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HEALTHY
Drug and Pharmacy Information
General Purpose
Health Net ‘s National Medical Policies ( the “ Policies ” ) are developed to assist Health Net in administering design benefits and determining whether a finical operation, drug, service, or supply is medically necessary. The Policies are based upon a follow-up of the available clinical information including clinical consequence studies in the peer-reviewed published medical literature, regulative status of the drug or device, evidence-based guidelines of governmental bodies, and evidence-based guidelines and positions of choose national health master organizations. coverage determinations are made on a individual footing and are subject to all of the terms, conditions, limitations, and exclusions of the Member ‘s contract, including checkup necessity requirements. Health Net may use the Policies to determine whether, under the facts and circumstances of a particular case, the proposed operation, drug, service, or add is medically necessary. The conclusion that a procedure, drug, service, or supply is medically necessity does not constitute coverage. The Member ‘s compress defines which procedure, drug, service, or issue is covered, excluded, limited, or submit to dollar caps. The policy provides for distinctly written, reasonable and current criteria that have been approved by Health Net ‘s National Medical Advisory Council ( MAC ). The clinical criteria and checkup policies provide guidelines for determining the medical necessity criteria for particular procedures, equipment and services. In rate to be eligible, all services must be medically necessary and otherwise defined in the Member ‘s benefits contract as described in this “ crucial Notice ” disavowal. In all cases, final profit determinations are based on the applicable shrink language. To the extent there are any conflicts between medical policy guidelines and applicable sign lyric, the contract speech prevails. medical policy is not intended to override the policy that defines the Member ‘s benefits, nor is it intended to dictate to providers how to practice music .
Policy Effective Date and Defined Terms.
The date of stake is not the effective date of the Policy. The policy is effective as of the date determined by Health Net. All policies are submit to applicable legal and regulative mandates and requirements for prior presentment. If there is a discrepancy between the policy effective date and legal mandates and regulative requirements, the requirements of law and regulation shall govern. In some states, prior notice or posting on the web site is required before a policy is deemed effective. For information regarding the effective dates of Policies, contact your provider representative. The Policies do not include definitions. All terms are defined by Health Net. For information regarding the definitions of terms used in the Policies, contact your provider representative .
Policy Amendment without Notice.
Health Net reserves the right to amend the Policies without notice to providers or Members. In some states, prior detect or web site station is required before an amendment is deemed effective .
No Medical Advice.
The Policies do not constitute medical advice. Health Net does not provide or recommend treatment to Members. Members should consult with their treat doctor in connection with diagnosis and treatment decisions.
Health Net ‘s National Medical Policies ( the “ Policies ” ) are developed to assist Health Net in administering design benefits and determining whether a finical operation, drug, service, or supply is medically necessary. The Policies are based upon a follow-up of the available clinical information including clinical consequence studies in the peer-reviewed published medical literature, regulative status of the drug or device, evidence-based guidelines of governmental bodies, and evidence-based guidelines and positions of choose national health master organizations. coverage determinations are made on a individual footing and are subject to all of the terms, conditions, limitations, and exclusions of the Member ‘s contract, including checkup necessity requirements. Health Net may use the Policies to determine whether, under the facts and circumstances of a particular case, the proposed operation, drug, service, or add is medically necessary. The conclusion that a procedure, drug, service, or supply is medically necessity does not constitute coverage. The Member ‘s compress defines which procedure, drug, service, or issue is covered, excluded, limited, or submit to dollar caps. The policy provides for distinctly written, reasonable and current criteria that have been approved by Health Net ‘s National Medical Advisory Council ( MAC ). The clinical criteria and checkup policies provide guidelines for determining the medical necessity criteria for particular procedures, equipment and services. In rate to be eligible, all services must be medically necessary and otherwise defined in the Member ‘s benefits contract as described in this “ crucial Notice ” disavowal. In all cases, final profit determinations are based on the applicable shrink language. To the extent there are any conflicts between medical policy guidelines and applicable sign lyric, the contract speech prevails. medical policy is not intended to override the policy that defines the Member ‘s benefits, nor is it intended to dictate to providers how to practice music .
Policy Effective Date and Defined Terms.
The date of stake is not the effective date of the Policy. The policy is effective as of the date determined by Health Net. All policies are submit to applicable legal and regulative mandates and requirements for prior presentment. If there is a discrepancy between the policy effective date and legal mandates and regulative requirements, the requirements of law and regulation shall govern. In some states, prior notice or posting on the web site is required before a policy is deemed effective. For information regarding the effective dates of Policies, contact your provider representative. The Policies do not include definitions. All terms are defined by Health Net. For information regarding the definitions of terms used in the Policies, contact your provider representative .
Policy Amendment without Notice.
Health Net reserves the right to amend the Policies without notice to providers or Members. In some states, prior detect or web site station is required before an amendment is deemed effective .
No Medical Advice.
The Policies do not constitute medical advice. Health Net does not provide or recommend treatment to Members. Members should consult with their treat doctor in connection with diagnosis and treatment decisions.
Reading: Drug and Pharmacy Information
No Authorization or Guarantee of Coverage.
The Policies do not constitute mandate or guarantee of coverage of any particular procedure, drug, service, or supply. Members and providers should refer to the Member condense to determine if exclusions, limitations and dollar caps apply to a particular routine, drug, service, or supply .
Policy Limitation: Member’s Contract Controls Coverage Determinations.
Statutory Notice to Members : The materials provided to you are guidelines used by this plan to authorize, modify or deny care for persons with like illnesses or conditions. Specific care and treatment may vary depending on person want and the benefits covered under your contract. The determination of coverage for a particular procedure, drug, service, or issue is not based upon the Policies, but quite is discipline to the facts of the individual clinical case, terms and conditions of the Member ‘s contract, and requirements of applicable laws and regulations. The contract linguistic process contains specific terms and conditions, including preexistent conditions, limitations, exclusions, benefit maximums, eligibility, and other relevant terms and conditions of coverage. In the consequence the Member ‘s compress ( besides known as the profit sign, coverage text file, or attest of coverage ) conflicts with the Policies, the Member ‘s condense shall govern. The Policies do not replace or amend the Member abridge .
Policy Limitation: Legal and Regulatory Mandates and Requirements
The determinations of coverage for a particular procedure, drug, serve, or supply is capable to applicable legal and regulative mandates and requirements. If there is a discrepancy between the Policies and legal mandates and regulative requirements, the requirements of jurisprudence and regulation shall govern.
Reconstructive Surgery
California Health and Safety Code 1367.63 requires health care service plans to cover reconstructive surgery. “ reconstructive operation ” means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the be :
1. To improve function ; or
2. To create a normal appearance, to the extent possible .
reconstructive operating room does not mean “ cosmetic operation, ” which is surgery performed to alter or reshape normal structures of the body in arrange to improve appearance.
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Requests for reconstructive surgery may be denied, if the proposed procedure offers only a minimal improvement in the appearance of the enrollee, in accordance with the standard of care as practiced by physicians specializing in reconstructive operating room .
Reconstructive Surgery after Mastectomy
California Health and Safety Code 1367.6 requires treatment for breast cancer to cover prosthetic devices or reconstructive operating room to restore and achieve symmetry for the patient incident to a mastectomy. coverage for prosthetic devices and reconstructive operation shall be national to the copayment, or deductible and coinsurance conditions, that are applicable to the mastectomy and all other terms and conditions applicable to other benefits. “ Mastectomy ” means the removal of all or separate of the breast for medically necessary reasons, as determined by a license doctor and surgeon .
Policy Limitations: Medicare and Medicaid
Policies specifically developed to assist Health Net in administering Medicare or Medicaid design benefits and determining coverage for a detail operation, drug, servicing, or provision for Medicare or Medicaid Members shall not be construed to apply to any other Health Net plans and Members. The Policies shall not be interpreted to limit the benefits afforded Medicare and Medicaid Members by law and regulation .