Surgery Services This plan covers surgery services to treat a disease or injury when: • the operation is not experimental or investigational, or cosmetic in nature; • the operation is being performed at the appropriate place of service; and • the physician is licensed to perform the surgery. Preauthorization may be required for certain surgical services. Reconstructive Surgery for a Functional Deformity or Impairment This plan covers reconstructive surgery and procedures when the services are performed to relieve pain, or to correct or improve bodily function that is impaired as a result of: • a birth defect; • an accidental injury; • a disease; or • a previous covered surgical procedure. Functional indications for surgical correction do not include psychological, psychiatric or emotional reasons. This plan covers the procedures listed below to treat functional impairments. • abdominal wall surgery including panniculectomy (other than an abdominoplasty); • blepharoplasty and ptosis repair; • gastric bypass or gastric banding; • nasal reconstruction and septorhinoplasty; • orthognathic surgery including mandibular and maxillary osteotomy; • reduction mammoplasty; • removal of breast implants; • removal or treatment of proliferative vascular lesions and hemangiomas; • treatment of varicose veins; or • gynecomastia. Preauthorization may be required for these services.
Special Services Should the Trust have occasion to request the Adviser to perform services not herein contemplated or to request the Adviser to arrange for the services of others, the Adviser will act for the Trust on behalf of the Fund upon request to the best of its ability, with compensation for the Adviser's services to be agreed upon with respect to each such occasion as it arises.
Mastectomy Services Inpatient This plan provides coverage for a minimum of forty-eight (48) hours in a hospital following a mastectomy and a minimum of twenty-four (24) hours in a hospital following an axillary node dissection. Any decision to shorten these minimum coverages shall be made by the attending physician in consultation with and upon agreement with you. If you participate in an early discharge, defined as inpatient care following a mastectomy that is less than forty-eight (48) hours and inpatient care following an axillary node dissection that is less than twenty-four (24) hours, coverage shall include a minimum of one (1) home visit conducted by a physician or registered nurse.
Pharmacy Services The Contractor shall establish a network of pharmacies. The Contractor or its PBM must provide at least two (2) pharmacy providers within thirty (30) miles or thirty (30) minutes from a member’s residence in each county, as well as at least two (2) durable medical equipment providers in each county or contiguous county.
Cloud Services You will not intentionally (a) interfere with other customers’ access to, or use of, the Cloud Service, or with its security; (b) facilitate the attack or disruption of the Cloud Service, including a denial of service attack, unauthorized access, penetration testing, crawling, or distribution of malware (including viruses, trojan horses, worms, time bombs, spyware, adware, and cancelbots); (c) cause an unusual spike or increase in Your use of the Cloud Service that negatively impacts the Cloud Service’s operation; or (d) submit any information that is not contemplated in the applicable Documentation.
Security Services CONTRACTOR shall provide security services designed for preventing escapes, maintaining order, providing care, custody, control, supervision and management of the inmate population. A successful security program depends heavily on staff training, effective administration, and the establishment of inmate programs. The organization, staffing, and administration of the security program are vital to the Facility. The direction provided by a well-organized and clearly articulated operations manual, and emergency planning provides a solid base for successful administration. The final operations manual shall be submitted to the Bureau prior to the Service Commencement Date and shall be reviewed annually and updated as needed. Documentation of the review shall be provided annually to the On- Site Contract Monitor. Changes to the plan require written permission by the Contract Manager. The Department reserves the right to require changes to plans submitted to the Bureau.
Autism Services This plan covers the following services for the treatment of autism spectrum disorders. • Applied behavior analysis when provided and/or supervised by an individual licensed by the state in which the service is rendered. See the Summary of Medical Benefits for the amount that you pay. • Physical therapy, occupational therapy, and speech therapy services when rendered as part of the treatment of autism spectrum disorder. A benefit limit will not apply to these services. • Psychological and psychiatric services, and prescription drugs are also covered. See Behavioral Health Services and Prescription Drugs and Diabetic Equipment or Supplies for additional information. Coverage for autism spectrum disorders does not affect any obligation of a school district, a state or other governmental entity to provide services to an individual under an individualized family service plan, an individualized education program, or similar services required under state or federal law. Services related to autism that are furnished by school personnel are not covered under this plan.
Outpatient Dental Anesthesia Services This plan covers anesthesia services received in connection with a dental service when provided in a hospital or freestanding ambulatory surgical center and: • the use of this is medically necessary; and • the setting in which the service is received is determined to be appropriate. This plan also covers facility fees associated with these services.
Ambulance Services Ground Ambulance This plan covers local professional or municipal ground ambulance services when it is medically necessary to use these services, rather than any other form of transportation as required under R.I. General Law § 27-20-55. Examples include but are not limited to the following: • from a hospital to a home, a skilled nursing facility, or a rehabilitation facility after being discharged as an inpatient; • to the closest available hospital emergency room in an emergency situation; or • from a physician’s office to an emergency room. Our allowance for ground ambulance includes the services rendered by an emergency medical technician or paramedic, as well as any drugs, supplies and cardiac monitoring provided. Air and Water Ambulance This plan covers air and water ambulance services when: • the time needed to move a patient by land, or the instability of transportation by land, may threaten a patient’s condition or survival; or • if the proper equipment needed to treat the patient is not available from a ground ambulance. The patient must be transported to the nearest facility where the required services can be performed and the type of physician needed to treat the patient’s condition is available. Our allowance for the air or water ambulance includes the services rendered by an emergency medical technician or paramedic, as well as any drugs, supplies and cardiac monitoring provided.
