Noblesville Schools Medical Plan 42 Section 1: Covered Health Care Services ▪ A cooperative group or center of any of the entities described above or the Department of Defense (DOD) or the Veterans Administration (VA). ▪ A qualified non-governmental research entity identified in the guidelines issued by the National Institutes of Health for center support grants. ▪ The Department of Veterans Affairs, the Department of Defense or the Department of Energy if the study or investigation has been reviewed and approved through a system of peer review. The peer review system is determined by the Secretary of Health and Human Services to meet both of the following criteria: ♦ Comparable to the system of peer review of studies and investigations used by the National Institutes of Health. ♦ Ensures unbiased review of the highest scientific standards by qualified individuals who have no interest in the outcome of the review. • The study or investigation takes place under an investigational new drug application reviewed by the U.S. Food and Drug Administration. • The study or investigation is a drug trial that is exempt from having such an investigational new drug application. • The clinical trial must have a written protocol that describes a scientifically sound study. It must have been approved by all relevant institutional review boards (IRBs) before you are enrolled in the trial. The Claims Administrator may, at any time, request documentation about the trial. • The subject or purpose of the trial must be the evaluation of an item or service that meets the definition of a Covered Health Care Service and is not otherwise excluded under the Plan. Congenital Heart Disease (CHD) Surgeries CHD surgeries which are ordered by a Physician. CHD surgical procedures include surgeries to treat conditions such as: • Coarctation of the aorta. • Aortic stenosis. • Tetralogy of Fallot. • Transposition of the great vessels. • Hypoplastic left or right heart syndrome. Benefits include the facility charge and the charge for supplies and equipment. Benefits for Physician services are described under Physician Fees for Surgical and Medical Services. Surgery may be performed as open or closed surgical procedures or may be performed through interventional cardiac catheterization. You can call the Claims Administrator at the telephone number on your ID card for information about the Claims Administrator's specific guidelines regarding Benefits for CHD services. Dental Services - Accident Only Dental services when all of the following are true: • Treatment is needed because of accidental damage. • You receive dental services from a Doctor of Dental Surgery or Doctor of Medical Dentistry.