Eligible Expenses
After your deductible is met, your coverage pays 80% of the Allowable Amount for the following Eligible Expenses:
Inpatient Hospital Expense:
- Preauthorized Hospital Admission, room and board charges for semi-private room
- Intensive care and coronary care units
- All other usual Hospital services
Medical-Surgical Expenses include but are not limited to:
- Services of Physicians or Other Professional Providers
- Physical Medicine Services (therapies) up to a maximum benefit of $500 per participant per Benefit Period
- Diagnostic X-ray, laboratory procedures and radiation therapy
- Rental of durable medical equipment
- Professional local ground or air ambulance service up to a maximum benefit of $750 per participant per Benefit Period
- Anesthetic and its administration
- Oxygen and its administration
- Blood, blood plasma and blood plasma expanders
- Prosthetic Appliances
- Orthopedic braces and crutches
- Home Infusion Therapy
- Diabetic Supplies and Equipment
- Certain tests for detection of prostate cancer
- Childhood immunizations through age 7 at 100% of allowable amount
- Outpatient contraceptive devices and services
- Certain test for detection of colorectal cancer
- Prescription drugs and medicines (not used in a Hospital) up to a maximum benefit of $750 per participant per Benefit Period, subject to separate drug deductible and copay
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