• 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.


• In this Section, unlike Sections 5(a) and 5(b), the calendar year deductible applies to only a few benefits. We added "(calendar year deductible applies)".  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 non-PPO benefits are the regular 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.


• The amounts listed below are for the charges billed by the facility (i.e., hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the professional charge (i.e., physicians, etc.) are in Sections 5(a) or 5(b).


• YOU MUST GET PRECERTIFICATION FOR HOSPITAL STAYS; FAILURE TO DO SO WILL RESULT IN A MINIMUM $500 PENALTY. Please refer to the precertification information shown in Section 3 to be sure which services require precertification.

• ward, semiprivate, or intensive care accommodations;


• general nursing care; and


• meals and special diets.

Note: We only cover a private room when you must be isolated to prevent contagion. Otherwise, we will pay the hospital's average charge for semiprivate accommodations. If the hospital only has private rooms, we base our payment on the lowest rate for a private room.

Note: When the non-PPO hospital bills a flat rate, we prorate the charges to determine how to pay them, as follows: 30% room and board and 70% other charges.

• Operating, recovery, maternity, and other treatment rooms


• Prescribed drugs and medicines


• Diagnostic laboratory tests and X-rays


• Blood or blood plasma, if not donated or replaced


• Dressings, splints, casts, and sterile tray services


• Medical supplies and equipment, including oxygen


• Anesthetics

Note: We base payment on whether the facility or a health care professional bills for the services or supplies. For example, when the hospital bills for anesthetics services, we pay Hospital benefits and when the anesthesiologist bills, we pay Anesthesia benefits.

Not covered:

• Any part of a hospital admission that is not medically necessary (see definition), such as when you do not need acute hospital inpatient (overnight) care, but could receive care in some other setting without adversely affecting your condition or the quality of your medical care. Note: In this event, we pay benefits for services and supplies other than room and board and in-hospital physician care at the level they would have been covered if provided in an alternative setting


• Custodial care; see definition


• Non-covered facilities or any facility used principally for convalescence, for rest, for a nursing home, for the aged, for domiciliary or custodial care, or as a school


• Personal comfort items, such as telephone, television, barber services, guest meals and beds

• Operating, recovery, and other treatment rooms


• Prescribed drugs and medicines


• Diagnostic laboratory tests, X-rays, and pathology services


• Administration of blood, blood plasma, and other biologicals


• Blood and blood plasma, if not donated or replaced


• Pre-surgical testing


• Dressings, casts, and sterile tray services


• Medical supplies, including oxygen


• Anesthetics and anesthesia service

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment.

• Any charges in excess of the $10,000 High Option or $5,000 Standard Option plan limitation for covered hospice care


• Charges incurred during a period of remission

Definition: A remission is a halt or actual reduction in the progression of illness resulting in discharge from a hospice care program with no further expenses incurred. A re-admission within 3 months of a prior discharge is considered the same period of care. A new period begins 3 months after a prior discharge, with maximum benefits available.

• Local professional ambulance service (within 100 miles) to and from the first hospital equipped to treat your condition

• All other local ambulance service when medically appropriate


• Air ambulance to nearest facility where necessary treatment is available if no emergency ground transportation is available or suitable and the patient's condition warrants immediate evacuation

• Ambulance transport for you or your family's convenience


• Air ambulance if transport is beyond the nearest available suitable facility, but is requested by the patient or physician for continuity of care or other reasons