ss results in an in-patient hospital stay.
Inpatient and outpatient hospital and surgery have a 90-day waiting period for the EasyShare Programs.
All outpatient CT Scan, MRI, and X-Ray imaging for the EasyShare Programs have a 90-day waiting
period and are sharable for up to two imaging series per year in each category, and only with a
physician’s prescription. Imaging services must be procured at a freestanding, in-network diagnostic
center, unless received as an admitted patient or performed in connection with an outpatient or
ambulatory surgical center procedure, in the same facility where the procedure is being performed, and
on the same day as the procedure is performed.
vii. Annual Visits & Hospitalization Sharing Limits
Sharing is limited to a maximum number of visits/days/incidents per Program Year for each Member, as
follows:
Type of Visit or Therapy Session
Max. Number of Visits/Days/Incidents Per Program
Year Eligible for Sharing
Annual Routine Physical or Well Child Exam 1 visit per Program Year
Primary Care, combined with Pediatrics 4 visits in total for any combination of Primary Care and
Pediatrics (Annual Physical or Well Child Exam does not
count towards this limit) per Program Year
Urgent Care 2 visits per Program Year
Specialty Care 2 visits per Program Year
Inpatient Hospital Care 10 days per Program Year
Surgery (Inpatient or Outpatient) 2 procedures per Program Year
Emergency Room 2 visits per Program Year
Ambulance 2 incidents per Program Year
CT Scan 2 visits/series per Program Year
MRI 2 visits/series per Program Year
X-Ray 2visits/series per Program Year
For the EasyShare Programs, once the 90-day waiting period has passed, the following portions of
Eligible Medical Expenses are generally sharable at the actual amount charged up to the maximum day
or incident limit amounts inclusive of any other eligible, sharable medical expenses incurred throughout
the Program Year based on the following schedule, subject to all exclusions, restrictions and limitations
set forth in these Guidelines:UHFR093021E100121 Page 106
Type of Medical Need
EasyShare Per-incident Limit 1
Maximum Number of
Days / Incidents 1
Type of Medical Need EasyShare50
Per-Incident Limit 1
EasyShare25
Per-Incident Limit 1
Maximum Number of
Days / Incidents 1
Hospitalization Room & Board $3,000 $2,500 10
Inpatient or Outpatient Surgical
Procedures
$3,000 per surgical
procedure
$2,500 per surgical
procedure
Two Surgical
Procedures per
Program Year
Emergency Room2 $1,000 $1,000 2 incidents per
Program Year
Ambulance 2
$500 $500 2 incidents per
Program Year
CT Scan 3
$400 $400 2 per Program Year
MRI 3
$400 $400 2 per Program Year
X-Ray – Non-Hospital Facility 3
$250 $250 2 per Program Year
1. EasyShare pays a maximum annual per member amount ($50,000 for EasyShare 50 and $25,0