SelecTEMP^® PPO

Policy Form Number: PPO-STM-3

Eligible Expenses

After your deductible is met, your coverage pays 80% 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 7 at 100% of 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