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This health plan covers routine Pap smear tests furnished by a Physician, Nurse Practitioner or Nurse Midwife for the number of tests described in the benefit limit.

This health plan covers surgical family planning services furnished by a Physician, Nurse Practitioner or Nurse Midwife.

This health plan covers outpatient care to treat a medical condition when the services are furnished by a General, Chronic Disease or Rehabilitation Hospital, Community Health Center, Physician, Nurse Practitioner or Nurse Midwife for the number of visits described in the benefit limit. These covered services include:

This health plan covers semiprivate room and board and special services furnished by the hospital during medically necessary inpatient admissions in a General Hospital.

This health plan covers semiprivate room and board and special services furnished by the hospital during medically necessary inpatient admissions in a Chronic Disease Hospital. This type of hospital is sometimes referred to as a chronic care or long term care hospital for medically necessary covered services.

This health plan covers semiprivate room and board and special services furnished by the hospital during medically necessary inpatient admissions in a Rehabilitation Hospital.

This health plan covers semiprivate room and board and special services furnished by the facility during medically necessary inpatient admissions in a Skilled Nursing Facility.

This health plan covers outpatient dialysis services furnished by a General or Chronic Disease Hospital, Community Health Center or Free-standing Dialysis Facility.

These benefits also include outpatient emergency medical services furnished by a hospital outpatient department or Community Health Center. These covered services include:

Diagnostic x-ray and other imaging tests furnished by a General, Chronic Disease, Rehabilitation or Mental Hospital, Surgical Day Care Unit, Ambulatory Surgical Facility or Community Health Center. These tests also include diagnostic imaging tests by a Free-standing Diagnostic Imaging Facility.