Res 1988-077 - Laserfiche WebLink

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AKEHDKEHT TO GROUP JUSTER CexTRACT This amendment shall be included as an addition to the Group Master Contract between Texas Health Plan and your company. This amendment is in effect for all Enrollees in accordance with the terms of such Group Kaster Contract. ADD. DELETE, AD!). CT87 .57-1/88 SECTION II, EHROLL~EHT AND EFFECTIVE DATE OF COVERAGE, EHROLI.!EH'I', add as a new second Subparagraph: Covered Persons must choose (or the Enrollee must choose on behalf of Family Dependents) a Participating Primary Care Physician and identity these choices on the Health Care enrollment form. Health Plan will maintain and provide to the Enrollees upon request a list of Participating Primary Care Physicians who will accept new Enrollees. Covered Persons shall be entitled to covered services in accordance with their Group ~aster Contract/Enrollees Certiticate of Coverage provided these services are provided, authorized or arranged by the Covered Person's Participating Primary Care Physician. Covered Persons may change their Participating Primary Care Physician by notifying the Health Plan's Member Services Department. SECTION X, PREVENTION OF MEDICALLY HARMFUL USE OF SERVICES AND LIKITATIONS ON COVERAGE RELATED THERETO, Subparagraph 1, If two (2) or more Participating Physicians who have rendered care to a Covered Person inform Health Plan that the Covered Person is receiving Health Services or Prescription Medications in a manner or in a quantity which is not Medically Necessary or not medically beneficial, the Covered Person may be required by Health Plan to select a single Participating Physician (hereafter referred to as a .Coordinating Health Plan Physician8) and a single Participating Pharmacy for the provision and coordinqtion of all future Health Services. SECTION X, PREVENTION OF MEDICALLY HARMFUL USE OF SERVICES AND LIMITATIONS ON COVERAGE RELATED THERETO, Subparagraph 1, If after reasonable efforts to establish and maintain a satisfactory physician-patient relationship, a Participating Physician who has rendered care to a Covered Person informs Health Plan that a Covered Person is receiving Health Services or Prescription Medication in a manner or in a quantity which is not Medically Necessary or not medically beneficial, the Covered Person may be required by Health Plan to select a Health Plan designated Primary Care Physician (hereafter referred to as .Coordinating Health Plan Physician8) and a single Par~icipating Pharmacy for the provision and coordination of all future Health Services.