| Hospital Services |
|
| Inpatient hospital - Semi - private room and board or intensive care units; $1500 Copayment maximum per person per plan year for any hospital inpatient confinement (including behavioral health). |
$100 per day; not to exeed $500 Copayment per admission |
| Other inpatient charges, including medically necessary surgical procedures. Includes orthognathic surgery. Guest trays, cots, telephone, maternity kits, paternity kits, and other personal items not covered. |
No Copayment |
| Blood and blood products - Inpatient and Outpatient |
No Copayment |
| Private Duty Nursing, based on medical necessity |
No Copayment |
| Outpatient facilities, including pre-admission testing and or treatment room |
No Copayment |
| Emergency care - ER Copayment waived if admitted - Hospital stay of at least 24 hours; Inpatient Copayment will apply. |
$100 Copay |
| Urgent care - Includes Physician's after hours care or services provided at an urgent care facility |
$50 Copay |
| Extended Care Services (Based on medical necessity) |
|
| Skilled Nursing facility - Covered up to 60 days per plan year |
No Copayment |
| Hospice Care - Inpatient and Outpatient |
No Copayment |
| Home Health |
No Copayment |
| Private duty nursing |
No Copayment |
| Other Medical Services |
|
| Hearing aids (Repairs not covered) |
Plan pays $500 per ear every
3 years |
| Hearing aid batteries - Not subject to any maximum amounts |
No Copayments |
| Dental - Restoration and correction of damage caused by external violent accidental injury to healthy, natural teeth, occurring while covered under the plan for services provided within 24 months of the date of the accident. Certain oral surgeries are covered. |
$40 Copay |
| Durable Medical Equipment - Includes medically necessary purchase and/or rental. Benefits for rental are limited to, and will not exceed, the purchase price of the equipment. (Repairs are covered if not due to neglect or abuse.) This benefit also includes Diabetic Equipment. |
20% of the Allowable Amount |
| Medical Supplies - Limited to 30 day supply per Copayment. This benefit also includes Diabetic Supplies. |
20% of the Allowable Amount |
| Organ Transplants - Covered as any other illness for kidney, cornea, liver, heart, heart-lung, pancreatic-kidney, bone marrow, and other organ transplants that the HMO determines to be non-experimental and/or investigational according to current medical policy guidelines. Artificial organs (e.g. heart) not covered. Donor expenses are covered. |
Application Copayments will apply dependent upon place of service |
| Ambulance - professional local ground or air ambulance transportation services to the nearest hospital appropriately equipped and staffed for treatment of the participant's condition. |
No Copayment |
