ALL of the following

• Service is medically necessary.
• Service is provided by a participating (in-network) provider (except for specified exceptions such as emergency services, pre-hospital emergency medical services, and mobile crisis services).
• Service is listed as a covered service and does not exceed benefit limits in the Benefits Overview.
• Service is obtained while the contract is in effect.

ANY of the following

• Emergency services, pre-hospital emergency medical services provided to treat an emergency condition, and mobile crisis services are covered even when provided by an out‑of‑network provider.

ALL of the following

• 服務必須為醫療必要性（見醫療必要性定義與判定要點）。
• 服務通常須由參與提供者提供，網絡外服務僅在合同列明之例外情形（例如緊急服務、為治療急診狀況之院前急診醫療服務、移動式危機服務或合約另有規定時）下承保。
• 某些服務在獲得給付前須取得預先授權；參與提供者負責依規定提出預先授權申請並遵循授權程序與時限（例如建議住院或計劃手術時應在入院或手術前至少兩週提出申請）。
• 承保之服務需經服務前、同步或回溯性醫療使用審查以確認醫療必要性；醫療必要性判定依臨床適當性、治療效果、替代方案之成本與效果及可在較低成本機構安全提供性等要素。

ANY of the following

• 緊急服務與為治療急診狀況而提供之院前急診醫療服務（由認可救護車服務提供）即使由網絡外提供者提供亦承保。
• 移動式危機服務在本合約相關章節列明者得為承保服務。

ALL of the following

• Member may request an in‑network specialist to serve as PCP when the member has a life‑threatening, degenerative, or disabling condition that requires long‑term specialty care; plan will consult the specialist and the member’s PCP and approve a treatment plan governing the authorization.

ALL of the following

• Members needing ongoing specialty care may receive a long‑term authorization to an in‑network specialist so the member need not obtain new PCP authorizations for each visit; approved treatment plan may limit visit frequency/duration and require periodic updates to the PCP.

ALL of the following

• Members may request authorization to an accredited specialty care center for life‑threatening, degenerative, or disabling conditions; plan consults PCP, specialist and center and approves a treatment plan; out‑of‑network centers are approved only if no suitable in‑network center exists.

ALL of the following

• If a provider leaves the network while a member is in ongoing treatment, covered services continue for up to 90 days from the contract termination date; pregnant members may continue care until delivery; provider must accept previously contracted rates and supply necessary medical information.
• Member remains responsible for any applicable in‑network cost‑sharing for approved out‑of‑network authorizations and continuity care.

ALL of the following

• New members in ongoing out‑of‑network treatment at coverage start may receive coverage up to 60 days if the non‑participating provider agrees to accept plan payment and share medical information; member remains responsible for applicable cost‑sharing.

ALL of the following

• Providers outside the BlueCard service area typically require the member to pay at point of service; members must submit claims for reimbursement using the BCBS Global Core claim form with provider itemized bills to the service center.
• BCBS Global Core claim forms and assistance are available; members may call the service center (1.800.810.BLUE or designated payor‑paid number) 24/7 for help submitting claims.

ALL of the following

• Members should include provider itemized bills and completed BCBS Global Core claim form to initiate claim processing. Assistance available via the Global Core service center.

ALL of the following

• Preventive services described in HRSA‑supported comprehensive guidelines, USPSTF A/B recommended services, and ACIP‑recommended immunizations are covered without member copayment or coinsurance when delivered by in‑network providers; copay/coinsurance may apply to other services provided during the same visit or when preventive service is not the primary purpose of the visit.

ALL of the following

• Annual adult physical — one per calendar year (eligible regardless of whether 365 days have passed since prior exam).
• ACIP‑recommended adult immunizations — covered without cost‑sharing when provided per ACIP.
• Women’s preventive services including annual gynecologic exam and USPSTF A/B services — covered without cost‑sharing when provided per HRSA guidance.
• Breast cancer screening: baseline mammogram once at age 35–39; annual screening for age 40+, additional diagnostic imaging covered without cost‑sharing when indicated.
• Bone mineral density testing per Medicare/NIH conditions when criteria met; prostate cancer screening per applicable guidance.
• National Diabetes Prevention Program (CDC‑recognized): covered as 12‑month program with 22 group sessions when member meets eligibility criteria.
• Colorectal cancer screening for ages 45–65 including initial colonoscopy and appropriate follow‑up testing; covered without cost‑sharing when USPSTF A/B criteria met.

ALL of the following

• Members may contact the number on their ID card or visit the plan website to obtain the full list of covered preventive services and HRSA‑supported guidance.

ALL of the following

• Pre‑hospital emergency medical services and ambulance transport to treat emergency conditions are covered without prior authorization when provided by certified/licensed ambulance services.
• Emergency ground ambulance transport to the nearest facility capable of providing emergency services is covered. For non‑participating providers without negotiated rates, payment is usual and customary defined as the Fair Health 80th percentile or the provider’s billed charge, whichever is lower.

ANY of the following

• Non‑emergency inter‑facility ambulance transfers are covered when transport is from out‑of‑network to in‑network hospital, to a facility providing a higher level of care, to a more cost‑effective acute facility, or to a subacute facility.

ALL of the following

• Air ambulance (emergency and non‑emergency) covered when criteria are met; participating providers paid negotiated amounts; non‑participating providers paid negotiated/appropriate amounts not to exceed their charges; disputes may be submitted to IDRE and IDRE amount will be paid if applicable. Members responsible for applicable cost‑sharing; non‑participating providers may only balance‑bill up to the member’s cost‑sharing.

ALL of the following

• Travel or transportation costs are not covered unless related to an emergency condition or approved inter‑facility transfer; non‑ambulance transport (e.g., taxis) is not covered. Air transport may be covered for medical necessity when ground transport is inappropriate (e.g., inaccessible location or excessive distance).

ALL of the following

• Emergency room services for treatment of emergency conditions are covered regardless of network status, limited to medically necessary services to treat or stabilize the emergency condition.
• Members should go to the nearest hospital emergency department or call 911; emergency care does not require prior authorization. If unsure, members may contact the plan’s care management coordinator available 24/7.

ALL of the following

• If the emergency visit results in inpatient admission, the member or representative must notify the plan as soon as possible and no later than 48 hours after admission.
• Plan pays participating providers the negotiated amount; for non‑participating providers the plan will pay a reasonable amount up to the provider’s charge and the member’s financial liability is limited to contractual cost‑sharing; non‑participating providers may not collect amounts in excess of the member’s cost‑sharing.

ALL of the following

• Follow‑up or routine care provided in the emergency department is not covered as emergency services; urgent care services are covered and may be appropriate outside normal business hours. Clinical trial routine patient costs may be covered per contract terms.

ALL of the following

• 急診部（ED）為治療急診狀況提供之醫療服務承保，無需事前授權；僅承保為治療或穩定急診狀況之醫療必要項目。

ALL of the following

• 如遇急診請立即前往最近醫院急診部或撥打911；急診入院後，會員或代表須於入院後48小時內通知保險公司。

ALL of the following

• 向網絡內提供者支付協商金額；向非參與提供者支付合理金額（不超過其費用）；會員最多負擔合約分攤，非參與提供者不得向會員多收超出分攤之外費用；若有爭議，可提交 IDRE。

ALL of the following

• 承保多項門診及專科服務，包括先進影像（PET/MRI/CT/核醫）、門診化療/免疫療法、診斷與放射服務、糖尿病若干服務、透析、復健、居家醫療、部分不孕症服務及生育力維持等；但列舉之不孕相關特定項目（如IVF、胚凍存等）不承保。

ALL of the following

• 急診部提供之後續或常規護理不列為急診承保範圍；居家護理、復健及透析等可能有年度次數限制或其他事前授權要求，詳見各節。

ALL of the following

• Basic infertility services (e.g., initial evaluation, semen analysis, lab tests, ovulation assessment, HSG, pelvic ultrasound, endometrial biopsy, testicular biopsy, blood tests) are covered; additional testing may be covered if medically necessary.
• Comprehensive infertility services (if basic services are insufficient) — includes ovulation induction and monitoring, pelvic ultrasound, intrauterine insemination, hysteroscopy, laparoscopy and laparotomy.
• Fertility preservation — covered when treatment is expected to cause iatrogenic infertility (collection, preservation and storage of eggs, sperm or embryos as standard fertility preservation services).

ANY of the following

• In vitro fertilization (IVF), gamete/zygote intrafallopian transfer, donor‑related costs (including donor medical costs), sperm/egg/embryo cryopreservation and storage except when part of fertility preservation, ovulation predictor kits, sterilization reversal, surrogacy costs, cloning, and experimental/research procedures (unless an external appeal overturns a denial).

ALL of the following

• All infertility services must be provided by qualified providers in accordance with American Society for Reproductive Medicine guidance; coverage decisions will not discriminate based on age, gender, sexual orientation, marital status or other personal characteristics.

ALL of the following

• Abortion services are covered, including prescription medications provided for abortion; coverage includes generic and brand drugs even if not FDA‑approved for abortion when recognized by WHO lists, WHO abortion care guidance, or National Academies consensus report. Abortion services are covered without member cost‑sharing.

ALL of the following

• Prescribing and provision follow listed authoritative sources for recognized abortion medications; members may contact plan for details.

ALL of the following

• Tests must be performed in CLIA‑certified or CLIA‑exempt participating labs; coverage of biomarker tests requires demonstration of validity/appropriateness per listed criteria.

ALL of the following

• Prenatal care (including one genetic testing visit), postpartum care, delivery, and pregnancy complication coverage are provided. Midwife services covered if licensed per New York statutes. Lactation support and supplies covered including one breast pump per pregnancy (rental or purchase); donor pasteurized breast milk outpatient covered when medically indicated in specified infant conditions. Up to eight prenatal or postpartum visits per pregnancy are covered; one in‑person doula support visit during labor/delivery is covered per pregnancy.

ALL of the following

• Doula and midwife coverage contingent on state licensure/registration requirements as described; refer to contract for detailed provider eligibility.

ALL of the following

• Prescriptions administered in the provider office for prevention or treatment (excluding self‑injectables) are covered under this benefit rather than under the prescription drug section.

ALL of the following

• Rehab services must begin within 6 months of the injury/illness date, hospital discharge from surgery, or date of outpatient surgery, and in no event extend beyond 365 days after those events.

ANY of the following

• Jaw or adjacent tissue oral surgery, repair/replacement of natural teeth following accidental injury (within 12 months), congenital anomaly‑related jaw/oral surgery, surgery for non‑dental physiologic conditions causing severe functional impairment, tumor/cyst removal in jaw/adjacent tissues with exceptions for tooth‑related cysts, and TMJ/orthognathic procedures as specified.

ALL of the following

• Non‑emergency internet‑based consultations with participating telemedicine providers are covered; not all network providers participate. Members should check provider directory or contact the plan for participating telemedicine providers. Access requires high‑speed internet, an up‑to‑date browser and Adobe Flash, and is suitable for conditions like cold/flu, cyclical pain and general health issues. Telemedicine services delivered by network providers will not be denied solely because of delivery method and cost‑sharing cannot be less favorable than face‑to‑face.

ALL of the following

• Members access telemedicine via their account; plan provides details on participating providers and technical requirements.

ANY of the following

• Covered transplants include kidney, cornea, liver, heart, pancreas, lung, and bone marrow. Plan covers recipient hospital and medical costs and donor search fees; donor medical expenses are not covered unless donor is also insured by the plan. Donor travel, lodging and related convenience costs are not covered.

ALL of the following

• All transplants require explicit plan approval and must be performed at designated hospitals; refer to transplant prior authorization procedures.

ALL of the following

• Supply quantities limited to physician treatment plan; basic glucose meters covered unless visual impairment requires special device. Some diabetes supplies and medications are subject to step therapy and prior authorization; medical exceptions may be requested by phone and decided by the medical director. We will not add step therapy mid‑year except for FDA safety reasons.

ALL of the following

• Implanted prosthetic devices that improve or restore function are covered (including post‑mastectomy implants); repairs/replacements for normal wear covered; only standard devices covered.

ALL of the following

• Medically necessary bone‑anchored (implantable) hearing devices (e.g., cochlear implants) are covered; one implant per ear covered during the period of coverage; repair/replacement of implant covered.

ALL of the following

• Hospice must be provided by programs certified under NY Public Health Law Section 40 (or similar certification for out‑of‑state care). Funeral arrangements, pastoral/financial/legal counseling, household/home‑keeping or respite care are not covered.

ALL of the following

• Inpatient physician services are covered for any day of covered inpatient care. Refer to the Benefits Summary for applicable cost‑sharing, day/visit limits and any prior authorization or referral requirements.

ALL of the following

• Online internet consultations for non‑emergency conditions with participating telemedicine providers are covered; not all network providers participate. Access requires high‑speed internet, an up‑to‑date browser and Adobe Flash; members should check the provider directory or contact the plan to find participating telemedicine providers. Telemedicine delivered by network providers cannot be denied solely because of the delivery method and cost‑sharing must be no less favorable than face‑to‑face services.

ALL of the following

• Members access telemedicine via their member account; plan provides guidance on technical requirements and participating providers.

ALL of the following

• See the diabetes supplies section for specifics on diabetes‑related items (designated manufacturers/pharmacies and supply limits apply).

ALL of the following

• Covered drugs are those on the plan formulary; members may request formulary exceptions per the formulary exception process. Certain specialty drugs may require use of designated specialty pharmacies.

ALL of the following

• Members should consult the plan’s formulary and Benefits Summary for cost‑sharing and day/visit limits; mail‑order prescriptions are delivered to member’s home or office.

ALL of the following

• Quantity and day supply limits, step therapy, split‑fill, half‑tablet programs and initial limited supplies for certain opioids may apply. Oral anticancer drugs have parity with IV/infusion anticancer drugs for cost‑sharing. Members can appeal denials and request exceptions, including expedited reviews when criteria met.

ALL of the following

• Plan may limit quantity, day supply, early refill and require prior authorization based on medical necessity and accepted standards; all compound prescriptions with aggregate price over $250 require provider prior authorization. Utilization management programs (designated/general) may be used and members will receive prior notice if drugs they use are affected.

ALL of the following

• Drugs prescribed or dispensed contrary to standard medical practice may be denied as not medically necessary or experimental; members may appeal denials under the medical utilization review and external appeal provisions. Pharmacies are not required to fill prescriptions if pharmacist professional judgment determines it should not be dispensed.

ALL of the following

• Drugs prescribed or dispensed contrary to accepted medical practice may be denied as not medically necessary or as experimental/research; members may appeal per medical utilization review and external appeal provisions. Pharmacist professional judgment may preclude dispensing.

ALL of the following

• Member discount programs provide health and lifestyle‑related discounts (e.g., gyms, classes, nutrition, weight and stress management); members may check the website or call member services for current listings.
• Diabetes management program provides glucose meters, test strips and lancets, education, automatic refill and home delivery of testing supplies; members participating in the program are entitled to supported devices each plan year and supply quantities for testing supplies are not limited within the program.

ALL of the following

• Primary access to diabetes management program is via the plan’s website; telephone support is available for members without internet access.

ALL of the following

• If a member chooses non‑standard lenses or frames the plan pays the amount for standard items and the member pays the difference (difference does not count toward out‑of‑pocket maximum). To find or change participating vision providers, call the number on the ID card or visit the website.

ALL of the following

• Orthodontic services are covered for severe craniofacial/structural disorders (e.g., cleft palate, maxillofacial abnormalities) with specified procedure lists; members should call the number on their ID card to find or change dentists. Multilingual assistance available.

ANY of the following

• Aviation‑related services (except fare‑paying passengers on scheduled or charter flights).
• Custodial/caretaking care and attendant care for ADLs (not included unless identified as medically necessary services).
• Conversion therapy for members under 18 is excluded; supportive gender‑affirming counseling is not considered conversion therapy.
• Cosmetic/plastic surgery is excluded except reconstructive procedures required due to trauma, infection, disease, covered congenital functional deficits, and post‑mastectomy breast reconstruction.
• Orthodontic services excluded except as explicitly stated in the dental care section.
• Experimental or research treatments excluded generally; narrow outpatient/professional trial‑related exceptions and appeal‑overturned coverage limited to contract terms; investigational drugs/devices and research administration costs excluded.
• Criminal activity related injuries and treatment excluded (victim exceptions apply).
• Routine foot care generally excluded unless related to specified medical conditions causing circulatory disease or sensory loss.
• Care provided in publicly owned institutions (federal/state hospitals) excluded unless legally required or nearest facility for emergency services.
• Services not medically necessary are excluded (may be covered if external appeal overturns denial within contract terms).
• Services covered by Medicare or other government programs (except Medicaid) are not covered under this contract.
• Military service‑related conditions excluded.
• No‑fault automobile insurance covered services are excluded.
• Services not listed as covered in the contract are excluded.
• Services by immediate family members are excluded.
• Separately billed hospital‑employee services excluded.
• Free services not covered.
• Vision corrective device fittings (glasses/contact fitting) excluded under this section (covered under vision).
• War‑related injuries excluded.
• Workers’ compensation/occupational disease benefits covered by other programs are excluded.

ALL of the following

• Services subject to prohibited referral under NY Public Health Law 238‑a(1) are not payable to providers for listed services; retrospective reviews may apply to crisis stabilization centers and other items per contract.

ALL of the following

• Services from crisis stabilization centers may be retrospectively reviewed for medical necessity; member cost‑sharing applies if treatment is not medically necessary. Services subject to prohibited referral under NY Public Health Law 238‑a(1) are not payable to providers for specified services.

ALL of the following

• Services deemed not medically necessary are excluded but may be covered if an external appeal overturns the denial within the contract terms.

ALL of the following

• Home health services post‑discharge: decision within 1 business day after necessary info (72 hours if next day is weekend/holiday); if application and all info received prior to discharge, coverage will not be denied before decision. Substance use disorder inpatient: if application submitted at least 24 hours before discharge, decision within 24 hours and coverage provided until decision; OASAS‑authorized inpatient stays not subject to prior authorization for first 28 days if facility notifies within 2 business days; retrospective review may assess medical necessity after first 28 days. OASAS‑certified outpatient medication‑assisted and intensive outpatient: no prior authorization for initial treatment if facility notifies within 2 business days; first 4 weeks (up to 28 visits) not subject to authorization.

ALL of the following

• Decisions and notifications are communicated via phone and written notice per timelines; special program rules and tools (e.g., OASAS clinical review tools) are used for substance use services.

ALL of the following

• If external appeal overturns plan's denial, plan will provide coverage per contract terms; for clinical trials, coverage limited to services required by the trial protocol (research drugs/devices and research admin costs remain excluded). Standard external appeal adjudication: agent decision within 30 days; expedited non‑drug: 72 hours; expedited drug/formulary exceptions: 24 hours if internal expedited, otherwise 72 hours. The state provides forms and forwards eligible appeals to certified agents.

ALL of the following

• Members must submit completed external appeal forms to the NY State Department of Financial Services within required timeframes; member may appoint a representative with possible DFS confirmation. Notifications to member, designated person and prescribing clinician required per timelines.

ALL of the following

• The plan may develop or adopt more detailed standards to determine payment and medical necessity for inpatient care, surgical treatments, and professional care; such standards must not conflict with contract language. Members may request copies or explanations of applicable standards and the plan will provide copies on request.