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as an addition to ambulatory treatment when it doesn't offer the intensity and structure needed to help you
with recovery.
· Supervised living arrangements which are residences such as facilities, group homes and supervised
apartments. They provide members with stable and safe housing and the opportunity to learn how to
manage their activities of daily living. They may be used as an addition to treatment when it doesn't offer
the intensity and structure needed to help you with recovery.

Therapeutically Equivalent - when Prescription Drug Products can be expected to produce essentially the same
therapeutic outcome and toxicity.
Unproven Service(s) - services, including medications, that are determined not to be effective for treatment of
the medical condition and/or not to have a beneficial effect on health outcomes due to insufficient and inadequate
clinical evidence from well-conducted randomized controlled trials or cohort studies in the prevailing published
peer-reviewed medical literature.

· Well-conducted randomized controlled trials. (Two or more treatments are compared to each other, and
the patient is not allowed to choose which treatment is received.)
· Well-conducted cohort studies. (Patients who receive study treatment are compared to a group of
patients who receive standard therapy. The comparison group must be nearly identical to the study
treatment group.)
The Claims Administrator has a process by which it compiles and reviews clinical evidence with respect to certain
Health Care Services. From time to time, the Claims Administrator issues medical and drug policies that describe
the clinical evidence available with respect to specific health care services. These medical and drug policies are
subject to change without prior notice.

NOTE:
· if you have a life-threatening Sickness or condition (one that is likely to cause death within two years of
the request for treatment) the Claims Administrator may, as we determine, consider an otherwise
Unproven Service to be a Covered Health Care Service for that Sickness or condition. Prior to such a
consideration, the Claims Administrator must first establish that there is sufficient evidence to conclude
that, even though unproven, the service has significant potential as an effective treatment for that
Sickness or condition, and that the service would be provided under standards equivalent to those
defined by the National Institutes of Health;
· the Claims Administrator may, as we determine, consider an otherwise Unproven Service to be a
Covered Health Care Service for a Covered Person with a Sickness or Injury that is not life-threatening.
For that to happen, all of the following conditions must be met:
· if the service is one that requires review by the U.S. Food and Drug Administration (FDA), it must be
FDA-approved;

· it must be performed by a Physician and in a facility with demonstrated experience and expertise;
· the Covered Person must consent to the procedure acknowledging that the Claims Administrator
does not believe that sufficient clinical evidence has been published in peer-reviewed medical
literature to conclude that the service is safe and/or effective;
· at least two studies must be available in published peer-reviewed medical literature that would allow
us to conclude that the service is promising but unproven; and
· the service must be available from a Network Physician and/or a Network facility.

The decision about whether such a service can be deemed a Covered Health Care Service is solely at the
authority of the Claims Administrator. Other apparently similar promising but Unproven Services may not qualify.
Urgent Care Center - a facility that provides Covered Health Care Services that are required to prevent serious
deterioration of your health, and that are required as a result of an unforeseen Sickness, Injury, or the onset of
acute or severe symptoms.
Usual and Customary Charge - the usual fee that a pharmacy charges individuals for a Prescription Drug
Product without reference to reimbursement to the pharmacy by third parties. The Usual and Customary Charge
includes a dispensing fee and any applicable sales tax.

Page 88 Section 15 - Glossary
PPO - 2017