Covered inpatient and outpatient hospital services and supplies include the following:
Hospital room and board (including dietary and general nursing services), subject to the $20 per day private room co-payment
Operating or treatment rooms
Anesthetics and their administration
Intravenous injections and solutions
Physical/ Occupational/ Speech therapy
Oxygen and its administration
Intensive, coronary, and Burn Care Unit services
Drugs and medicines, sera, biological and pharmaceutical preparations used during hospitalization, including charges for take-home drugs
Dressings and supplies
Blood transfusions, including the cost of whole blood, blood plasma and expanders, except for the first 3 pints of blood used during inpatient admission or outpatient service
Psychological testing when ordered by the attending physician
All inpatient admissions to a hospital require certification by Intracorp. Inpatient rehabilitative services are limited to acute short-term care in a hospital or rehabilitation hospital as approved by Intracorp.
The private room co-payment will not be charged after a participant in Base Coverage has met the coinsurance/co-payment maximum
Mastectomy The following services related to medically necessary mastectomies are covered:
Reconstruction of the breast on which the mastectomy has been performed;
Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
Prostheses and care of physical complications of mastectomy, including lymphedemas, in a
manner determined in consultation with the attending physician and patient.
Maternity Maternity benefits are provided to covered enrollees or covered spouses. Other female dependents are not eligible for maternity benefits. See the Medical Management and Utilization Review section for more information.
The attending physician will be reimbursed for covered routine prenatal care and delivery at 100% of the allowable charge (90% for non-participating physician), not subject to the calendar year deductible.