49 • Routine nursery care for newborns during the mother’s normal Hospital stay. • Meals, special diets. • General nursing services. Benefits for ancillary services include: • Operating, childbirth, and treatment rooms and equipment. • Prescribed Drugs. • Anesthesia, anesthesia supplies and services given by the Hospital or other Provider. • Medical and surgical dressings and supplies, casts, and splints. • Diagnostic services. • Therapy services. Inpatient Professional Services Covered Services include: • Medical care visits. • Intensive medical care when your condition requires it. • Treatment for a health problem by a Doctor who is not your surgeon while you are in the Hospital for surgery. Benefits include treatment by two or more Doctors during one Hospital stay when the nature or severity of your health problem calls for the skill of separate Doctors. • A personal bedside exam by another Doctor when asked for by your Doctor. Benefits are not available for staff consultations required by the Hospital, consultations asked for by the patient, routine consultations, phone consultations, or EKG transmittals by phone. • Surgery and general anesthesia. • Newborn exam. A Doctor other than the one who delivered the child must do the exam. • Professional charges to interpret diagnostic tests such as imaging, pathology reports, and cardiology. *When available in your area, certain Providers have programs available that may allow you to receive Inpatient Services in your home instead of staying in a Hospital. To be eligible, your condition and the Covered Services to be delivered must be appropriate for the home setting. Your home must also meet certain accessibility requirements. These programs are voluntary and are separate from the benefits under “Home Health Care Services.” Your Provider will contact you if you are eligible, and provide you with details on how to enroll. If you choose to participate, the cost-shares listed in your Schedule of Benefits under “Inpatient Services” will apply. Maternity and Reproductive Health Services Maternity Services Covered Services include services needed during a normal or complicated pregnancy and for services needed for a miscarriage. Covered maternity services include: • Professional and Facility services for childbirth in a Facility or the home including the services of an appropriately licensed nurse midwife; • Routine nursery care for the newborn during the mother’s normal Hospital stay, including circumcision of a covered male Dependent; • Prenatal, postnatal, and postpartum services; and • Fetal screenings, which are genetic or chromosomal tests of the fetus, as allowed by the Plan. If you are pregnant on your Effective Date and in the first trimester of the pregnancy, you must change to a Participating Provider to have Covered Services covered at the Participating level. If you are pregnant
2025 Retiree Indemnity Plan Booklet Page 49 Page 51