Services Subject to a Deductible--Osteoporosis Screening, Childhood Wellness and Preventive Care, General Anesthesia for Dental Procedures, Outpatient Prescription Drug Benefit
Participating Provider Services Subject to Calendar Year Deductible
(The following introductory wording is a summary. See "Benefits and Claim Procedures: Health Insurance co-pays and deductibles: A Primer" for complete wording.
(Typical wording*)
Subject to all Policy limitations, exclusions, applicable deductibles, co-pays and maximums, the Company agrees to pay for Policy-defined Covered Expenses for the following described services, if they are Medically Necessary:
16. Osteoporosis Screening: Services Provided by Participating Providers related to the diagnosis, treatment and management of osteoporosis, including bone mass measurement (bone density testing), on the same basis as any other Sickness.
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This provision allows for coverage for bone density testing measuring the strength of your bones.
| 17. Childhood Wellness and Preventive Care: Beginning on the first anniversary of the Issue Date, services Provided by Participating Providers to each Insured under the age 19 (24 if a Full-Time Student) for necessary Childhood Wellness Preventive Care by a Participating Provider no more than once every twelve (12) months up to a Calendar Year maximum payment by US of $250 per person per Calendar Year. |
This benefit provides coverage, subject to the stated limit, for a routine annual outpatient physical exam of each young insured, as defined above, performed by a participating provider, not in connection with any sickness or injury, but rather as an annual evaluation of the health status of the individual. It includes any necessary lab blood tests, urinalysis and x-rays.
18. General Anesthesia for Dental Procedures: Services for general anesthesia Provided by Participating Providers, and facility charges for outpatient Treatment in a Hospital or Ambulatory Surgical Center in connection with dental care if the Insured:
a. is 5 years of age or younger;
b. is a person with a diagnosed severe disability; or
c. is a person with a medical or behavioral condition which requires hospitalization or general anesthesia when dental care is provided.
Covered Expenses do not include dental care benefits, which may require general anesthesia in a Hospital or Ambulatory Surgical Center. |
Take note of the fact that this is only section covering the general anesthesia expense – not any of the other expenses related to the dental care that required the use of the anesthesia.
19. Outpatient Prescription Drug Benefit: Prescriptions filled and dispensed by a Participating Pharmacy. Provided, however, only the cost of the least expensive drug that may be used to treat the Insured's Sickness or Injury will be covered.
If a Generic Drug is available at the participating Pharmacy in substitute for a Brand Name Drug that was prescribed for the Insured, the amount of Covered Expenses for such Prescription shall be limited to the cost of such Generic Drug at the Participating Pharmacy. |
The coverage here is carefully limited to the cost of the least expensive drug that can effectively treat the condition and to the cost of the generic version if one is available. A "generic drug" is a prescription drug that contains the same active ingredients as an equivalent brand name drug that is no longer protected by patent. The brand name will not appear on the label of the generic equivalent; you will, however, see the same active ingredient(s) listed.
*Wording may vary from contract to contract and from state to state.
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