| {"answer": "Semi-private room and board is eligible during a covered admission, subject to the stated deductible, coinsurance, and daily limit. The additional charge for a private room chosen for comfort is not eligible; it may be eligible if the hospital assigns the room for medical isolation and documents the reason.", "question": "Are inpatient room-and-board charges covered if a member chooses a private room for comfort?", "source_clause": "Eligible inpatient hospital expenses include medically necessary room and board in a semi-private room and related nursing services during a covered admission. The plan pays 80% of eligible charges after the $500 admission deductible, subject to a maximum of $1,200 per day for room and board. Any charge above the semi-private room rate is not eligible unless the hospital assigns a private room for medical isolation and documents the reason in the medical record.", "evidence_quote": "Any charge above the semi-private room rate is not eligible unless the hospital assigns a private room for medical isolation and documents the reason in the medical record.", "coverage_status": "conditional", "coverage_conditions": ["The admission must be covered and the room and board must be medically necessary.", "The plan pays 80% of eligible charges after the $500 admission deductible.", "Room-and-board benefits are limited to $1,200 per day.", "A private-room charge above the semi-private room rate is eligible only when the hospital assigns the room for medical isolation and documents the reason in the medical record."]} | |
| {"answer": "Prescription drugs may be covered if the treating physician orders them and a licensed pharmacy dispenses them within 30 days after the covered outpatient procedure. The member is responsible for a $20 copayment per prescription. Over-the-counter products and prescriptions dispensed after the 30-day period are not eligible under this benefit.", "question": "Are prescription drugs obtained after a covered outpatient procedure eligible for reimbursement?", "source_clause": "After a covered outpatient procedure, the plan covers prescription drugs ordered by the treating physician and dispensed by a licensed pharmacy within 30 days after the procedure. The member pays a $20 copayment per prescription; over-the-counter products and drugs dispensed more than 30 days after the procedure are not eligible under this benefit.", "evidence_quote": "The plan covers prescription drugs ordered by the treating physician and dispensed by a licensed pharmacy within 30 days after the procedure.", "coverage_status": "conditional", "coverage_conditions": ["The outpatient procedure must be covered.", "The drug must be ordered by the treating physician.", "A licensed pharmacy must dispense the drug within 30 days after the procedure.", "The member pays a $20 copayment per prescription.", "Over-the-counter products and drugs dispensed more than 30 days after the procedure are not eligible under this benefit."]} | |
| {"answer": "Emergency ground ambulance transport is eligible when a sudden illness or injury requires immediate transport to the nearest facility equipped to provide the necessary emergency care, and the attending clinician's record documents the emergency and why private transport was inappropriate. Non-emergency transport is excluded. Eligible transport is reimbursed up to $800 per trip after the annual medical deductible.", "question": "Does the plan cover emergency ground ambulance transport to a hospital?", "source_clause": "Emergency ground ambulance transport is an eligible expense when sudden illness or injury requires immediate transport to the nearest facility equipped to provide the necessary emergency care. The attending clinician's record must state the emergency condition and why private transport was inappropriate. Non-emergency transport, including transport requested solely for convenience or transfer to a facility selected by the member when a nearer suitable facility is available, is excluded. Eligible transport is reimbursed up to $800 per trip after the annual medical deductible.", "evidence_quote": "Emergency ground ambulance transport is an eligible expense when sudden illness or injury requires immediate transport to the nearest facility equipped to provide the necessary emergency care.", "coverage_status": "conditional", "coverage_conditions": ["A sudden illness or injury must require immediate transport.", "Transport must be to the nearest facility equipped to provide the necessary emergency care.", "The attending clinician's record must state the emergency condition and why private transport was inappropriate.", "Reimbursement is limited to $800 per trip after the annual medical deductible.", "Non-emergency transport is excluded."]} | |