Eligible Expenses

After the deductible is met, the policyholder's coverage pays 80 percent of the allowable amount for the following eligible expenses:

Inpatient Hospital Expense

• Preauthorized hospital admission, room and board charges 
  for semi-private room
• Intensive care and coronary care units
• All other usual hospital services

Medical-Surgical Expenses include but are not limited to

• Services of physicians or other professional providers
• Physical Medicine Services (therapies) up to a maximum 
  benefit of $500 per participant per benefit period
• Diagnostic X-ray, laboratory procedures and radiation 
  therapy
• Rental of durable medical equipment
• Professional local ground or air ambulance service up to a maximum benefit of $750 per participant per benefit period
• Anesthetic and its administration
• Oxygen and its administration
• Blood, blood plasma and blood plasma expanders
• Prosthetic appliances
• Orthopedic braces and crutches
• Home infusion therapy
• Diabetic supplies and equipment
• Certain tests for detection of prostate cancer
• Childhood immunizations through age seven (7) at 100 percent of the allowable amount
• Outpatient contraceptive devices and services
• Certain test for detection of colorectal cancer
• Prescription drugs and medicines (not used in a hospital) up 
  to a maximum benefit of $750 per participant per benefit period, subject to separate drug deductible and copay