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Covered Expense: the expense incurred for eligible services, supplies, and prescription drugs subject to the allowable charge, received on or after the effective date of the participant’s coverage. The expense incurred, or portion of such expense, for medical care, services, supplies, or prescription drugs that are prescribed by a physician and are necessary in conjunction with the therapeutic treatment of the injury or sickness involved, are not excluded from payment of benefits by the provisions of a particular coverage or by the exclusions and limitations, and are not in excess of the allowable charges for the same or similar medical care, services, supplies, or prescription drugs.

Covered Provider or Provider: health care professionals or facilities (as defined in this Plan Document) providing services within the scope of their license under state law. No other practitioners are considered covered providers.

Creditable Coverage: prior health insurance coverage as defined by HIPAA used to reduce the length of a pre-existing condition exclusion period.

Custodial Care: services and supplies furnished primarily to assist an individual in the activities of daily living, including room and board, with or without routine nursing care, training in personal hygiene and other forms of self-care, or supervisory care by a physician for a participant who is mentally or physically disabled. Such services and supplies are custodial care without regard to whom they are prescribed, by whom they are recommended, or by whom or by which they are performed. This term also includes convalescent or domiciliary care.

Deductibles (Base Coverage):

Individual Calendar Year Deductible: a specific dollar amount that a participant must meet for covered expenses before the Plan will pay benefits in a calendar year.

Family Calendar Year Deductible: a cumulative dollar amount that, when met, satisfies the calendar year deductible for covered expenses for all family members.

Deductibles (Select Coverage):

Calendar Year Deductible: a specific dollar amount that a participant must meet for covered medical expenses before the Plan will pay benefits in a calendar year.

Family Deductible: a cumulative dollar amount that, when met, satisfies the calendar year deductible for covered medical expenses for all family members.

Prescription Drug Deductible: a specific dollar amount that a participant must meet for covered prescription drugs before the co-payment amount is applied in a calendar year.

Disabled dependent: a child who is: Unmarried,

  • Permanently mentally or physically disabled or incapacitated,

  • So incapacitated as to be incapable of self-sustaining employment,

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