Allergy Testing See Diagnostic Testing

Ambulance Transportation in Emergency $100.00 per trip

Anesthesia 80%

Chemotherapy/Radiation Therapy for cancer 80% to $1000.00 per year maximum

Colostomy Bags (Only) 50% reimbursement

Diagnostic Testing (outpatient lab, x-ray, etc.) 80% to maximum of $700.00 per year

Dietary Consultation up to $50.00 once per year

Eye Exam (routine) $40.00 once per year

Flu Shots 80%

Hearing Test (must be under physician supervision) $25.00

Hospital Emergency Room $100.00 per visit

Hospital:
Inpatient (must be pre-certified with Health Cost Consultants) 100% up to $3,000.00, then 80% to a maximum of $16,000.00 per calendar year in-network 80% up to $3,000.00 then 64% to a maximum of $16,000.00 per year out-of-network
Outpatient (excluding Diagnostic Testing covered under 80% in-network separate benefit) 64% out-of-network

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

Magnetic Resonance Imaging (MRI) See Scan Benefit

Mammogram (screening) 80% (one per year)

Physician Services: Office Visits $25.00 per visit

Hospital Visits 80% out-of-network
100% in-network

Prosthetics: breast prosthesis 80% after $100.00 deductible

Scans & MRIs
Outpatient: 80% to $1000.00 per calendar year
Inpatient: paid under hospital inpatient benefits

Surgery 100% in-network up to $2500.00 maximum per year
80% out-of-network

(1) Appliances/Braces/Trusses

(2) Cardiac/Pulmonary Rehabilitation

(3) Chiropractic Care

(4) Dialysis

(5) Durable Medical Equipment (DME)

(6) Hearing Aids

(7) Home Health Care

(8) Hospice - Home Care

(9) Immunizations

(10) Injections

(11) Oxygen

(12) Penile Erection Device (external)

(13) Penile Implant

(14) Physical Therapy

(15) Prescription Medications

(16) Psychiatric & Substance Abuse Treatment

(17) Skilled Nursing Facility

(18) Transplantation of Vital Organs

(19) Weight Loss Program