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This health plan covers outpatient non-routine podiatry (foot) care furnished by a General Hospital, Surgical Day Care Unit, Ambulatory Surgical Facility or Community Health Center. These covered services include:

This health plan covers outpatient radiation and x-ray therapy and chemotherapy furnished by a General, Chronic Disease or Rehabilitation Hospital, Community Health Center or Free-standing Radiation Therapy and Chemotherapy Facility. These covered services include:

This health plan covers outpatient surgical services furnished by a Surgical Day Care Unit, Ambulatory Surgical Facility, General, Chronic Disease or Rehabilitation Hospital or Community Health Center. These covered services include:

This health plan covers temporomandibular joint (TMJ) disorder treatment furnished by a General, Chronic Disease or Rehabilitation Hospital, Community Health Center, Surgical Day Care Unit or Ambulatory Surgical Facility. These covered services include:

Delivery of one or more than one baby, including prenatal and postnatal medical care exams and lab tests, furnished by a General Hospital or Community Health Center.

Inpatient semiprivate room and board and special services furnished by the hospital for admissions in a General or Mental Hospital.

Outpatient services furnished by a Community Health Center (that is a part of a General Hospital), Day Care Center, Detoxification Facility, General Hospital, Mental Health Center, Mental Hospital, Licensed Marriage and Family Therapist (effective May 1, 2008) or Psychiatric Nurse Practitioner (effective October 1, 2008).

Inpatient semiprivate room and board and special services furnished by the facility for admissions in a General or Mental Hospital, Detoxification Facility or Alcohol and Drug Treatment Facility up to the number of days described in the benefit limit.

Outpatient services up to the number of visits described in the benefit limit. This includes services furnished by a Community Health Center (that is a part of a General Hospital), Day Care Center, Detoxification Facility, General Hospital, Mental Health Center, Mental Hospital, Licensed Marriage and Family Therapist (effective May 1, 2008) or Psychiatric Nurse Practitioner (effective October 1, 2008).

Inpatient semiprivate room and board and special services furnished by the facility for admissions in a General or Mental Hospital, Detoxification Facility or Alcohol and Drug Treatment Facility up to the number of days described in the benefit limit.