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<br />COST CONTAINMENT PROVISIONS <br /> <br />Home Health Care: This benefit provides coverage for medical treatment and <br />services performed at the patient's home by a licensed home health care <br />agency. It is designed to save time spent as a hospital in-patient, and to <br />allow patients to recover more quickly in a home environment. Benefits are <br />provided based on the following criteria. <br /> <br />1 . <br /> <br />Services and supplies are furnished by a home beal th care agency that is <br />state licensed. <br /> <br />2. <br /> <br />The services and supplies provided by the agency are provided within 15 <br />days following the end of a hospital confinement and/or the physician <br />certifies that in the absence of home health care, inpatient confinement <br />would be necessary. <br /> <br />3. <br /> <br />A written plan of home health care is established in advance by the <br />attending physician. <br /> <br />4. <br /> <br />The home health treatment is ordered for the same or related conditions <br />that necessitated hospital confinement and is not custodial care. <br /> <br />Benefits will be provided at 80% subject to the plan year deductible. <br /> <br />Second Opinion Sur~ery: In order to receive the highest bene1"it, the plan <br />will require a second opinion regarding the need for surgery for certain <br />specified non-emergency procedures. The plan will pay 100% of the cost of <br />obtaining this second surgical opinion and, if necessary, a third surgical <br />opinion. <br /> <br />If a second surgical opinion is obtained, the plan will pay regular benefits <br />regardless of the result of the second opinion. If the second opinion is not <br />obtained, however, the plan will reduce benefits payable for surgical charges <br />to 60% of reasonable and customary charges. Surgical procedures which will <br />require second surgical opinions in non-emergency situations in order to <br />receive the higher benefits are as follows: <br /> <br />.. <br />.. <br />.. <br />.. <br />.. <br />.. <br />.. <br />of <br />of <br />of <br />of <br />.. <br />.. <br />.. <br />.. <br />.. <br />.. <br /> <br />Appendectomy <br />Hysterectomy <br />Knee Surgery <br />Cholecystectomy <br />Inguinal Herniorraphy <br />Herniated Lumbar Intervertebral Disk Removal <br />Cataract Removal <br />Submucous Resection (Diviated Septum) <br />Hemorrhoidectomy <br />Cesarean Section <br />Coronary Bi-pass <br />Mastectomy <br />Dilation and Curettage (D&C) <br />Varicose Vein Removal/Stripping <br />Bunionectomy <br />Wisdom Teeth Removal <br />Tonsillectomy/Adenoidectomy <br /> <br />5 <br />