Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.

A written order or refill notice issued by a licensed medical professional for drugs available only through a pharmacy.

A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:

• Doctor of medicine
• Doctor of osteopathy
• Dentist
• Chiropractor
• Doctor of podiatric medicine
• Physical therapist
• Nurse midwife
• Certified and registered psychologist
• Certified and qualified social worker
• Optometrist
• Nurse anesthetist
• Speech-language pathologist
• Audiologist
• Clinical laboratory
• Screening center
• General hospital
• Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes

A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.