55 To be Covered Services, rehabilitation services must involve goals you can reach in a reasonable period of time. Benefits will end when treatment is no longer Medically Necessary and you stop progressing toward those goals. Respiratory Therapy Please see “Therapy Services” later in this section. Skilled Nursing Facility When you require Inpatient skilled nursing and related services for convalescent and rehabilitative care, Covered Services are available if the Facility is licensed or certified under state law as a Skilled Nursing Facility. Custodial Care is not a Covered Service. Smoking Cessation Please see “Preventive Care” section in this booklet. Speech Therapy Please see “Therapy Services” later in this section. Surgery Your Plan covers surgical services on an Inpatient or outpatient basis, including office surgeries. Covered Services include: • Accepted operative and cutting procedures; • Other invasive procedures, such as angiogram, arteriogram, amniocentesis, tap or puncture of brain or spine; • Endoscopic exams, such as arthroscopy, bronchoscopy, colonoscopy, laparoscopy; • Treatment of fractures and dislocations; • Anesthesia (including services of a Certified Registered Nurse Anesthetist) and surgical support when Medically Necessary; • Medically Necessary pre-operative and post-operative care. Oral Surgery Important Note: Although this Plan covers certain oral surgeries, many oral surgeries (e.g. removal of wisdom teeth) are not covered. Benefits are limited to certain oral surgeries including: • Treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; • Orthognathic surgery for a physical abnormality that prevents normal function of the upper and/or lower jaw and is Medically Necessary to attain functional capacity of the affected part. • Oral / surgical correction of accidental injuries as indicated in the “Dental Services” section. • Treatment of non-dental lesions, such as removal of tumors and biopsies. • Incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses.
2025 Retiree Indemnity Plan Booklet Page 55 Page 57