COMPREHENSIVE MAJOR MEDICAL EXPENSE COVERAGE. Agreements of this category are designed to provide, to persons covered under the Agreement, coverage for major hospital, medical, and surgical expenses incurred as a result of a covered accident or sickness. Coverage is provided for daily hospital room and board, miscellaneous hospital services, surgical services, anesthesia services, in-hospital medical services, out-of-hospital care, prosthetic appliances and durable medical equipment, preventive services, emergency services and transplant services. Outpatient prescription drug coverage is provided for prescription drugs when purchased at a participating pharmacy provider. Coverage is provided at network and out-of-network benefit levels with cost-sharing options such as deductibles, coinsurance, and annual and lifetime maximums. Benefits are subject to the Health Care Management Services Provision with possible loss of benefits for non- compliance. Benefits for emergency care are provided at the network benefit level. A gatekeeper is not required to access benefits from providers. Except for a newborn child of a member, enrollment under the Agreement is subject to medical underwriting. BSMUHDHP1200-O 23081 (6/05) III. A BRIEF DESCRIPTION OF THE BENEFITS CONTAINED IN THE AGREEMENT IS AS FOLLOWS:
COMPREHENSIVE MAJOR MEDICAL EXPENSE COVERAGE. Policies of this category are designed to provide, to persons insured coverage for, major hospital, medical, and surgical expenses incurred as a result of a covered accident or sickness. Coverage is provided for daily hospital room and board; miscellaneous hospital services; surgical services; anesthesia services; in-hospital medical services; out-of-hospital care; and prosthetic appliances; subject to any deductibles, copayment provisions or other limitations which may be set forth in the Policy. Coverage is not provided for unlimited hospital or medical-surgical expenses. Coverage is provided for most benefits at Preferred and Non-Preferred benefit levels with cost sharing options such as Deductibles, Coinsurance, Copayments and Annual and Lifetime Maximums. However, benefits for certain services are only available if received from a Preferred Provider. Benefits are subject to utilization review procedures and precertification processes with penalties and possible loss of benefits for non-compliance. Benefits for Emergency Care are provided at the Preferred Provider benefit level.
COMPREHENSIVE MAJOR MEDICAL EXPENSE COVERAGE. Agreements of this category are designed to provide, to persons covered under the Agreement, coverage for major hospital, medical, and surgical expenses incurred as a result of a covered accident or sickness. Coverage is provided for daily hospital room and board, miscellaneous hospital services, surgical services, anesthesia services, in-hospital medical services, out-of-hospital care, prosthetic appliances and durable medical equipment, preventive services, emergency services and transplant services. Outpatient prescription drug coverage is provided for prescription drugs when purchased at a participating pharmacy provider. Coverage is provided at network and out-of-network benefit levels with cost-sharing options such as deductibles, coinsurance, and annual and lifetime maximums. Benefits are subject to the Health Care Management Services Provision with possible loss of benefits for non- compliance. Benefits for emergency care are provided at the network benefit level. A gatekeeper is not required to access benefits from providers.
