Covered Medical Expenses

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
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