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Covered expenses
All benefits, except physician office visits applied to the copay, are subject to the selected plan
deductible maximum and coinsurance percentage. Covered expenses are limited by the usual,
reasonable and customary charge as well as any benefit-specific maximum as listed in the
schedule of benefits. If a benefit-specific maximum does not apply to the covered expense, benefits
are limited by the coverage period maximum. Benefits may vary based on your state of residence.
• Inpatient hospital room and board and general nursing care for the amount billed for a
semi-private room or 90 percent of the private room billed amount (only if semi-private is not
offered)
• Inpatient intensive care or specialized care unit for three times the amount billed for a semi-
private room or three times 90 percent the private room billed amount
• Prescription drugs administered while hospital confined
Covered expenses include treatment, services and supplies for:
• Inpatient physician office visits
• X-ray exams, laboratory tests and analysis
• Mammography, Pap smear and prostate antigen test (covered at specific age intervals, not
subject to deductible)
• Emergency room, outpatient hospital surgery or ambulatory surgical center
• Surgeon services in the hospital or ambulatory surgical center
• Anesthesiologist services not to exceed 20 percent of the primary surgeon’s covered charges
• Assistant surgeon services not to exceed 20 percent of the primary surgeon’s covered
charges
• Surgeon’s assistant services not to exceed 15 percent of the primary surgeon’s covered
charges
• Ground ambulance services not to exceed $500 per occurrence
• Air ambulance services not to exceed $1,000 per occurrence
• Organ, tissue, or bone marrow transplants not to exceed $150,000 per coverage period
• Acquired Immune Deficiency Syndrome (AIDS) not to exceed $10,000 per coverage period
• Blood or blood plasma and their administration, if not replaced
• Oxygen, casts, non-dental splints, crutches, non-orthodontic braces, radiation and
chemotherapy services and equipment rental
Pre-existing condition limitation and definition
A pre-existing condition is defined as any medical condition or sickness for which medical advice,
care, diagnosis, treatment, consultation or medication was recommended or received from a
doctor within five years* immediately preceding the covered persons’ effective date of coverage; or
symptoms within the five years* immediately prior to the coverage that would cause a reasonable
person to seek diagnosis, care or treatment will not be a covered benefit. Consultation means
evaluation, diagnosis, or medical advice was given with or without the necessity of a personal
examination or visit.
*Six months in ID, KY, MI, ND, NH, NM, OH, WA, WY; 12 months in CO, CT, IN, LA, MD, ME, MS,
NC, NV, SD, VA; 24 months in FL, IL, UT; and 36 months in MT.
Precertification
Precertification is required prior to each inpatient confinement for injury or illness and outpatient
chemotherapy or radiation treatment, at least seven days prior to receiving treatment. Emergency
inpatient confinements must be pre-certified within 48 hours following the admission, or as soon
as reasonably possible. Precertification may also be conducted for a continued stay review for an
ongoing inpatient confinement. Benefits are not paid for days of inpatient confinement which extend
beyond the number of days deemed medically necessary. Failure to complete precertification will
result in a benefit reduction of 50 percent which would have otherwise been paid unless the covered
person is incapacitated and unable to contact the administrator.. Precertification is not a guarantee
of benefits. Precertification is not required in some states.
5 Brochure Connect STM 1018
All benefits, except physician office visits applied to the copay, are subject to the selected plan
deductible maximum and coinsurance percentage. Covered expenses are limited by the usual,
reasonable and customary charge as well as any benefit-specific maximum as listed in the
schedule of benefits. If a benefit-specific maximum does not apply to the covered expense, benefits
are limited by the coverage period maximum. Benefits may vary based on your state of residence.
• Inpatient hospital room and board and general nursing care for the amount billed for a
semi-private room or 90 percent of the private room billed amount (only if semi-private is not
offered)
• Inpatient intensive care or specialized care unit for three times the amount billed for a semi-
private room or three times 90 percent the private room billed amount
• Prescription drugs administered while hospital confined
Covered expenses include treatment, services and supplies for:
• Inpatient physician office visits
• X-ray exams, laboratory tests and analysis
• Mammography, Pap smear and prostate antigen test (covered at specific age intervals, not
subject to deductible)
• Emergency room, outpatient hospital surgery or ambulatory surgical center
• Surgeon services in the hospital or ambulatory surgical center
• Anesthesiologist services not to exceed 20 percent of the primary surgeon’s covered charges
• Assistant surgeon services not to exceed 20 percent of the primary surgeon’s covered
charges
• Surgeon’s assistant services not to exceed 15 percent of the primary surgeon’s covered
charges
• Ground ambulance services not to exceed $500 per occurrence
• Air ambulance services not to exceed $1,000 per occurrence
• Organ, tissue, or bone marrow transplants not to exceed $150,000 per coverage period
• Acquired Immune Deficiency Syndrome (AIDS) not to exceed $10,000 per coverage period
• Blood or blood plasma and their administration, if not replaced
• Oxygen, casts, non-dental splints, crutches, non-orthodontic braces, radiation and
chemotherapy services and equipment rental
Pre-existing condition limitation and definition
A pre-existing condition is defined as any medical condition or sickness for which medical advice,
care, diagnosis, treatment, consultation or medication was recommended or received from a
doctor within five years* immediately preceding the covered persons’ effective date of coverage; or
symptoms within the five years* immediately prior to the coverage that would cause a reasonable
person to seek diagnosis, care or treatment will not be a covered benefit. Consultation means
evaluation, diagnosis, or medical advice was given with or without the necessity of a personal
examination or visit.
*Six months in ID, KY, MI, ND, NH, NM, OH, WA, WY; 12 months in CO, CT, IN, LA, MD, ME, MS,
NC, NV, SD, VA; 24 months in FL, IL, UT; and 36 months in MT.
Precertification
Precertification is required prior to each inpatient confinement for injury or illness and outpatient
chemotherapy or radiation treatment, at least seven days prior to receiving treatment. Emergency
inpatient confinements must be pre-certified within 48 hours following the admission, or as soon
as reasonably possible. Precertification may also be conducted for a continued stay review for an
ongoing inpatient confinement. Benefits are not paid for days of inpatient confinement which extend
beyond the number of days deemed medically necessary. Failure to complete precertification will
result in a benefit reduction of 50 percent which would have otherwise been paid unless the covered
person is incapacitated and unable to contact the administrator.. Precertification is not a guarantee
of benefits. Precertification is not required in some states.
5 Brochure Connect STM 1018
