Inpatient Hospital and Related Services

Allergy testing and treatment, when provided as part of inpatient care for another covered condition;
Anesthetics and their administration;
Bariatric surgery, subject to claims administrator guidelines. Please Note: To receive benefits for bariatric surgery, you must contact your health care company before obtaining services; you will be informed of any required precertification. If you and/or your covered spouse/domestic partner use a Center of Excellence (COE) for your treatment you may be eligible for reimbursement of travel and lodging expenses. To learn more about the travel and lodging benefit including reimbursement see the bullet in the list below starting with "Travel Benefit" for further details.
Basic metabolic examinations;
Cosmetic surgery when needed to:
Reconstruct or treat a functional defect of a congenital disorder or malfunction;
Treat an infection or disease;
Treat an injury or accident; or
Reconstruct a breast after mastectomy. Coverage for the following services is available under the Medical Plan in a manner determined in consultation with you and your physician:
Reconstruction of the breast on which the mastectomy was performed;
Surgery and reconstruction for the other breast to produce a symmetrical appearance; and
Prostheses and treatment of physical complications for all stages of mastectomy, including lymphedemas.
Diagnostic services, including:
EEG, EKG, and other diagnostic medical procedures;
Laboratory and pathology tests; and
Radiology services.
Electrocardiographic and physiotherapeutic equipment usage;
Hemodialysis for kidney failure;
Intensive care unit service;
Maternity care, including:
Any required care for an illness or injury that the newborn develops either before or after birth, as long as you and your newborn are enrolled in the appropriate coverage level within prescribed enrollment time frames;
Newborns will have a separate deductible and coinsurance maximum applied

Care required because of miscarriage or ectopic pregnancy;
Coverage of eligible expenses if your covered child has a baby, but not including nursery or other expenses incurred by the newborn child;
Delivery by a certified, registered nurse or midwife in a birthing center;
Drugs, medications, and anesthesia;
Normal or cesarean section delivery;
Routine medical and hospital nursery care for your covered newborn child, as long as you and your newborn are enrolled in the appropriate coverage level within prescribed enrollment time frames;
Circumcision by a licensed provider (for your covered newborn child), as long as you and your newborn are enrolled in the appropriate coverage level within prescribed enrollment time frames; and
A semi-private room. The period of hospitalization for childbirth (for either the mother or the covered newborn child) is up to 48 hours after a vaginal delivery or 96 hours after a cesarean section. (However, your attending physician — after consulting with the mother — may decide to discharge the mother or newborn child earlier.)
Mental health care/substance abuse care;
Operative and surgical procedures by a licensed provider for the treatment of a disease or injury, including pre-operative preparation and post-operative care;
Organ or tissue transplants including replacing a non-functioning or damaged organ or tissue with a working organ or tissue from another person. Please Note: To receive benefits for transplant surgery, you must contact your health care company before obtaining services; you will be informed of any required precertification. Covered services include physician and hospital costs, donor search, tests to establish donor suitability, organ harvesting and procurement, and anti-rejection drugs. Donor expenses related to the transplant procedure are covered if the transplant recipient is a covered member under this Plan, but only to the extent that the donor expenses are not covered under another health insurance plan. If you and/or your covered spouse/domestic partner uses a Center of Excellence (COE) or designated facility for your treatment, you may be eligible for reimbursement of travel and lodging expenses if your treatment facility is more than 50 miles away from your home, see the Travel Benefit below for more information. To locate a COE, visit your health care company's website at My Health or call your health care company.
Pre-admission testing when completed within seven days of hospital admission;
Semi-private room and board;
Take-home drugs and medications; and
Travel Benefit: The Plan offers travel benefits for the following conditions/surgery: bariatric surgery and organ transplant up to a maximum of $10,000 per covered person per surgery/condition for all transportation and lodging expenses incurred by you and reimbursed under the Plan in connection with all certified and approved procedures. To qualify for this, benefit the procedure/treatment needs to take place more than 50 miles from your home.
The claims administrator must receive valid receipts for such charges before you will be reimbursed. The items/services listed above may change at any time so check with your health care company to see if your condition or surgery qualifies for this benefit and for additional details on this benefit.