Summary Plan Description

Hospital Services and Supplies

90% Network and 80% Non-Network

Inpatient Hospital
Inpatient Admissions Must Be Precertified Unless the Patient Is A Medicare-Eligible Retiree

Benefits are provided for the following services and supplies:

  • A semiprivate room and hospital services and supplies to treat an illness or injury.
  • Intensive and coronary care units.
  • Operating rooms and equipment.
  • Nursing services (other than the services of a private-duty nurse or attendant).
  • Diagnostic or therapeutic items or services that are ordinarily furnished by the hospital for the care and treatment of the patient.
  • Anesthesia including administration and materials.
  • Drugs, biologicals, supplies, appliances, and equipment for use in the hospital that are ordinarily furnished by the hospital for the care and treatment of the patient.

Benefits are not provided for:

  • A bed or room set aside for a patient while the patient is in a special care unit.
  • Fees for a hospital, ambulatory surgical center or other surgical facility for surgical services commonly and primarily performed in a clinic or physician's office.

Outpatient Hospital

Benefits are provided for:

  1. Services and supplies otherwise provided on an inpatient hospital basis.
  2. Facility fees for outpatient surgery, a same-day surgical center or an ambulatory surgical center.
  3. Treatment including x-ray, radium therapy and other radioactive substances, chemotherapy, and laboratory and diagnostic radiology and imaging.
  4. Care in a hospital emergency room. There is a $50 copayment for each visit to the emergency room. The $50 copayment is waived if the patient is admitted as an inpatient directly following treatment in the emergency room.

Benefits are not provided for fees for a hospital, ambulatory surgical center or other surgical facility for surgical services commonly and primarily performed in a clinic or physician's office.

Care in an emergency room is expensive. An emergency room should only be used when the patient's condition requires immediate medical attention. You may want to identify an urgent care facility near your home or work which can be used in less emergent situations.