The following are considered covered medical expenses. Covered medical expenses are the actual charges incurred for the following types of services and supplies which are medically necessary. Except where specifically stated otherwise, the services and supplies must be required in connection with the treatment of a person’s injury or sickness. The amount payable is subject to the maximum benefits and limitations shown on the Schedule of Benefits and to all other limitations and exclusions that apply. Please refer to your Summary Plan Description for a complete explanation describing a particular benefit.

 

Hospital service supplies	PPO ambulatory surgical center	Other freestanding medical facilities
Surgery	Anesthetics	Doctor's professional services
Chiropractor care	Professional services by other covered providers	X-ray, laboratory
Chemotherapy and radiation	Rehabilitative Therapy (Physical Therapy, Occupational Therapy, Cardiovascular Rehabilitation Therapy)	Speech Therapy
Preventive care	Breast reconstructive surgery	Dialysis treatment
Diabetic treatment	Ambulance	Mental or nervous disorders
Substance abuse treatment	Dental treatment	Maternity expenses
Vasectomies	Certain infertility-related services	Obstructive sleep apnea
Hearing Aids	Cochlear implants	Organ/tissue/bone marrow transplants
Home health care	Inpatient skilled nursing facility care	TMJ treatment
Durable medical equipment	Prosthetics appliances	Medical supplies
Hospice