Res 1988-077 - Laserfiche WebLink

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"Appr'c.ved Heal th Car'e Faci 1 i ty ,:)r' Progr'am" means a faci 1 i ty or p,.'ogram which is licensed, cet'tified or otherwise authorized pursuant to the laws of the State c.f Texas tc. provide health care and which is approved by Heal th Plarl Qr' with whom Health Plan has contr'acted to pt'.:)vide the Càt'e described in this Contract. "Calendar' Year,lI means January 1, 12:01 a. n1. to January 1, 12:01 a. m. I:)f the followirlg year'. "Corlgefli tal Arlomaly." means a defect i ve develclpmerlt or f,:)t'mat ion c.f a part of the body which is determined by a Participating Physician to have been present at the time of birth. "C':lntract Charge" mearls the sum Enrollees and Family Dependents. I:)f the Health Services Fees for all "C,:mtract Yea,.'s" and date of this contract. "C':)ntract Months" are determined from the effective "C.:) payment Char'ge" means the charge, in addi t i':'n to the Health Services Fees, which the Covered Person is required to pay for certain health services and medical supplies provided under this Contract. The covered person is responsible at the time of set'vice for the payment of any CQpayment Chat'ge directly tCI the Prt:)videt' of the health services received. The maxinll.tm aml:)IJrit ()f CI:,payment Charge to be paid by a Covered Pet'son in any Calendar Year shall be limited to 2ØØ~ of the total annual Health Set'vices Fee t'equit'ed to be paid fat' cl:)ver'age under this Contract. "C'jve..'ed Pers,:)n" means either the Enrollee or a Family Dependent, but applies only while coverage of such person under this Contract is in ef-!"ect. "Dentist" means any D,:)ct.,t' I:)f Dental Surgery, "D.D.S.", who is duly 1 icensed and qual i fled to prJjvide dental sl.n'gery, treatment or care Imde,.' the laws Ijf the state ,:)r' I:)ther Jurisdictil)n in which treatment is received. "Drug Formulary" is a listing of by Heal th Plan wh ich wi 11 be Cover'ed Pe,.'sl:)n. When direct ed witl be dispensed. This list modification by Health Plan. Prescripti,:)n Medicaticms approved for Ilse dispensed by Pat'ticipating Pharmacy to a by Health Plan, a generic equivalent drug will be subject to periodic review and "DI.wable Medical Equipment" means Medically Necessary equipment which is nclt disp,jsable, which is not r':Jutinely available in a physician's l:Jffice and which would normally be required for long-term (over a two month period) use as a result of a chronic diagnosis and which is generally not I.\seful t'J a perslJn lr' the absence Ijf illness or Injury. "Eligible Dependerlt" mea"(IS a dependent Ijf any C,:)Vered Person covered under this Contract that meets the requirements of the definition of Family Dependent. "Eligible Expenses" are fee schedules for Health Services as established by Health Plan and covered under this Contract. GM-12-4