y is sharable when prescribed due to symptoms for a condition not evident prior
to your membership. Routine or screening colonoscopies are not sharable.
(h) Cosmetic Surgery.
Cosmetic Surgery, including breast reduction or enhancement operations and any other elective cosmetic
surgery or procedures done primarily to alter appearance or for any other non-health reasons, is not
sharable.
(i) CT Scan.
For CT Scans in a non-hospital environment EasyShare limits sharing to a fixed amount of $400 per
visit/series with the member responsible for any amount above that limit. All outpatient CT scan imaging
have a 90-day waiting period, are sharable only with a physician prescription and must be procured at a
free standing in-network diagnostic center unless received as an admitted patient.
(j) Diagnostic Imaging
See individual entries for CT scan, Mammogram, MRI, X-Ray imaging.
(k) Emergency Room.
Emergency room services provided on an outpatient basis at a Hospital, Clinic or Urgent Care Facility for
stabilization or initiation of treatment of an Emergency medical condition, including when Hospital
Admission occurs within 23 hours of emergency room treatment. EasyShare limits sharing to a fixed
amount of $1,000 per visit and is only intended for Emergency treatment. Emergency room cost sharing
is only intended for Emergency treatment, and Emergency Room expenses incurred for a non-
Emergency situation will not be shared; provided, however, that for children six years and under any
Emergency Room expenses will be presumed to be incurred for an Emergent Situation unless there is a
compelling reason to conclude otherwise.
(l) Hearing Surgery.
N/A
(m) Hearing Therapy.
See Audiological Therapy.
(n) Home Health Care.
N/A
(o) Hospice Care.
N/A
(p) Hospital Charges.
Daily room and board charges up to a maximum of $2,500 per day for EasyShare 25 or $3,000 per day
for EasyShare 50 for a maximum of 10 days annually for Inpatient hospital care or procedure for a
medically diagnosed condition, but only when such care or procedure cannot be provided or performed
on an outpatient basis or in a non-hospital, ambulatory facility. A separate sharable amount for an
individual surgical procedure is available for up to $2,500 per procedure for EasyShare 25 or $3,000 perUHFR093021E100121 Page 109
procedure for EasyShare 50 for up to two surgical procedures per program year. There is a 90-day
waiting period before Hospital and surgical charges can be eligible for sharing.
(q) Hyperbaric Oxygen Therapy.
N/A
(r) Infusion Therapy.
N/A
(s) Mammograms.
Mammograms may be eligible for sharing once every two years for Members up to and including age
forty-nine (49), and once every year for Members fifty (50) years of age and older, after the applicable
waiting period. Only charges for conventional