You and your dependents, while eligible, are entitled to benefit payments for the medical services and supplies described below, if medically necessary for the treatment of sickness or injury and if ordered by a physician. Benefit payments are subject to all other provisions of this Plan including those relating to PPO providers, care management, definitions, and specific and general exclusions.

Inpatient Hospital Expenses

Hospital Charges for Standard Semi-private Room and Board - If the hospital does not have semi-private rooms, the eligible charge limit is 90% of the daily charge for its lowest private room rate.

Hospital Charges for Private Room - If necessary for isolation of the patient because of the patient’s communicable disease.

Other Hospital Services - Hospital charges for other services and supplies furnished by the hospital for medical care such as operating room, medicines, drugs, anesthesia, X-ray examinations, treatment with radiation and other radioactive substances, laboratory tests, surgical dressings and supplies, etc., but not professional services.

Other Covered Expenses In or Out of the Hospital

Doctors Services - Surgery, home, office and hospital visits, and other medical care and treatment.

Nursing Care - Private duty nursing by a registered nurse.

Speech Therapy - Treatment by a qualified speech therapist to restore or rehabilitate any speech loss or impairment caused by injury or sickness (except a mental, psychoneurotic or personality disorder), or by surgery for that injury or sickness. In the case of congenital defect, speech therapy expenses will be considered only if incurred after corrective surgery for the defect.

Physical and Occupational Therapy - Treatment by a licensed or registered physical or occupational therapist.

Ambulance - Ambulance service for local travel if medically necessary.

Anesthesia - Cost of anesthetics and their administration.

X-ray and Laboratory Tests and analysis.

X-ray and Radiation Treatments - and treatments with other radioactive substances.

Durable Medical Equipment and Medical Supplies - Artificial limbs, eyes and larynx; surgical dressings; casts, splints, trusses, braces, crutches; blood glucose monitor; rental of wheel chair, hospital bed, or respirator; oxygen and rental of equipment for its administration. The rental cost of durable medical equipment is covered but not to exceed the purchase price of the equipment.

Dental Services - Medical benefits are normally not payable for dental services. The medical portion of your plan, however, will cover charges made for the treatment or removal of a malignant tumor or for treatment by a doctor, dentist or dental surgeon of injuries to natural teeth caused by an accident (including replacement of such teeth, and related X-rays) if incurred within 12 months after an accident. Medical benefits are not payable though, for charges for doctor’s services or X-ray exams involving one or more teeth, the tissue or structure around them, the alveolar process or the gums. This applies even if a condition requiring any of these services involves a part of the body other than the mouth such as treatment of Temporomandibular Joint Disorders (TMJD) or malocclusion involving joints or muscles by methods including but not limited to, crowning, wiring or repositioning teeth.

Orthotics - When determined to be medically necessary.

Services of the Spine - Charges for medically necessary treatment of the spine and its supporting structures (including, but not limited to, physical therapy and chiropractic services) will be covered to a maximum of 30 (combined PPO/Non-PPO) treatments per calendar year. You or your doctor may be required to provide supportive materials to establish medical necessity including X-ray, chart notes and treatment plans.

Inpatient Well Baby Care For Newborns - Eligible inpatient hospital expenses for well newborns from birth for up to the first seven days of life. For the child’s charges to be covered, the Mother must also be hospital confined.

Routine Mammography - Diagnostic and screening mammography recommended by your physician.

Hospital and Professional Obstetrical Care - Pregnancy and childbirth are covered on the same basis as any other condition for the member or the spouse.

Dietary Formula - Which is medically necessary for the treatment of phenylketonuria (PKU).

Blood Transfusions - Including the cost of blood and blood derivatives.