Page 31 - Aegion PPO SPDs
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The most appropriate procedure, supply, equipment, or service must also be cost-effective compared to
other alternative interventions, including no intervention or the same intervention in an alternative setting.
Cost-effective does not always mean lowest cost. It does mean that as to the diagnosis or treatment of
Your illness, Injury or disease, the service is: (1) not more costly than another service or group of services
that is medically appropriate, or (2) the service is performed in the least costly setting that is medically
appropriate. For example, we will not provide coverage for an Inpatient admission for surgery if the surgery
could have been performed on an outpatient basis or an infusion or injection of a specialty drug provided
in the outpatient department of a Hospital if the Drug could be provided in a Physician’s office or the home
setting.
Medicare - The program of health care for the aged and disabled established by Title XVIII of the Social
Security Act, as amended.
Member - A Subscriber or Dependent who has satisfied the eligibility conditions, applied for coverage, been
approved by the Employer and for whom Fee payment has been made. Members are sometimes called
“You” or “Your.”
Network Provider - A Physician, health professional, Hospital, Pharmacy, or other individual, organization
and/or Facility that has entered into a contract, either directly or indirectly, with the Claims Administrator to
provide Covered Services to Members through negotiated reimbursement arrangements. A Network
Provider for one plan may not be a Network Provider for another. Please see “How to Find a Provider in
the Network” in the section How Your Plan Works for more information on how to find a Network Provider
for this Plan.
For Missouri residents, only POS Providers are Network Providers.
Network Transplant Facility – A Provider who has entered into a contractual agreement or is otherwise
engaged by the Claims Administrator or with another organization which has an agreement with the Claims
Administrator to provide Covered Services and certain administrative functions to You for the network
associated with this Benefit Booklet. A Hospital may be a Network Transplant Facility with respect to:
Certain Covered Transplant Procedures; or
All Covered Transplant Procedures.
New FDA Approved Drug Product or Technology - The first release of the brand name product or
technology upon the initial FDA New Drug Approval. Other applicable FDA approval for its biochemical
composition and initial availability in the marketplace for the indicated treatment and use.
New FDA Approved Drug Product or Technology does not include:
new formulations: a new dosage form or new formulation of an active ingredient already on the
market;
already marketed drug product but new manufacturer; a product that duplicates another firm’s
already marketed drug product (same active ingredient, formulation, or combination);
already marketed drug product, but new use: a new use for a drug product already marketed by
the same or a different firm; or
newly introduced Generic medication (Generic medications contain the same active ingredient as
their counterpart brand-named medications).
Non-Network Provider/Out-of-Network Provider - A Provider, including but not limited to, a Hospital,
Freestanding Ambulatory Facility (Surgical Center), Physician, Skilled Nursing Facility, Hospice, Home
Health Care Agency, other medical practitioner or Provider of medical services or supplies, that does not
have an agreement or contract with the Claims Administrator to provide services to its Members at the
time services are rendered.
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other alternative interventions, including no intervention or the same intervention in an alternative setting.
Cost-effective does not always mean lowest cost. It does mean that as to the diagnosis or treatment of
Your illness, Injury or disease, the service is: (1) not more costly than another service or group of services
that is medically appropriate, or (2) the service is performed in the least costly setting that is medically
appropriate. For example, we will not provide coverage for an Inpatient admission for surgery if the surgery
could have been performed on an outpatient basis or an infusion or injection of a specialty drug provided
in the outpatient department of a Hospital if the Drug could be provided in a Physician’s office or the home
setting.
Medicare - The program of health care for the aged and disabled established by Title XVIII of the Social
Security Act, as amended.
Member - A Subscriber or Dependent who has satisfied the eligibility conditions, applied for coverage, been
approved by the Employer and for whom Fee payment has been made. Members are sometimes called
“You” or “Your.”
Network Provider - A Physician, health professional, Hospital, Pharmacy, or other individual, organization
and/or Facility that has entered into a contract, either directly or indirectly, with the Claims Administrator to
provide Covered Services to Members through negotiated reimbursement arrangements. A Network
Provider for one plan may not be a Network Provider for another. Please see “How to Find a Provider in
the Network” in the section How Your Plan Works for more information on how to find a Network Provider
for this Plan.
For Missouri residents, only POS Providers are Network Providers.
Network Transplant Facility – A Provider who has entered into a contractual agreement or is otherwise
engaged by the Claims Administrator or with another organization which has an agreement with the Claims
Administrator to provide Covered Services and certain administrative functions to You for the network
associated with this Benefit Booklet. A Hospital may be a Network Transplant Facility with respect to:
Certain Covered Transplant Procedures; or
All Covered Transplant Procedures.
New FDA Approved Drug Product or Technology - The first release of the brand name product or
technology upon the initial FDA New Drug Approval. Other applicable FDA approval for its biochemical
composition and initial availability in the marketplace for the indicated treatment and use.
New FDA Approved Drug Product or Technology does not include:
new formulations: a new dosage form or new formulation of an active ingredient already on the
market;
already marketed drug product but new manufacturer; a product that duplicates another firm’s
already marketed drug product (same active ingredient, formulation, or combination);
already marketed drug product, but new use: a new use for a drug product already marketed by
the same or a different firm; or
newly introduced Generic medication (Generic medications contain the same active ingredient as
their counterpart brand-named medications).
Non-Network Provider/Out-of-Network Provider - A Provider, including but not limited to, a Hospital,
Freestanding Ambulatory Facility (Surgical Center), Physician, Skilled Nursing Facility, Hospice, Home
Health Care Agency, other medical practitioner or Provider of medical services or supplies, that does not
have an agreement or contract with the Claims Administrator to provide services to its Members at the
time services are rendered.
31
