Covered benefits include:
- Semi-private room and board. For network charges, this rate is based on network repricing. For non-network charges, any charge over a semi-private room charge will be a covered expense only when clinical eligibility for coverage is met. If the hospital has no semi-private rooms, the plan will allow the private room rate subject to usual, customary, and reasonable charges (UCR) or the network negotiated rate, whichever is applicable.
- Intensive care unit room and board.
- Surgery, therapies and ancillary services including, but not limited to:
- Blood, blood plasma and plasma expanders, when not available without charge;
- Cornea transplant;
- Breast reconstruction surgery or prostheses following mastectomy and lumpectomy is available to both females and males. A diagnosis of breast cancer is not required for breast reconstruction services to be covered, and the timing of reconstructive services is not a factor in coverage;
- Cosmetic/reconstructive surgery to repair a functional disorder caused by disease or injury;
- Cosmetic/reconstructive surgery to repair a congenital defect or abnormality for a member younger than nineteen; and
- Sterilization for the purpose of birth control.
Certain types of services such as radiology, anesthesiology and pathology are sometimes performed by non-network providers in a network facility. Expenses for these services are paid as network benefits and are not subject to UCR.
Except for observation, preauthorization by medical plan is required.
See also: Mental Health Services (Includes Inpatient and Outpatient)