51 • Services for a condition that is not directly related, or a direct result, of the Covered Procedure, • Phone calls, • Laundry, • Postage, • Entertainment, • Travel costs for donor companion/caregiver, • Return visits for the donor for a treatment of an illness found during the evaluation , • Meals. Infertility Services Please see ”Maternity and Reproductive Health Services” later in this section. Inpatient Services Inpatient Hospital Care Covered Services include acute care in a Hospital setting. Benefits for room, board, and nursing services include: • A room with two or more beds. • A private room. The most the Plan will cover for private rooms is the Hospital’s average semi - private room rate unless it is Medically Necessary that you use a private room for isolation and no isolation facilities are available. • A room in a special care unit approved by us. The unit must have facilities, equipment, and supportive services for intensive care or critically ill patients. • 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 including infusion 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.

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