32. Hospital Services (Including Inpatient Services, Surgical Centers, and Inpatient Birthing Centers). The following services are covered: • Semi-private and private room and board services: ➢ For network charges, this rate is based on the network agreement. Semi-private rate reductions may apply. ➢ For non-network charges, any charge over a semi-private room charge will be a Covered Expense only if determined by the Plan to be Medically Necessary. If the Hospital has no semi-private rooms, the Plan will allow the private room rate, subject to the Protection from Balance Billing allowed amount, Usual and Customary charges, or the Negotiated Rate, whichever is applicable. • Intensive care unit room and board. • Miscellaneous and Ancillary Services. • Blood, blood plasma, and plasma expanders, when not available without charge. Observation in a Hospital room will be considered Inpatient treatment if the duration of the observation status exceeds 72 hours. Observation means the use of appropriate monitoring, diagnostic testing, treatment, and assessment of patient symptoms, signs, laboratory tests, and response to therapy for the purpose of determining whether a patient will require further treatment as an Inpatient or can be discharged from the Hospital setting. 33. Hospital Services (Outpatient). Observation in a Hospital room will be considered Outpatient treatment if the duration of the observation status is 72 hours or less. Observation means the use of appropriate monitoring, diagnostic testing, treatment, and assessment of patient symptoms, signs, laboratory tests, and response to therapy for the purpose of determining whether a patient will require further treatment as an Inpatient or can be discharged from the Hospital setting. 34. Infant Formula administered through a tube as the sole source of nutrition for the Covered Person. 35. Infertility Treatment to the extent required to treat or correct underlying causes of infertility, when such treatment is Medically Necessary and cures the condition of, alleviates the symptoms of, slows the harm to, or maintains the current health status of the Covered Person. Once the patient is receiving fertility treatment to achieve pregnancy, diagnostic tests and treatments are then considered part of the infertility benefit. Infertility Treatment does not include genetic testing. (See General Exclusions for details). 36. Laboratory or Pathology Tests and Interpretation Charges for covered benefits. Charges by a pathologist for interpretation of computer-generated automated laboratory test reports are not covered by the Plan. 37. Manipulations: Treatments for musculoskeletal conditions when Medically Necessary. Also refer to Maintenance Therapy under the General Exclusions section of this SPD. 38. Maternity Benefits for Covered Persons include: • Hospital or Birthing Center room and board. • Vaginal delivery or Cesarean section. • Non-routine prenatal care. • Postnatal care. • Diagnostic testing. • Abdominal operation for intrauterine pregnancy or miscarriage. • Outpatient Birthing Centers. • Midwives. 39. Medical and/or Routine Services Provided in a Foreign Country, except that no coverage is provided if the sole purpose of travel to that country is to obtain medical services and/or supplies. -62- 7670-00-413597