52 For lodging and ground transportation benefits, the Plan will cover costs up to the current limits set forth in the Internal Revenue Code. Non - Covered Services for transportation and lodging include, but are not limited to: • Child care, • Mileage within the city where the Covered Procedure is performed, • Rental cars, buses, taxis, or shuttle service, except as specifically approved by us, • Frequent Flyer miles, • Coupons, Vouchers, or Travel tickets, • Prepayments or deposits, • 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.
Benefit Booklet: Plan 1 Page 52 Page 54