the Service Area, we will cover reasonable charges for Urgent Care Services as defined in this section. All follow-up care must be provided by a Plan Provider or Plan Facility. If you obtain prior approval from Health Plan, covered benefits include the cost of necessary ambulance or other special transportation Services medically required to transport you to a Plan Hospital or Plan Medical Office in the Service Area, or in the nearest Xxxxxx Foundation Health Plan Region for continuing or follow-up treatment. Urgent Care Limitations: We do not cover Services outside our Service Area for conditions that, before leaving the Service Area, you should have known might require Services while outside our Service Area, such as dialysis for end-stage renal disease, post-operative care following surgery, and treatment for continuing infections, unless we determine that you were temporarily outside our Service Area because of an extreme personal emergency. Urgent Care Exclusions: • Urgent Care Services within our Service Area that were not provided by a Plan Provider or Plan Facility. HH. Vision Services Medical Treatment We will provide coverage for Medically Necessary treatment for diseases of or injuries to the eye. Such treatment shall be covered to the same extent as for other Medically Necessary treatments for illness or injury. Eye Exams We cover routine and necessary eye exams, including: • Routine tests such as eye health and glaucoma tests; and • Refraction exams to determine the need for vision correction and to provide a prescription for corrective lenses. Pediatric Eye Exams We cover the following for children under age 19 at no charge: • One routine eye exam per year, including: Routine tests such as eye health and glaucoma tests; and Refraction exams to determine the need for vision correction and to provide a prescription for corrective lenses. Pediatric Lenses and Frames We cover the following for children under age 19 at no charge: • One pair of lenses per year; • One pair of frames per year from a select group of frames; • Regular contact lenses (in lieu of lenses and frames) for the first regular supply for that contact lens per year; or • Medically Necessary contact lenses up to two pair per eye per year. In addition, we cover the following Services: Eyeglass Lenses We provide a discount on the purchase of regular eyeglass lenses, including add-ons, when purchased at a Xxxxxx Permanente Optical Shop. Regular eyeglass lenses are any lenses with a refractive value. If only one eye needs correction, we also provide a balance lens for the other eye. Frames We provide a discount on the purchase of eyeglass frames, when purchased at a Xxxxxx Permanente Optical Shop. The discount includes the mounting of eyeglass lenses in the frame, original fitting of the frames, and subsequent adjustment. Contact Lenses We provide a discount on the initial fitting for contact lenses, when purchased at a Xxxxxx Permanente Optical Shop. Initial fitting means the first time you have ever been examined for contact lens wear at a Plan Facility. The discount includes the following Services: • Fitting of contact lenses; • Initial pair of diagnostic lenses (to assure proper fit); • Insertion and removal of contact lens training; and • Three (3) months of follow-up visits. You will also receive a discount on your initial purchase of contact lenses, if you choose to purchase them at the same time. Note: Additional contact lens Services are available without the discount from any Xxxxxx Permanente Optical Shop. Vision Exclusions: • Industrial and athletic safety frames. • Eyeglass lenses and contact lenses with no refractive value. • Sunglasses without corrective lenses unless Medically Necessary. • Any eye surgery solely for the purpose of correcting refractive defects of the eye, such as near-sightedness (myopia), far-sightedness (hyperopia), and astigmatism (for example, radial keratotomy, photo-refractive keratectomy, and similar procedures). • Eye exercises. • Contact lens Services other than the initial fitting and purchase of contact lenses as provided in this section. • Replacement of lost, broken, or damaged lenses frames and contact lenses. • Plano lenses. • Lens adornment, such as engraving, faceting, or jewelling. • Low-vision devices. • Non-prescription products, such as eyeglass holders, eyeglass cases, and repair kits. • Orthoptic (eye training) therapy.
Appears in 1 contract
Samples: Group Agreement
Transplant Services. If the following criteria are met, we cover stem cell rescue and transplants of organs, tissue, or bone marrow: • You satisfy all medical criteria developed by Medical Group and by the facility providing the transplant; • The facility is certified by Medicare; and • A Plan Provider provides a written referral for care at the facility. After the referral to a transplant facility, the following applies: • Unless otherwise authorized by Medical Group, transplants are covered only in our Service Area. • If either Medical Group or the referral facility determines that you do not satisfy its respective criteria for transplant, we will pay only for covered Services you receive before that determination was made. • Health Plan, Plan Hospitals, Medical Group and Plan Providers are not responsible for finding, furnishing, or ensuring the availability of a bone marrow or organ donor. • We cover reasonable medical and hospital expenses as long as these expenses are directly related to a covered transplant for a donor, or an individual identified by Medical Group as a potential donor even if not a Member. Transplant Services Exclusions: • Services related to non-human or artificial organs and their implantation. GG. Urgent Care As described below you are covered for Urgent Care Services anywhere in the world. “Urgent Care Services” are defined as Services required as the result of a sudden illness or injury, which requires prompt attention, but is not of an emergent nature.” Your Copayment or Coinsurance will be determined by the place of Service (i.e., at a Provider’s office or at an after hours urgent care center, as shown in the Summary of Services and Cost Shares section. Inside our Service Area We will cover reasonable charges for Urgent Care Services received from Plan Providers and Plan Facilities within the Service Area. If you require Urgent Care Services please call your primary care Plan Provider as follows: If your primary care Plan Physician is located at a Plan Medical Office please call: Inside the Washington, D.C. Metropolitan Area (000) 000-0000 TTY (000) 000-0000 Outside the Washington, D.C. Metropolitan Area 0-000-000-0000 TTY 0-000-000-0000 If your primary care Plan Physician is located in our network of Plan Providers, please call his or her office directly. You will find his or her telephone number on the front of your identification card. Outside our Service Area If you are injured or become ill while temporarily outside the Service Area, we will cover reasonable charges for Urgent Care Services as defined in this section. All follow-up care must be provided by a Plan Provider or Plan Facility. If you obtain prior approval from Health Plan, covered benefits include the cost of necessary ambulance or other special transportation Services medically required to transport you to a Plan Hospital or Plan Medical Office in the Service Area, or in the nearest Xxxxxx Foundation Health Plan Region for continuing or follow-up treatment. Urgent Care Limitations: We do not cover Services outside our Service Area for conditions that, before leaving the Service Area, you should have known might require Services while outside our Service Area, such as dialysis for end-stage renal disease, post-operative care following surgery, and treatment for continuing infections, unless we determine that you were temporarily outside our Service Area because of an extreme personal emergency. Urgent Care Exclusions: • Urgent Care Services within our Service Area that were not provided by a Plan Provider or Plan Facility. HH. Vision Services Medical Treatment We will provide coverage for Medically Necessary treatment for diseases of or injuries to the eye. Such treatment shall be covered to the same extent as for other Medically Necessary treatments for illness or injury. Eye Exams We cover routine and necessary eye exams, including: • Routine tests such as eye health and glaucoma tests; and • Refraction exams to determine the need for vision correction and to provide a prescription for corrective lenses. Pediatric Eye Exams We cover the following for children under age 19 at no charge: • One routine eye exam per year, including: Routine tests such as eye health and glaucoma tests; and Refraction exams to determine the need for vision correction and to provide a prescription for corrective lenses. Pediatric Lenses and Frames We cover the following for children under age 19 at no charge: • One pair of lenses per year; • One pair of frames per year from a select group of frames; • Regular contact lenses (in lieu of lenses and frames) for the first regular supply for that contact lens per year; or • Medically Necessary contact lenses up to two pair per eye per year. In addition, we cover the following Services: Eyeglass Lenses We provide a discount on the purchase of regular eyeglass lenses, including add-ons, when purchased at a Xxxxxx Permanente Optical Shop. Regular eyeglass lenses are any lenses with a refractive value. If only one eye needs correction, we also provide a balance lens for the other eye. Frames We provide a discount on the purchase of eyeglass frames, when purchased at a Xxxxxx Permanente Optical Shop. The discount includes the mounting of eyeglass lenses in the frame, original fitting of the frames, and subsequent adjustment. Contact Lenses We provide a discount on the initial fitting for contact lenses, when purchased at a Xxxxxx Permanente Optical Shop. Initial fitting means the first time you have ever been examined for contact lens wear at a Plan Facility. The discount includes the following Services: • Fitting of contact lenses; • Initial pair of diagnostic lenses (to assure proper fit); • Insertion and removal of contact lens training; and • Three (3) months of follow-up visits. You will also receive a discount on your initial purchase of contact lenses, if you choose to purchase them at the same time. Note: Additional contact lens Services are available without the discount from any Xxxxxx Permanente Optical Shop. Vision Exclusions: • Industrial and athletic safety frames. • Eyeglass lenses and contact lenses with no refractive value. • Sunglasses without corrective lenses unless Medically Necessary. • Any eye surgery solely for the purpose of correcting refractive defects of the eye, such as near-sightedness (myopia), far-sightedness (hyperopia), and astigmatism (for example, radial keratotomy, photo-refractive keratectomy, and similar procedures). • Eye exercises. • Contact lens Services other than the initial fitting and purchase of contact lenses as provided in this section. • Replacement of lost, broken, or damaged lenses frames and contact lenses. • Plano lenses. • Lens adornment, such as engraving, faceting, or jewelling. • Low-vision devices. • Non-prescription products, such as eyeglass holders, eyeglass cases, and repair kits. • Orthoptic (eye training) therapy.
Appears in 1 contract
Samples: Your Group Agreement
