| General Covered Medical Benefits | 保险范围(100%至皇冠搏彩中心网站费用津贴，在适用的共同支付后) **Copayment amounts vary per plan. See Copayment schedule for your plan’s copayment amounts |
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| 医院住院, including semi-private room, intensive or coronary care unit, 肾透析, 精神疾病, alcohol/chemical dependency and maternity. | 如果由持牌医生接收到认可医院并确定是医疗上必需的，则承保.
医疗保险受益人必须有医疗保险A部分批准的服务. 医疗保险 Part A is the primary payer. 非医疗保险受益人必须获得皇冠搏彩中心网站预认证部门批准的服务 1-800-292-2288. |
| 医院门诊部，包括急诊、事故、外科、化验室 & x光，化疗，放射治疗，物理治疗和肾透析. | Covered if medically necessary.
医疗保险受益人必须有医疗保险A部分批准的服务. 医疗保险 Part A is the primary payer. |
| 医生的服务, including surgical care, 助理外科医生, 产科/交付, 麻醉, 紧急救治, 实验室 & x光、放射、化疗、会诊、足病、初级保健和专科护理. | Covered if medically necessary. |
| Skilled Nursing Care Facility | 如果由有执照的医生在有执照的熟练护理机构接受治疗，并且在医学上是必要的，则承保.
Custodial/non-skilled care is not covered (i.e. bathing, housework, day care) 必须是医疗保险批准的熟练护理机构，并且在入院前必须有合格的住院时间. 医疗保险受益人必须有医疗保险A部分批准的服务. 医疗保险 Part A is the primary payer for the first 100 days. 的资金 will pay the Part A coinsurance during that time. After the first 100 医疗保险 days are exhausted, 如果护理水平熟练，皇冠搏彩中心网站将成为主要付款人. 超过100天的天数需要预认证. 非医疗保险受益人必须获得资金预认证部门批准的服务 1-800-292-2288. |
| 家庭保健服务，包括由注册护士和家庭保健助理进行的护理探访. | Covered if under the care of a physician, 病情需要熟练的护理或语言/物理治疗至少每60天一次, a physician treatment plan exists, and patient is confined to home.
Requires approval by the Funds’ Precertification Department at 1-800-292-2288. 医疗保险 beneficiaries – 医疗保险 Part A is the primary payer. |
| Physical (PT) and Speech Therapy (ST) | 医生为恢复因疾病或受伤而丧失或减少的功能而开的处方. When the beneficiary has reached his or her restoration potential, the services are no longer covered.
医疗保险受益人受医疗保险门诊PT和ST上限的限制. 超出此上限的服务必须得到资金预认证部门的批准 1-800-292-4488. 非医疗保险受益人必须获得皇冠搏彩中心网站预认证部门批准的服务 1-800-292-2288. |
| Durable Medical Equipment (DME) and Supplies | Covered for rental or, 在适当的地方, purchase when determined to be medically necessary by a physician.
所有DME和医疗用品都需要由医生填写的医疗需要证明(CMN). 所有受益人都必须使用七家皇冠搏彩中心网站网络DME供应商之一. Provider must obtain precertification for any DME items over $300. Rent-to-cap period of 15 months applies to all rentals. 尿失禁用品，如成人尿布和chux都包括在内，每月限制为3盒. Maximum allowable of $150 per month per benefit. |
| 氧气 | Covered when ordered by attending physician, 患者被转介给指定的肺部顾问进行测试，顾问的报告与氧气订单一起提交给计划管理员.
15个月的租金至上限期限适用于所有氧气设备的租金. 氧气 requires precertification and must be recertified annually. 必须在医疗需要证明(CMN)上提供医疗理由，才能批准氧气设备和用品. Additional documentation is also required. |
| Prosthetics and Orthopedic Devices | Covered when prescribed by a physician and is medically necessary. |
| 预防保健 | 例行体检包括:新生儿和6岁以下儿童, 55岁及以上, existing medical condition and being treated by physician, undergoing annual or semi-annual exam by gynecologist, 或接受由专科医生指定的例行检查，作为专科医生对医疗状况护理的一部分.
美国医学协会(AMA)的指导方针用于报销的就诊. 如果超过准则，索赔将暂停进行医疗审查. Benefits are provided for immunizations, allergy desensitization injections, 巴氏涂片, screening for hypertension and diabetes, and examinations for cancer, 失明和耳聋以及其他医学上必要的筛查和诊断程序. 1993/预先供资计划-年龄限制不适用于医疗保险合格受益人. CBF/1992 Plans – Age limit does not apply to any beneficiary. |
| Non-Emergency Transportation | 如果用于往返医院的救护车运输，需事先获得计划管理者的批准, 诊所, 医疗中心, physician’s office or skilled nursing care facility, when considered medically necessary by a physician.
如果在受益人住所附近无法获得医疗服务，并且必须将受益人带离该地区，则可获得补贴, or if the beneficiary requires frequent transportation, such as for radiation or physical therapy. 如果陪同人员提供了令人满意的证据，也可以为陪同人员提供保险. 需要通过资金运输预认证部进行预认证 1-800-292-2288. 只有卧床不起或只能用担架抬到救护车上的病人，才可安排非紧急救护车运送去接受医疗护理. Alternate forms of transportation for scheduled trips (i.e. Ambulette, 范, 出租车, 航天飞机, 只有在医疗上需要辅助运输，而受益人需要救护车运输的情况下，才会批准. 指定次数的旅行将按协商的费率授权付款. Meals and lodging may be covered for beneficiary and escort, 如果事先批准, for out-of-area transports. |
| 助听器 | 服务必须由经批准的助听器供应商提供，该供应商必须签署助听器供应商协议，并在经批准的29家供应商名单上.
超过600美元的助听器需要通过皇冠搏彩中心网站助听器预认证部门进行预认证 1-800-292-2288. Benefits for necessary repairs and maintenance, except the replacement of batteries, will be provided after the expiration of the warranty period. 只有当受益人的状况发生变化而需要使用新的助听器时，才会为更换助听器提供补贴, or the aid no longer functions properly. |
| 按摩保健 | 医疗保险受益人通过医疗保险获得脊椎按摩福利. 医疗保险 does not cover spinal manipulation.
本皇冠搏彩中心网站将按医疗保险允许的80%将这些索赔作为医疗保险福利处理. 本皇冠搏彩中心网站将不支付医疗保险共同保险，因为脊医护理不包括在本皇冠搏彩中心网站的福利计划内. For Non-医疗保险 beneficiaries this is not a covered benefit. |
| 常规视力护理 | Covered as a limited benefit. 福利每24个月提供一次，每次服务的最高金额为上限.
See Vision fee schedule for reimbursement amounts. 除非新的处方与最近的处方有20度或20度的变化，否则镜片将不会被覆盖 .50屈光度的球体或圆柱形镜片必须在标准视力表上至少提高一条线的视力. |
