BCNEPA - Our Health Plans - Individual Health Plans

Hospital Expense Coverage
Chemotherapy	Covered
Initial accident or medical emergency care	Covered
Inpatient hospital room and board and ancillary services	21 days per benefit period
Maternity and newborn care	Covered
Oral surgery	Covered
Outpatient diagnostic services (in a hospital setting)	$1,000 maximum per calendar year
Radiation therapy	Covered
Routine gynecological exam	One per calendar year
Routine mammogram screening	One per calendar year for all females over 40 or when physician recommended
Surgical services	Covered
Medical-Surgical Expense Coverage
Anesthesia services	Covered
Assistant surgery	Covered
Concurrent care	Covered
Consultation services	Maximum of one per consultant
Emergency accident or medical care	Covered within 24 hours
Inpatient medical care	21 days per benefit period
Maternity services	Covered
Oral surgery	Covered
Outpatient diagnostic services (in a hospital setting)	$1,000 maximum per calendar year
Outpatient medical visits	$10 copayment; maximum 4 visits per calendar year
Preventive services	Covered according to schedule in contract
Routine gynecological exam	One per calendar year
Routine mammogram screening	One per calendar year for all females over 40 or when physician recommended
Routine newborn care	Covered
Second surgical opinion	Covered
Surgery	Covered
Therapy services	Covered
Transplant services	Covered

*Precertification is required for all inpatient admissions.

Note: This is a brief description of the health care benefits available under this Plan. For complete information, consult your Blue Cross of Northeastern Pennsylvania and Highmark Blue Shield Subscriber Agreements.

This summary is an abridged overview of the benefits covered by the traditional plan. This summary highlights general features and is not intended to be a substitute for the terms, provisions, limitations, exclusions and conditions imposed by the controlling contract(s). Since benefits are reviewed annually and are often modified, if there is a condition that you are treated for on a regular basis, be sure to inquire about your specific coverage needs.

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