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Prenatal Laboratory and Diagnostic Procedures

Limit Per Pregnancy

Initial Obstetric Screening Panel Ultrasound Urinalysis, screening dip stick Urinalysis, spun Hemoglobin/Hematocrit Antibody Test for Rh-Negative (if unsensitized) Alpha-fetoprotein Diabetes Screening Cervical Cytology (PAP)

1 2 3 1 2 1 1 1 1

Benefits for the following prenatal laboratory and diagnostic procedures will be provided at 100% of the allowable charge (90% for non-participating physician), not subject to the calendar year deductible:

Regular Plan benefits will be provided for other prenatal laboratory and diagnostic procedures, inpatient hospital delivery, and other covered services.

Hospital nursery care of a healthy newborn child is not covered by the Plan, unless the enrollee elects High Option for Children.

As soon as a participant finds out that she is pregnant, she should call Intracorp to participate in the voluntary maternity management program. This program is an education and monitoring service that provides:

  • Early identification of risk factors,

  • High-risk screening,

  • Pregnancy education and support, and

  • Ongoing monitoring.

The participant is encouraged to enroll in the program as soon as she knows she is pregnant. Intracorp must be contacted within the first 4 months of pregnancy in order to participate. An obstetrical review specialist will explain how the maternity management program works and how it can help improve the prospects for a healthy pregnancy and delivery. As part of the program, the participant will receive an educational book and access to a special nurse line for any questions that arise during the pregnancy. All services provided in this program are at no cost to the participant. Important Note: Whether or not the participant chooses to participate in the maternity management program, she is still responsible for certifying the hospital admission for delivery.

Adding a Newborn In order for a newborn to be covered from date of birth, an Application for Coverage form must be completed within 31 days of the date of birth (see Special Enrollment Periods) and the appropriate premiums must be paid. Reporting the baby’s birth by phone to Intracorp or Blue Cross & Blue Shield does not automatically add the baby to the enrollee’s coverage.


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