What Are My Benefits?

Benefit Schedule

This section includes the 17 qualified cosmetic procedures listed below:

• Abdominoplasty
• Breast Augmentation
• Breast Lift
• Breast Reduction
• Brow Lift
• Buttock Lift
• Cheek Implant
• Chin Augmentation
• Cosmetic Eyelid Surgery
• Face Lift
• Treatment of Gynecomastia
• Liposuction
• Lower Body Lift
• Otoplasty
• Rhinoplasty
• Thigh Lift
• Upper Arm Lift

Incurral Period

Only complications which occur and are treated within 30 days after the procedure are covered.

Maximum Benefit Amounts

Please see the schedule below:

Benefit	Maximum Amount
Inpatient Hospital Expense	$5,000 per day up to a maximum of 45 days
Intensive Care/Trauma Expense	Additional $1,000 per day up to a maximum of 10 days
Emergency Medical Expense	$2,500
Ambulance Expense	$2,000
Follow-Up Outpatient Physician Expense	$1,500
Outpatient Procedure to Rule Out Deep Vein Thrombosis	$750

Admission Diagnosis

Only the following complications are covered:

Cardiopulmonary Related
Myocardial Infarction	Rule Out Pulmonary Embolus
Rule Out Myocardial Infarction	Fluid Overload
Arrhythmia	Cardiac Arrest
Hypoxia	Shock
Pulmonary Dysfunction	Deep Vein Thrombosis
Pulmonary Embolus	Rule Out Deep Vein Thrombosis
Surgery Related
Hemorrhage	Infection
Anesthesia Related
Severe hypotension - defined as systolic BP equal to or less than 80 three hours after the covered procedure.	Severe hypertension - defined as systolic BP equal to or greater than 200 or diastolic BP equal to or greater than 100 three hours after the covered procedure.

Inpatient Hospital and Intensive Care / Trauma Expense

1. Hospital room and board charge, up to the hospital's average semi-private room rate and intensive care unit and/or trauma unit charge;
2. Miscellaneous hospital ancillary charges, including but not limited to, oxygen, diagnostic tests, radiological procedures and professional fees;
3. Recovery room;
4. Operating room;
5. Observation room;
6. Blood or blood derivatives that are not donated or replaced, and their administration;
7. Anesthesia, including the administration thereof;
8. Physician services, other than the plastic surgeon who performed the qualified cosmetic surgical procedure or any plastic surgeon in the original plastic surgeon's group;
9. Prescription drugs prescribed during the hospitalization, and as a follow-up thereto; and
10. Registered nurse (R.N.)

Emergency Medical Expense

1. Emergency room;
2. Blood or blood derivatives that are not donated or replaced, and their administration;
3. Diagnostic tests, including professional fees;
4. Observation room;
5. Supplies;
6. Oxygen, including the administration thereof;
7. Physician services, other than the plastic surgeon who performed the qualified cosmetic surgical procedure or any plastic surgeon in the original plastic surgeon's group;
8. Prescription drugs prescribed during the hospital visit and as a follow-up thereto;
9. Radiological procedures, including professional fees;
10. Registered nurse (R.N.);
11. Anesthesia, including the administration thereof; and
12. Miscellaneous Hospital ancillary charges, including but not limited to, operating room

Ambulance Expense

1. The use of a ground ambulance to a hospital within 50 miles of the patient's home.
2. The use of an air ambulance to a hospital when ordered by a physician and when accomplished by an aircraft used primarily for transporting sick or injured patients.

Follow-Up Outpatient Physician Expense

When a patient requires follow-up outpatient services rendered no later than 30 days after:

1. an unscheduled inpatient admission to a hospital; or
2. a hospital emergency visit; or
3. an ambulance service to a hospital,

the following outpatient services ordered by a physician other than the plastic surgeon who performed the qualified procedure are covered:

1. Diagnostic tests, including professional fees;
2. Physician services, other than the plastic surgeon who performed the qualified cosmetic surgical procedure or any plastic surgeon in the original plastic surgeon's group;
3. Prescription drugs prescribed during a follow-up visit or as a follow-up thereto;
4. Radiological procedures, including professional fees;
5. Anesthesia, including the administration thereof;
6. Oxygen, including the administration thereof;
7. Blood or blood derivatives that are not donated or replaced, and their administration; and
8. Supplies

Outpatient Procedure to Rule Out Deep Vein Thrombosis Expense

When a patient requires an outpatient procedure to rule out deep vein thrombosis after:

1. an unscheduled inpatient admission to a hospital; or
2. a hospital emergency visit; or
3. an ambulance service to a hospital,

the following outpatient expenses are covered:

1. Diagnostic tests, including professional fees;
2. Physician services, other than the plastic surgeon who performed the qualified cosmetic surgical procedure or any plastic surgeon in the original plastic surgeon's group; and
3. Radiological procedures, including professional fees.

Benefit Period

Covered expenses are payable for 6 months from the date of the original inpatient hospitalization or emergency medical treatment.