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11. Any services provided by a local, state or federal government agency (except Medicaid), except when payment under this Policy is expressly required by federal or state law. 12.Any services required by state or federal law to be supplied by a public school system or school district. 13.
This brings your baby's head down and to one side. This is known as congenital muscular torticollis. Experts don't know exactly what causes the shortened neck muscle. Some cases of congenital torticollis are caused by a bone problem in the neck portion of the spine (cervical spine). This is known as a congenital malformation of the cervical spine.
Non-preferred medication Step Therapy criteria. Applicable MAC regions: Palmetto JJ, Palmetto JM. Myobloc may be covered when the criteria listed below is satisfied: Myobloc is being prescribed to treat one of the following conditions: Overactive Bladder with Symptoms of Urge Urinary Incontinence, Urgency, and Frequency or.
or a congenital abnormality. Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies. Preauthorization is required. Coverage is limited to an annual max of 60 days. Durable medical equipment No charge 30% coinsurance Preauthorization may be required. Children's eye exam 30% coinsurance
Prior Authorization Criteria 2025 Assurance PDP 5 Tier Last Updated: 10/15/2024 ABRYSVO Products Affected • ABRYSVO (PF)
Germline loss-of-function variants in the master hematopoietic transcription factor, GATA2, can cause cellular deficiencies that have a high propensity to develop into myeloid malignancies. Initial reports identified GATA2 deficiency in cohorts of patients with the following conditions: .
CLASS IV: ORTHODONTIA. You pay 50% of the provider’s contracted fee. charges and 50% (45% in NC) of the contracted fee (after deductible) (after deductible) e difference between the provider’s actual billed*If you choose to visit a dentist out-of-network, you will pay the out-of-network benefit and the diference in the amount that Cigna ...
Prior Authorization Criteria 2025 PDP Extra 5 Tier Last Updated: 10/15/2024 ABRYSVO Products Affected • ABRYSVO (PF)
SUMMARY OF BENEFITS PLAN INFOR. TIONAll States – except MD & NY. For. N INFORMATIONCigna Dental 1500 PlanWit. You get flexible benefits and premium levels to meet your needs and budget, plus: Access to the Cigna DPPO Advantage Network with 89,000+ dentists at more than 300,000 locations across the U.S.1.
Individual Calendar-Year Deductible. $150 per person. $50 per person. Family Calendar-Year Deductible. $300 per family. $150 per family. Calendar-Year Out-of-Pocket Maximum. $400 per person/$800 per family. Not applicable.