Arizona Health Insurance > Golden Rule Insurance Company > Covered Expenses

Copay Select^SM , HSA 100^®, Plan 100^®, and Plan 80^SM

Medical Expense Benefits

• Daily hospital* room and board and nursing services at the most common semiprivate rate.
• Charges for intensive care unit.
• Hospital emergency room treatment of an injury or illness (subject to an additional $100 copay each time the emergency room is used for an illness not resulting in confinement - does not apply to HSA Plans.
• Services and supplies, including drugs and medicines, which are routinely provided by the hospital to persons for use while they are inpatients.
• Professional fees of doctors and surgeons (but not for standby availability).
• Dressings, sutures, casts, or other necessary medical supplies.
• Professional fees for outpatient services of licensed physical therapists.
• Diagnostic testing using radiologic, ultrasonographic, or laboratory services in or out of the hospital.
• Local ground ambulance service to the nearest hospital for necessary emergency care.  Air ambulance, within U.S., if requested by police or Medical authorities at the site of emergency.
• Charges for operating, treatment, or recovery room for surgery.
• Dental expenses due to an injury which damages natural teeth if expenses are incurred within six months.
• Surgical treatment of TMJ disorders (See Limitations)
• Cost and administration of anesthetic, oxygen, and other gases.
• Radiation therapy or chemotherapy.
• Prescription drugs.
• Hemodialysis, processing, and administration of blood and components.
• Mammography, Pap smear, and PSA test fees.
• Artificial eyes, Larynx, breast prosthesis, or basic artificial limbs (but not replacements).
• Surgery in a doctor's office or at an outpatient surgical facility, including services and supplies.
• Occupational therapy following a covered treatment for traumatic hand injuries.
• Rehabilitation and extended care facility services that begin within 14 days of a 3-day or more hospital stay, for the same illness or injury.  Combined calendar year maximum of 60 days for both rehabilitation or extended care facilites expenses.

Saver PLans - Copay Saver^SM , HSA Saver ^®, and Saver 80^SM

Inpatient Expense Benefits

• Daily hospital* room and board and nursing services at the most common semiprivate rate.
• Charges for intensive care unit.
• Drugs, medicines, dressings, sutures, casts, or other necessary medical supplies.
• Artificial limbs, eyese, larynx, or breast prosthesis (but not replacements).
• Professional fees of doctors and surgeons (but not for standby availability).
• Hemodialysis, processing, and administration of blood and components.
• Charges for operating, treatment, or recovery room for surgery.
• Cost and administration of anesthetic, oxygen, and other gases.
• Radiation therapy or chemotherapy and diagnostic testing using radiologic, ultrasonographic, or laboratory services in or out of the hospital.
• Local ground ambulance service to the nearest hospital for necessary emergency care.  Air ambulance, within U.S., if requested by police or Medical authorities at the site of emergency.

Outpatient Expense Benefits

• Charges for outpatient surgery, including the fee made by an outpatient surgical facility, the primary surgeon, the assistant surgeon, and/or administration of anesthetic.
• Hemodialysis, radiation, and chemotherapy.
• Presctiption drugs to protest against organ rejection in transplant cases.
• Hospital emergency room treatment of an injury or illness (See Limitations)
• Mammography, Pap smear, and PSA test fees.
• CAT scan and MRI testing.
• Diagnostic testing related to, and performed within, 14 days prior to surgery or inpatient confinement.
• Copay Saver^SM plan includes two doctor office copay visits per year
• Copay Saver^SM plan includes coverage for generic presctiption brugs.

Important note about Saver Plans:

Premiums for Saver Plans are significantly less because coverage is not provided for most outpatient services.  Outpatient expenses not specifically listed in the policy are not covered.  Please review the Saver Plans impatient and outpatient expense benefits, exclusions and limitations for details.

Some outpatient expenses are not covered under the Saver Plans include:

• Outpatient doctor office visit fees (limited benefit provided under Copay Saver^SM), diagnosti testing, prescription drugs (limited benefit provided under Copay Saver^SM), and other outpatient medical services not specifically listed under the Inpatient, Outpatient, or Transplant Expense Benefits;
• Outpatient professional fees of licensed physical therapists, durable medical equipment, and medical supplies, except those covered under the Home Health Care Expense Benefits;
• Outpatient expenses incurred for mental or nervous disorders or substance abuse; and
• Preventive care office visits (unless the optional Preventive Care Package is added)

*Hospital does not include a nursing home or convalescent home or an extended care facility.