services under Medicare, if such institution is accredited as a hospital by the Joint Commission on the Accreditation of Healthcare Organizations; or an institution which: specializes in treatment of Mental Health and Substance Use Disorder or other related illness; provides residential treatment programs; and is licensed in accordance with the laws of the appropriate legally authorized agency. The term Hospital will not include an institution which is primarily a place for rest, a place for the aged, or a nursing home.
Maintenance Drug Product A Prescription Drug Product that is prescribed for use over an extended period of time for the treatment of chronic or long- term conditions such as asthma, hypertension, diabetes and heart disease, and is identified principally based on consideration of available data resources, including, but not limited to, First DataBank or another nationally recognized drug indicator source and clinical factors. For the purposes of benefits, the list of your plan’s Maintenance Drug Products does not include compounded medications, Specialty Prescription Drug Products or Prescription Drug Products, such as certain narcotics that a Pharmacy cannot dispense above certain supply limits per Prescription Drug Order or Refill under applicable federal or state law. You may determine whether a drug is a Maintenance Medication by calling member services at the telephone number on your ID card.
HC-DFS806
12-15
Hospital Confinement or Confined in a Hospital A person will be considered Confined in a Hospital if he is: a registered bed patient in a Hospital upon the recommendation of a Physician; receiving treatment for Mental Health and Substance Use Disorder Services in a Mental Health or Substance Use Disorder Residential Treatment Center.
HC-DFS847
10-16
Maintenance Treatment The term Maintenance Treatment means: treatment rendered to keep or maintain the patient's current status.
HC-DFS807
12-15
Injury The term Injury means an accidental bodily injury.
HC-DFS56
04-10
V1
Maximum Reimbursable Charge - Medical The Maximum Reimbursable Charge for covered services for OPEN ACCESS PLUS is determined based on the lesser of: the provider’s normal charge for a similar service or supply; or a policyholder-selected percentage of a fee schedule Cigna has developed that is based upon a methodology similar to a methodology utilized by Medicare to determine the allowable fee for the same or similar service within the geographic market. The percentage used to determine the Maximum Reimbursable Charge is listed in The Schedule. In some cases, a Medicare based schedule will not be used and the Maximum Reimbursable Charge for covered services is determined based on the lesser of: the provider’s normal charge for a similar service or supply; or the 80th percentile of charges made by providers of such service or supply in the geographic area where it is received as compiled in a database selected by Cigna. If sufficient
HC-DFS12
04-10
V1
70
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