• Hospital room and board charge, up to the hospital's average semi-private room rate and intensive care unit and/or trauma unit charge;
  • Miscellaneous hospital ancillary charges, including but not limited to, oxygen, diagnostic tests, radiological procedures and professional fees;
  • Recovery room;
  • Operating room;
  • Observation room;
  • Blood or blood derivatives that are not donated or replaced, and their administration;
  • Anesthesia, including the administration thereof;
  • Physician services, other than the plastic surgeon who performed the covered procedure;
  • Prescription drugs prescribed during the hospitalization, and as a follow-up thereto; and
  • Registered nurse (R.N.).
  • Emergency room;
  • Blood or blood derivatives that are not donated or replaced, and their administration;
  • Diagnostic tests, including professional fees;
  • Observation room;
  • Supplies;
  • Oxygen, including the administration thereof;
  • Physician services, other than the plastic surgeon who performed the covered procedure;
  • Prescription Drugs prescribed during the Hospital visit and as a follow-up thereto;
  • Radiological procedures, including professional fees;
  • Registered nurse (R.N.);
  • Anesthesia, including the administration thereof; and
  • Miscellaneous Hospital ancillary charges, including but not limited to, operating room.
  • The use of an ambulance to a hospital within 50 miles of the patient’s home;
  • The use of an air ambulance to a hospital when such service is ordered by a physician and is accomplished in an aircraft used primarily for transporting sick or injured persons,

When a patient’s covered complication 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 services are covered:

  • Diagnostic tests, including professional fees;
  • Physician services, other than the plastic surgeon who performed the covered procedure;
  • Prescription drugs prescribed during a follow-up visit or as a follow-up thereto;
  • Radiological procedures, including professional fees;
  • Anesthesia, including the administration thereof;
  • Oxygen, including the administration thereof;
  • Blood or blood derivatives that are not donated or replaced, and their administration; and
  • Supplies.

The follow-up outpatient services must be ordered by a physician other than the plastic surgeon who performed the covered procedure.

When a patient’s covered complication 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 services are covered:

  • Diagnostic tests, including professional fees;
  • Physician services, other than the plastic surgeon who performed the covered procedure; and
  • Radiological procedures, including professional fees.