| Service |
Inclusions |
| Office Services |
- Medical history, exams, diagnosis and in-office surgeries*
|
| Wellness |
- Exams, immunizations, lab tests, Pap smears, mammograms and PSAs up to $500 in paid benefits (benefit varies by plan)
|
| Lab and X-ray |
- Screening for covered illness or injury
|
| Emergency Room |
- $75 access fee (waived if you are admitted to the hospital), then deductible and coinsurance
|
| |
- Covered emergency services are always paid at network coinsurance levels
|
| Ground/Air Ambulance |
- Emergency transportation to the nearest hospital equipped to provide appropriate care
|
| Physician |
- Diagnosis and treatment for covered illness or injury, including surgery and anesthesia
|
| Hospital |
- The hospital semiprivate room rate and covered ancillary charges
|
| |
- Intensive Care Unit services have no special limit
|
| Organ Transplants |
- Up to the lifetime maximum benefit at a designated provider or a $100,000 lifetime maximum per transplant at a non-designated provider
|
| |
- Kidney, cornea and skin transplants are covered the same as any other covered illness
|
| Complications of pregnancy |
- You get benefits for complications of pregnancy as defined in the contract. Covered complications of pregnancy include treatment of ectopic pregnancy, treatment of gestational diabetes mellitus, and medically necessary Caesarean section.
|
| Rehabilitation |
- Inpatient: covered the same as any other covered illness with a 180-day calendar year maximum
|
| |
- Outpatient: occupational, physical and speech therapies, and cardiac rehabilitation with a $3,000 combined calendar year maximum
|
| Supplies and Equipment |
- Whole blood, prosthetic devices, crutches, basic hospital bed, non-motorized wheelchair, braces, oxygen and apnea monitor
|
| Outpatient Treatment of Back/Spine/Neck |
- Covered the same as any other covered illness with a $750 calendar year maximum (non-surgical)
|
| Home Health Care |
- Covered the same as any other covered illness with a 160-hour calendar year maximum
|
| Hospice Care |
- Inpatient or home care covered the same as any other covered illness with no limit
|
| Skilled Nursing Facility |
- Covered the same as any other covered illness with a 30-day calendar year maximum
|
| Dental Injury |
- Treatment for injury to sound teeth if the treatment begins within 90 days of the injury and is completed within 180 days of the injury
|
| TMJ/CMJ |
- Covered the same as any other covered illness with a $1,000 lifetime maximum
|
| Sterilization |
- $500 benefit after you have been insured by the plan for one year
|
| Mental Illness/Nervous Disorder/Substance Abuse |
- 50% coinsurance after deductible
|
| |
- $2,500 calendar year maximum (up to $500 of this benefit is available for outpatient treatment)
|
| |
- Family and marriage counseling are included
|
| |
- Value Plan does not include
benefits for these services. |
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