HomeMy WebLinkAboutRESPONSE - RFP - P682 BENEFITS (13)13. Charges for medical and related services including but not limited to, drugs, biological products, devices and medical,
surgical and diagnostic services which are determined by TakeCare to be experimental or investigational. Drugs,
biological products and devices are considered experimental or investigational if:
a. they have not received final approval from the appropriate government regulatory bodies, including the FDA; or
b. their use for the particular illness or injury being treated is not accepted as the standard of medical practice in the
community; or
c. drugs and biological products, when prescribed for experimental or non -FDA approved indications, unless listed as
a specific indication in the Drug Information for the Health Care Professional, published by the United States
Pharmacopeial Convention or in the American Hospital Formulary Services edition of Drug Information.
TakeCare considers any health care service, including organ and tissue transplants, to be experimental or
investigational, unless all of the following criteria are met:
a. the health care services are accepted in the appropriate medical community in which the treatment is rendered as
standard, safe, effective, and non -experimental or non -investigational for the illness or injury being treated;
b. the health care services are attainable outside of a research institution or research program for the illness or injury
being treated;
c. based on credible and accepted medical evidence, the health care services clearly improve the net health
outcomes as evaluated against alternative non -experimental or non -investigational health care services for the
illness or injury being treated.
14. Charges for medical supplies unless provided elsewhere in this Policy.
15. Charges for non-prescription drugs; vitamins, nutrients and food supplements - even if prescribed or administered by a
Doctor. This does not apply to the extent any of these is the only available source of nutrients.
16. Charges for nutritional counseling, educational services or food supplements.
17. Charges for penile prostheses are not covered unless in treatment of a documented non -psychiatric organic condition.
18. Charges for private duty nursing.
19. Charges for professional services for treatment which involves manual manipulation (with or without the application of
treatment modalities such as, but not limited to diathermy, ultrasound, heat and cold) of the spinal skeletal system
and/or surrounding tissue to restore proper articulation of joints, alignment of bones or nerve functions which are in
excess of:
a. a payment of $10.00 for each visit;
b. one visit on any one day; or
c. 50 visits during any one Calendar Year.
Except that, this limitation does not apply if such services are rendered:
a. during general anesthesia;
b. during a cutting operation; or
c. while the patient is confined in a hospital.
20. Charges for services of a person who usually lives in the same household as the Insured Individual, or who is a
member of his or her immediate family or the family of his or her spouse.
21. Charges for services or supplies furnished by an agency of the United States Government or a foreign government or
agency, unless excluding them is prohibited by law.
22. Charges for smoking cessation programs for treatment of nicotine or tobacco use, including nicotine gum and patches.