| Hospital Admissions |
| Benefit period |
Unlimited days (30 days for mental health care) |
| Copayment |
$100 per admission and $25 per day for the
first 15 days of hospitalization |
|
Medical/Surgical |
|
Deductible |
$250 individual
no more than 3 times per calendar year non-aggregate;
$750 non-aggregate family
$5,000,000 lifetime maximum
|
Lifetime maximum
Calendar year maximum
|
$1,000,000 calendar year maximum (The calendar year maximum is part of and not
in addition to the lifetime maximum.) |
| Hospital Services |
| Anesthesia |
Covered |
| Inpatient hospital admissions* |
Covered |
| Maternity |
Covered |
| Newborn care |
Covered |
| Outpatient surgery |
Covered |
| Transplants* |
Covered |
| Emergency Services |
|
| Emergency medical care/accident |
Covered |
| Preventive Services |
|
| Mammography |
$15 copay - Annual screening mammogram (for women age 40 and over or when
recommended by a doctor) |
| Gynecological examinations |
Annual routine gynecological examination (includes Pap test and breast exam) |
| Pediatric immunizations |
Covered |
| Diabetic Supplies and Education |
| Diabetic supplies |
Covered |
Diabetic training
and education
(outpatient, self-management) |
Covered (under the supervision of a licensed health care professional with
expertise in diabetes) |
| Outpatient visits |
Covered (when determined to be medically necessary by a
licensed doctor) |
| Mental Health Services |
Inpatient mental
health services* |
Up to 30 days per calendar year |
Outpatient mental
health services* |
Each visit counts as 1/2 day toward the 30-day inpatient benefit. |
| Substance Abuse Services |
| Inpatient substance abuse* |
30 days per calendar year (lifetime limit 90 days) |
| Outpatient substance abuse* |
30 visits per calendar year (lifetime limit 120 visits)
An additional 30 visits or equivalent partial visits may be exchanged on a 2:1
basis for up to 15 non-hospital residential days. |
| Detoxification* |
7 days per admission (lifetime limit of 4 admissions) |
| Other Services |
| Allergy testing |
Covered |
Chemotherapy and
radiation therapy |
Covered |
| Diagnostic X-ray and pathology services |
Covered, $15 copayment for each test/service |
| Home health care* |
100 visits per calendar year |
| Hospice care |
Covered, $5,000 limit |
| Oral surgery |
Covered |
|
Outpatient respiratory therapy |
Covered |
| Second surgical opinion |
Covered |
| Skilled nursing care* |
180 days per calendar year |
