Inpatient Services. Hospital This plan covers services provided while inpatient in a general or specialty hospital including, but not limited to the following: • anesthesia; • diagnostic tests and lab services; • dialysis; • drugs; • intensive care/coronary care; • nursing care; • physical, occupational, speech and respiratory therapies; • physician’s services while hospitalized; • radiation therapy; • surgery related services; and • room and board. Notify us if you are admitted from the emergency room to a hospital that is not in our network. Our Customer Service Department can assist you with any questions you may have about your coverage. Rehabilitation Facility This plan covers rehabilitation services received in a general hospital or specialty hospital. Coverage is limited to the number of days shown in the Summary of Medical Benefits.
Inpatient Services. Hospital services which are not performed in a hospital. Organ Transplants • Medical services of the donor that are not directly related to the organ transplant. ▪ Services related to obtaining, storing, or other services performed for the potential future use of umbilical cord blood. • Non-cadaveric small bowel transplants. • Services related to donor searches. • Xxxxx related medical and surgical expenses when the recipient is not covered as a member. • Services or supplies related to an excluded transplant procedure. Pregnancy and Maternity Services • Preimplantation genetic diagnosis, also known as embryo screening. • Amniocentesis or any other service when performed solely to determine gender. • Services related to surrogate parenting or the newborn child of the surrogate parent, when the surrogate is not a member of this plan.
Inpatient Services. General hospital or specialty hospital services* Unlimited days 0% - After Deductible 20% - After Deductible Rehabilitation facility services* Limited to 45 days per plan year. 0% - After Deductible 20% - After Deductible Physician hospital visits 0% - After Deductible 20% - After Deductible
Inpatient Services. Inpatient services are covered when such services are prescribed by a physician and when the services are medically necessary for the diagnosis or treatment of the member's condition.
Inpatient Services. General hospital or specialty hospital services* - Unlimited Days 0% - After deductible 20% - After deductible Rehabilitation facility services* - Limited to 45 days per plan year. 0% - After deductible 20% - After deductible Physician hospital visits 0% - After deductible 20% - After deductible Mastectomy Services Inpatient - see Mastectomy Services in Section 3 for details. 0% 20% - After deductible Surgery services - includes mastectomy and reconstructive surgery. See Mastectomy Services in Section 3 for details. 0% 20% - After deductible Mastectomy-related treatment - includes prostheses and treatment for physical complications. 0% 20% - After deductible
Inpatient Services. General hospital or specialty hospital services* - Unlimited Days 10% - After deductible Not Covered Rehabilitation facility services* - Limited to 45 days per plan year. 10% - After deductible Not Covered Physician hospital visits 10% - After deductible Not Covered Mastectomy Services Inpatient - see Mastectomy Services in Section 3 for details. 0% Not Covered Surgery services - includes mastectomy and reconstructive surgery. See Mastectomy Services in Section 3 for details. 0% Not Covered Mastectomy-related treatment - includes prostheses and treatment for physical complications. 0% Not Covered
Inpatient Services. Hospital services which are not performed in a hospital. Organ Transplants Medical services of the donor that are not directly related to the organ transplant. Services related to obtaining, storing, or other services performed for the potential future use of umbilical cord blood. Noncadaveric small bowel transplants. Services related to donor searches. Donor related medical and surgical expenses when the recipient is not covered as a member. Services or supplies related to an excluded transplant procedure. Pregnancy and Maternity Services Preimplantation genetic diagnosis, also known as embryo screening. Amniocentesis or any other service when performed solely to determine gender. Prescription Drugs and Diabetic Equipment or Supplies Biological products for allergen immunotherapy and vaccinations. Blood fractions. Compound prescription drugs that are not made up of at least one legend drug. Bulk powders and chemicals used in compound prescriptions that are not FDA approved, are not covered unless listed on our formulary. Prescription drugs prescribed or dispensed outside of our dispensing guidelines. Prescription drugs that have not proven effective according to the FDA. Prescription drugs used for cosmetic purposes. Prescription drugs purchased from a non-designated pharmacy, if a pharmacy has been designated for you through the Pharmacy Home Assignment program. Experimental prescription drugs including those placed on notice of opportunity hearing status by the Federal Drug Efficacy Study Implementation (DESI). Prescription drugs provided to you that are not dispensed by a network pharmacy or covered under your medical plan. Prescription drugs and diabetic equipment and supplies purchased at a non-network pharmacy unless indicated as covered in the Summary of Pharmacy Benefits. Prescription drug related medical supplies except for diabetic, regardless of the reason prescribed, the intended use, or medical necessity. Examples include, but are not limited to, alcohol pads, bandages, wraps or pill holders. Off-label use of prescription drugs except as described in Experimental or Investigational Services in Section 3; Prescribed weight-loss drugs. Replacement of prescription drugs resulting from a lost, stolen, broken or destroyed prescription order or refill. Therapeutic devices and appliances, including hypodermic needles and syringes except when used to administer insulin. Prescription drugs, therapeut...
Inpatient Services. Hospital services which are not performed in a hospital. Organ Transplants • Medical services of the donor that are not directly related to the organ transplant. ▪ Services related to obtaining, storing, or other services performed for the potential future use of umbilical cord blood. • Non-cadaveric small bowel transplants. • Services related to donor searches. • Xxxxx related medical and surgical expenses when the recipient is not covered as a member. • Services or supplies related to an excluded transplant procedure.
Inpatient Services. General hospital or specialty hospital services* - Unlimited Days 0% - After deductible 40% - After deductible Rehabilitation facility services* - Limited to 45 days per plan year. 0% - After deductible 40% - After deductible Physician hospital visits 0% - After deductible 40% - After deductible Mastectomy Services Inpatient - see Mastectomy Services in Section 3 for details. 0% - After deductible 40% - After deductible Surgery services - includes mastectomy and reconstructive surgery. See Mastectomy Services in Section 3 for details. 0% - After deductible 40% - After deductible Mastectomy-related treatment - includes prostheses and treatment for physical complications. 0% - After deductible 40% - After deductible Observation Services In a hospital or other health care facility 0% - After deductible 40% - After deductible
Inpatient Services i. 155% of current rate under the Medicare Inpatient Psychiatric Facility Prospective Payment System.
