Plan pays 100%. One (1) of Plan pays 100%. One (1) of Plan pays 100%. One (1) of each type DME Every Five each type DME Every Five Plan pays 100%. Medical each type DME Every Five Years: Standard Years: Standard Years: Standard wheelchair, equipment/machine is wheelchair, standard wheelchair, standard standard hospital bed, limited to every five years. hospital bed, walker, hospital bed, walker, PA is required for walker, crutches, standard crutches, standard CPAP, crutches, standard CPAP, Durable Medical Equipment wheelchair, hospital bed, and CPAP, and oxygen and and oxygen and and oxygen and (DME) cpap/bipap machine only and accessories. Physician accessories. Physician accessories. Physician Prescription and PA is medical supplies. The lesser Prescription and PA is Prescription and PA is required. The lesser amount amount between purchase required. The lesser required. The lesser and rental of each type between purchase and amount between purchase amount between purchase DME. rental of each type DME. and rental of each type and rental of each type DME. DME. Plan pays 100%. PA is required Elective Surgery PA Plan pays 100%. for elective surgery with one or Required Outpatient $75.00 PA required $75.00 copay, PA required more day admission prior to Surgeries. surgery. Emergency Care Plan pays 100%. PA is Plan pays 100%. PA is 1. On/Off Island emergency required for medically required for medically facility, physician services, necessary services that are necessary services that are laboratory, X-rays not available on island. not available on island. 2. Ambulance Services (Ground Transportation Only)
Durable Medical Equipment (DME) Plan pays 100%. Medical equipment/machine is limited to every five years. PA is required for wheelchair, hospital bed, and cpap/bipap machine only and medical supplies. The lesser amount between purchase and rental of each type DME. Plan pays 100%. One (1) of each type DME Every Five Years: Standard wheelchair, standard hospital bed, walker, crutches, standard CPAP, and oxygen and accessories. Physician Prescription and PA is required. The lesser amount between purchase and rental of each type DME. Plan pays 100%. One (1) of each type DME Every Five Years: Standard wheelchair, standard hospital bed, walker, crutches, standard CPAP, and oxygen and accessories. Physician Prescription and PA is required. The lesser amount between purchase and rental of each type DME. Plan pays 100%. One (1) of each type DME Every Five Years: Standard wheelchair, standard hospital bed, walker, crutches, standard CPAP, and oxygen and accessories. Physician Prescription and PA is required. The lesser amount between purchase and rental of each type DME. Elective Surgery PA Required Plan pays 100%. PA is required for elective surgery with one or more day admission prior to surgery. Plan pays 100%. Outpatient Surgeries. $75.00 PA required $75.00 copay, PA required Emergency Care Plan pays 100%. PA is required for medically necessary services that are not available on island. Plan pays 100%. PA is required for medically necessary services that are not available on island. 1. On/Off Island emergency facility, physician services, laboratory, X-rays 2. Ambulance Services (Ground Transportation Only)