For off-island emergencies, Plan must be contacted and advised within 48 End Renal Disease / Plan pays 100% Plan pays 100% Plan pays 100% Plan pays 100% Hemodialysis Audiological examinations, Hearing Aids Plan pays 100%. Limited $500 every 3yrs (PA $500 every 3yrs (PA $500 every 3yrs (PA every 3yrs (PA required) required) required) required) Maximum $500 per member per plan year Hospitalization & Inpatient Benefits $75.00 copay, per day up to $75.00 copay, per day up to 1. Room & Board for a Plan pays 100%. Prior Plan pays 100%. Prior 10 days. No copay after 10 10 days. No copay after 10 room, intensive care, Authorization is required Authorization is required days. Authorization is days. Authorization is coronary care and surgery after the first 60 days that after the first 60 days that required after the first 30 required after the first 30 2. All other inpatient hospital includes weekends. includes weekends. days that includes days that includes services including laboratory, weekends. weekends. x-ray, operating room, anesthesia and medication 3. Physician's hospital services Implants
For off-island emergencies, Plan must be contacted and advised within 48 End Renal Disease / Hemodialysis Plan pays 100% Plan pays 100% Plan pays 100% Plan pays 100% Audiological examinations, Hearing Aids Plan pays 100%. Limited every 3yrs (PA required) $500 every 3yrs (PA required) $500 every 3yrs (PA required) $500 every 3yrs (PA required) Maximum $500 per member per plan year Hospitalization & Inpatient Benefits Plan pays 100%. Prior Authorization is required after the first 60 days that includes weekends. Plan pays 100%. Prior Authorization is required after the first 60 days that includes weekends. $75.00 copay, per day up to 10 days. No copay after 10 days. Authorization is required after the first 30 days that includes weekends. $75.00 copay, per day up to 10 days. No copay after 10 days. Authorization is required after the first 30 days that includes weekends. 1. Room & Board for a room, intensive care, coronary care and surgery 2. All other inpatient hospital services including laboratory, x-ray, operating room, anesthesia and medication 3. Physician's hospital services Implants
Bill%20No.%20132-34%20(COR).docx