• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
• The calendar year deductible is: $250 per person ($500 per family) under the High Option and $300 per person ($600 per family) under the Standard Option. The calendar year deductible applies to almost all benefits in this Section. We added "(No deductible)" to show when the calendar year deductible does not apply.
• The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO benefits apply.
• Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

• Office visits and consultations, including second surgical opinion

• Same day services performed and billed by the doctor in conjunction with the office visit

• In an urgent care center
• During a hospital stay
• In a skilled nursing facility
• Examination during a hospital stay of a newborn child covered under a family enrollment
• Emergency room physician care

• Blood tests
• Urinalysis
• Non-routine pap tests
• Pathology
• X-rays
• Non-routine Mammograms
• CAT Scans/MRI
• Ultrasound
• Electrocardiogram and EEG

• Fecal occult blood test for members age 40 and older
• Routine Prostate Specific Antigen (PSA) test -- one annually for men age 40 and older
• Routine pap test

• Sigmoidoscopy, screening -- every five years starting at age 50
• Colonoscopy -- every 10 years starting at age 50
• Double contrast barium enema -- every five years starting at age 50

• Total blood cholesterol
• Chlamydial infection
• Osteoporosis screenings, once every two years, for women age 65 and older

• From age 35 through 39, one during this five year period
• From age 40 and older, one every calendar year

Note: When billed by a facility, such as the outpatient department of a hospital, we provide benefits as shown here.

Note: When billed by a facility, such as the outpatient department of a hospital, we provide benefits as shown here.

• Childhood immunizations recommended by the American Academy of Pediatrics for dependent children to age 22

• The office visit for routine well-child care examinations (to age 22)
• Same day services performed and billed by the doctor in conjunction with the office visit

• Prenatal care
• Delivery
• Postnatal care

• You do not need to precertify your normal delivery; see page 11 for other circumstances, such as extended stays for you or your baby.
• You may remain in the hospital up to 48 hours after admission for a regular delivery and 96 hours after admission for a cesarean delivery. We will cover an extended stay if medically necessary, but you, your representative, your doctor, or your hospital must precertify.
• We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other care of an infant who requires non-routine treatment if we cover the infant under a Self and Family enrollment.
• We pay hospitalization and surgeon services (delivery and newborn circumcision) the same as for illness and injury. See Hospital benefits (Section 5(c)) and Surgery benefits (Section 5(b)).

• Voluntary sterilization (See Surgical procedures Section 5b)
• Surgically implanted contraceptives
• Injectable contraceptive drugs (such as Depo provera)
• Intrauterine devices (IUDs)
• Diaphragms

• Chemotherapy and radiation therapy

• Dialysis - Renal dialysis, hemodialysis and peritoneal dialysis
• Intravenous (IV)/Infusion Therapy - Home IV and antibiotic therapy
• Transparenteral nutrition (TPN)
• Medical foods and nutritional supplements when administered by catheter or nasogastric tubes
• Growth hormone therapy (GHT)

• Respiratory and inhalation therapies
• Cardiac rehabilitation

• Physical therapy
• Occupational therapy

Note: Visits that you pay for while meeting your calendar year deductible count toward the per person, per calendar year visit limitation.

PPO: 10% of the Plan allowance and all charges in excess of the 75 visit limitation

Non-PPO: 50% of the Plan allowance and any difference between our allowance and the billed amount and all charges in excess of the 75 visit limitation

PPO: 15% of the Plan allowance and all charges in excess of the 50 visit limitation

Non-PPO: 50% of the Plan allowance and any difference between our allowance and the billed amount and all charges in excess of the 50 visit limitation

Note: Covered expenses are limited to charges of a licensed speech therapist for speech loss or impairment due to (a) congenital anomaly or defect, whether or not surgically corrected or (b) due to any other illness or surgery.

Benefits are limited to 50 visits per person, per calendar year under High Option and 30 visits per person, per calendar year under Standard Option

Note: Visits that you pay for while meeting your calendar year deductible count toward the per person, per calendar year visit limitation.

PPO: 10% of the Plan allowance and all charges in excess of the 50 visit limitation

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount and all charges in excess of the 50 visit limitation

PPO: 15% of the Plan allowance and all charges in excess of the 30 visit limitation

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount and all charges in excess of the 30 visit limitation

• One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery (such as for cataracts)
• Vision therapy, such as eye exercises or orthoptics

• Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.
• Removal of nail root

• Artificial limbs and eyes; stump hose
• Orthopedic and corrective shoes
• Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
• Lumbosacral supports
• Crutches, surgical dressings, splints, casts, and similar supplies
• Braces, corsets, trusses, elastic stockings, support hose, and other supportive devices
• Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant following mastectomy. Note: See Section 5(b) for coverage of the surgery to insert the device.

• Are prescribed by your attending physician (i.e., the physician who is treating your illness or injury)
• Are medically necessary
• Are primarily and customarily used only for a medical purpose
• Are generally useful only to a person with an illness or injury
• Are designed for prolonged use; and
• Serve a specific therapeutic purpose in the treatment of an illness or injury

• Oxygen equipment and oxygen;
• Hospital beds;
• Wheelchairs; and
• Walkers

• prescribed by the attending physician;
• The physician indicates the length of time the services are needed, and
• The physician identifies the specific professional skills required by the patient and the medical necessity for skilled services.

• The initial visit/examination
• 12 manipulations per person, per calendar year

Note: X-rays are covered under Lab, X-ray and other diagnostic tests.

Note: Visits that you pay for while meeting your calendar year deductible count toward the 12 visit limit.

PPO: 10% of the Plan allowance and all charges in excess of the benefit limitations

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount and all charges in excess of the benefit limitations

PPO: 15% of the Plan allowance and all charges in excess of the benefit limitations

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount and all charges in excess of the benefit limitations

Acupuncture by a doctor of medicine, doctor of osteopathy or licensed acupuncturist for pain relief

Benefits are limited to 12 visits per person, per calendar year.

Note: Visits that you pay for while meeting your calendar year deductible count toward the 12 visit limit.

PPO: 10% of the Plan allowance and all charges in excess of the 12 visit limitation

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount and all charges in excess of the 12 visit limitation

PPO: 15% of the Plan allowance and all charges in excess of the 12 visit limitation

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount and all charges in excess of the 12 visit limitation