| Inpatient Hospital and Administered Services and Supplies |
Covered |
Emergency Room Services and Supplies
You pay the $250 access fee (per visit). The access fee is waived if you are admitted to the hospital |
Covered |
| Urgent Care Facility Services and Supplies |
Covered |
| Office Visits |
Covered
(with alternate benefits available) |
| Wellness Services |
Covered up to $500 per calendar year |
| Outpatient Prescription Drugs |
Generic drugs covered with $0 copay (with alternate benefit selections available) |
| Outpatient X-Ray and Lab |
Covered
(with alternate benefit selection available) |
| Outpatient MRI's CAT Scans and PET Scans |
Covered
(with alternate benefit selection available) |
Ground Ambulance and Air Ambulance
(Air Ambulance benefit up to $10,000 per calendar year) |
Covered |
| Durable Medical Equipment |
Covered |
Home Health Care
(up to 40 visits per calendar year) |
Covered |
Hospice
(Up to $100 per day on an outpatient basis; up to $200 per day on an inpatient basis with a $5,000 Lifetime Maximum Benefit |
Covered |
Skilled Nursing
(Up to 60 days per calendar year) |
Covered |
| Radiation/Chemotherapy |
Covered |
| Breast Reconstruction |
Covered |
| Acute Rehabilitation |
Covered |
Organ Transplants
(When performed in a Center of Excellence- $1,000,000 per transplant maximum. When not performed in a Center of Excellence $100,000 Lifetime Maximum Benefit |
Covered |
Outpatient Occupational, Physical and Speech Therapies
($50 per visit- up to $2,000 per calendar year for all therapies combined) |
Covered |
Emergency Foreign Travel
($100,000 Lifetime Maximum Benefit) |
Covered |
Treatment of Allergies
(up to $500 per calendar year) |
Covered |
Treatment for Sleep Apnea
($2000 Lifetime Maximum Benefit) |
Covered |
Treatment of Growth Disorders
($15,000 Lifetime Maximum Benefit) |
Covered |
Spinal Manipulation (on an outpatient basis)
(Up to $50 per visit- and $500 maximum per calendar year |
Covered |
Sterilization
($500 Lifetime Maximum Benefit. There is a 12 month waiting period) |
Covered |
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