Inpatient Hospital and Intensive Care/Trauma Expense
- Hospital room and board charge, up to the hospital's average semi-private room rate and intensive care unit and/or trauma unit charge;
- Miscellaneous hospital ancillary charges, including but not limited to, oxygen, diagnostic tests, radiological procedures and professional fees;
- Recovery room;
- Operating room;
- Observation room;
- Blood or blood derivatives that are not donated or replaced, and their administration;
- Anesthesia, including the administration thereof;
- Physician services, other than the plastic surgeon who performed the covered procedure;
- Prescription drugs prescribed during the hospitalization, and as a follow-up thereto; and
- Registered nurse (R.N.).
Emergency Medical Expense
- Emergency room;
- Blood or blood derivatives that are not donated or replaced, and their administration;
- Diagnostic tests, including professional fees;
- Observation room;
- Supplies;
- Oxygen, including the administration thereof;
- Physician services, other than the plastic surgeon who performed the covered procedure;
- Prescription Drugs prescribed during the Hospital visit and as a follow-up thereto;
- Radiological procedures, including professional fees;
- Registered nurse (R.N.);
- Anesthesia, including the administration thereof; and
- Miscellaneous Hospital ancillary charges, including but not limited to, operating room.
Ambulance Expense
- The use of an ambulance to a hospital within 50 miles of the patient’s home;
- The use of an air ambulance to a hospital when such service is ordered by a physician and is accomplished in an aircraft used primarily for transporting sick or injured persons,
Follow-Up Outpatient Physician Expense
When a patient’s covered complication requires follow-up outpatient services rendered no later than 30 days after: (1) an unscheduled Inpatient admission to a hospital; or (2) a hospital emergency visit; or (3) an ambulance service to a hospital, the following services are covered:
- Diagnostic tests, including professional fees;
- Physician services, other than the plastic surgeon who performed the covered procedure;
- Prescription drugs prescribed during a follow-up visit or as a follow-up thereto;
- Radiological procedures, including professional fees;
- Anesthesia, including the administration thereof;
- Oxygen, including the administration thereof;
- Blood or blood derivatives that are not donated or replaced, and their administration; and
- Supplies.
The follow-up outpatient services must be ordered by a physician other than the plastic surgeon who performed the covered procedure.
Outpatient Procedure to Rule Out Deep Vein Thrombosis Expense
When a patient’s covered complication requires an outpatient procedure to rule out deep vein thrombosis after: (1) an unscheduled inpatient admission to a hospital; or (2) a hospital emergency visit; or (3) an ambulance service to a hospital the following services are covered:
- Diagnostic tests, including professional fees;
- Physician services, other than the plastic surgeon who performed the covered procedure; and
- Radiological procedures, including professional fees.