Page 5 - FL_STM_Connect PLus
P. 5
Covered expenses
All benefits, except office visits applied to the copay, are subject to the selected plan deductible
and coinsurance. Covered expenses are limited by the usual, reasonable and customary charge as
well as any benefit-specific maximum. 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.
Covered expenses include treatment, services and supplies for:
• Physician services for treatment and diagnosis
• Hospital room and board, doctor visits and general nursing care not to exceed the amount
billed for a semi-private room or 90 percent of the private room billed amount
• Intensive care or specialized care unit not to exceed 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
• 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
• Services when a doctor administers anesthetics 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
Hospital and confinement definitions
Hospital means an institution which is legally constituted and operated in accordance with the
laws pertaining to Hospitals in the jurisdiction where it is located, which meets all of the following
requirements:
• It is engaged primarily in providing medical care and treatment to sick and injured persons on
an inpatient basis at the patient’s expense;
• It provides 24-hour-a-day nursing service by a nurse;
• It is under the supervision of a staff of duly-licensed physicians;
• It provides organized facilities for diagnosis and for major operative surgery either on its
premises or in facilities available on a prearranged basis; and
• Hospital does not mean primarily a clinic, nursing home, rest or convalescent home, extended
care facility, hospice or similar establishment nor, other than incidentally, a place providing
care for persons with mental illness or nervous disorders, the aged, or those suffering from
alcoholism or drug addiction.
Confinement means the time in which a covered person is a registered bed patient in a hospital on
the order of a physician for medically necessary medical treatment. Confinement in a special unit of
a hospital used primarily as a nursing, rest, or convalescent home shall be deemed to be confinement
in an institution other than a hospital.
Usual, reasonable and customary charge
Charges for services and supplies, which are the lesser of: a) the amount usually charged by the
provider for the service or supply given; b) the negotiated rate; or c) the average charged for the
service or supply in the locality in which it is received.
5 Brochure Connect Plus 1018
All benefits, except office visits applied to the copay, are subject to the selected plan deductible
and coinsurance. Covered expenses are limited by the usual, reasonable and customary charge as
well as any benefit-specific maximum. 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.
Covered expenses include treatment, services and supplies for:
• Physician services for treatment and diagnosis
• Hospital room and board, doctor visits and general nursing care not to exceed the amount
billed for a semi-private room or 90 percent of the private room billed amount
• Intensive care or specialized care unit not to exceed 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
• 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
• Services when a doctor administers anesthetics 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
Hospital and confinement definitions
Hospital means an institution which is legally constituted and operated in accordance with the
laws pertaining to Hospitals in the jurisdiction where it is located, which meets all of the following
requirements:
• It is engaged primarily in providing medical care and treatment to sick and injured persons on
an inpatient basis at the patient’s expense;
• It provides 24-hour-a-day nursing service by a nurse;
• It is under the supervision of a staff of duly-licensed physicians;
• It provides organized facilities for diagnosis and for major operative surgery either on its
premises or in facilities available on a prearranged basis; and
• Hospital does not mean primarily a clinic, nursing home, rest or convalescent home, extended
care facility, hospice or similar establishment nor, other than incidentally, a place providing
care for persons with mental illness or nervous disorders, the aged, or those suffering from
alcoholism or drug addiction.
Confinement means the time in which a covered person is a registered bed patient in a hospital on
the order of a physician for medically necessary medical treatment. Confinement in a special unit of
a hospital used primarily as a nursing, rest, or convalescent home shall be deemed to be confinement
in an institution other than a hospital.
Usual, reasonable and customary charge
Charges for services and supplies, which are the lesser of: a) the amount usually charged by the
provider for the service or supply given; b) the negotiated rate; or c) the average charged for the
service or supply in the locality in which it is received.
5 Brochure Connect Plus 1018
