Allergy Testing & Injections 80%

Ambulance Transportation in Emergency Base Rate 80%
Mileage & Ancillary Chgs. 80%
Hospital to Hospital transfer for special facilities 80%

Anesthesia 80%
 

Appliances/Braces/Trusses 80% up to $125.00 per item

Cardiac/Pulmonary Rehabilitation 80% up to 30 outpatient treatments or 30 inpatient days

Chemotherapy/Radiation Therapy for cancer 80%

Chiropractic Care 80% up to $600.00 per year

Colostomy Bags (Only) 50% reimbursement

Dental Care required due to accidental injury 80% up to $300.00 per year

Diagnostic Testing (outpatient lab, x-ray, scans, MRI's, sonograms, mammograms (excluding treadmills)  80% to max. of $10,000.00 per year

Dialysis 80% to total of $10,000.00 per year

Short term peritoneal dialysis 80% up to $4000.00 per year

Dietary Consultation up to $50.00 once per year

Eye Exam (routine) $40.00 once per year (Does not apply to Active Railway Employees covered by VSP)

Hearing Aids (hearing loss must be greater than 35 dB) 80% to maximum of $300.00 per item (renewable after 5 years)

Hearing Test (must be under physician supervision) 80% in-network
64% out-of-network

Home Health Care 80% for up to 40 visits per year
No limit on visits if patient is terminal

Hospice - Home Care Covered under Home Health Care

Inpatient Respite Care 80% up to $3000.00

Hospital Emergency Room 80%

Emergency Room Physician 80%

Inpatient (must pre-notify Assn. at 1-888-800-9161) 80% of first $5,000, then 100% per admit at semi-private rate for up to 183 days per calendar year in-network
64%% at semi-private rate for up to 183 days per calendar year out-of-network

Outpatient (excluding Diagnostic Testing covered under separate benefit) 80% in-network
64% out-of-network

Injections (includes those purchased through Pharmacy) 80%

Lab & X-ray Professional Fees when confined as a hospital inpatient 80% In-network

Oxygen - when ordered by a physician for patients who meet medical necessity guidelines 80% to a maximum of $3,000.00 per calendar year

Penile Erection Device (external) 75%

Penile Implant 80%

Physical Therapy 80% up to 15 treatments per calendar year, with doctor's order additional treatments must be pre-certified.

Physician Services: (office visits, hospital visits, surgery, podiatry, etc.) 80% in-network
64% out-of-network

Prescription Medications (must be FDA approved)

Preventive Services (routine physicals, immunizations, e.g., flu, pneu, childhood shots) 80% in-network
64% out-of-network

Prosthetics: artificial limb 60% to a maximum of 4,000.00 after a deductible of $500.00 per item (renews after 5 years)

Breast prosthesis 80% after $100.00 deductible

Psychiatric
Inpatient: (must be pre-certified) same as any other illness
Outpatient: maximum of 15 visits per year paid at:80% in-network
64% out-of network

Skilled Nursing Facility 80% for 31 days per year after a $100.00 deductible. Must be within 14 days of a hospital inpatient stay of at least 3 days.

Sterilization (Surgical, male or female) 80% in-network
64% out-of-network

Stress Tests (including Thallium Stress Test) 80% in-network
64% out-of-network

Substance Abuse/Chemical Dependency: (must be pre-certified) 
(Maximum of two admissions per lifetime)

First Admission:  80% limited to 30 days
Second Admission 80% limited to 30 days

Temporomandibular Joint Syndrome (TMJ) Treatment 50% to a lifetime maximum of $1,250.00 after a $50.00 deductible
Surgery 80% in-network
64% out-of-network

Transplantation of Vital Organs  80% in network and 64% out of network - Maximum benefit of $200,000.00 per case

Weight Loss Program (must be medically supervised) 80% up to a maximum of $3,000.00 after a $100.00 deductible, 1 lifetime benefit.