Medically Necessary/Medical Necessity For any service or supply which is excluded by Medicare, but which is listed as covered under this plan, Premera will determine medical necessity in accordance with the following definition: Medically necessary/medical necessity means those covered services and supplies that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are: • In accordance with generally accepted standards of medical practice; • Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and • Not primarily for the convenience of the patient, physician, or other health care provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease. For these purposes, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer reviewed medical literature generally recognized by the relevant medical community, physician specialty society recommendations and the views of physicians practicing in relevant clinical areas and any other relevant factors. Medicare The "Health Insurance for the Aged Act," Title XVIII of the Social Security Amendments of 1965, as then constituted or later amended. Medicare-approved Charge The dollar amount Medicare determines is reasonable for any Medicare-eligible service or supply. Medicare-eligible Service, Supply, or Expense Any service, supply, or expense of the kind covered by Medicare Parts A and B, to the extent recognized as reasonable and medically necessary by Medicare. Medicare Benefit Period A period that starts on the first day you receive inpatient hospital care after your Part A hospital coverage begins, and ends after you have been out of the hospital or other facility primarily providing skilled nursing or rehabilitative services for 60 days in a row (including the day of discharge). Subscriber The individual who has met the eligibility requirements of this plan and in whose name the coverage is established. A person enrolled as the result of a dependent relationship to a subscriber has the rights of a subscriber and is treated as a subscriber under this plan except when specifically stated otherwise. Subscription Charges The monthly rates set by us as consideration for the benefits offered in this plan. Totally Disabled This term is used and defined in Extended Benefits For Total Disability section of this booklet. We, Us and Our Premera Blue Cross (Premera). You and Your The subscriber. 17 Group Plan G/Dis