00 for
EasyShare25) for all services combined. The table above represents the amounts shared for
particular incidents and any limitations specifically related to such incidents. The program shares the
actual charges of room and board up to the maximum listed in the chart above per day. In addition,
for surgical procedures, the program shares the actual charges up to a maximum amount listed
above per incident. The member is responsible for any amounts above the EasyShare amounts. In
services where the member is responsible for the consultation fee EasyShare shares the balance up
to program maximums.
2. Emergency room cost sharing and ambulance limited to a maximum of 2 incidents per year.
Emergency room/ambulance are only available for sharing if the intended for treatment of medical
conditions that are life threatening or could seriously jeopardize the health of the individual and if the
illness results in an in-patient hospital stay, inclusive of any other eligible, sharable medical expenses
incurred throughout the Program Year.
3. All outpatient CT Scan, MRI, and X-Ray imaging have a 90-day waiting period and sharable only with
a physician prescription and must be procured at a free standing in-network diagnostic center unless
received as an admitted patient. For CT Scan, MRI, and X-Ray imaging in a non-hospital environment
EasyShare limits sharing to not more than$400 for CT Scan and MRI and not more than$250 for X-
Ray with the member responsible for any amount above that limit. These diagnostic procedures are
fully sharable if performed during an eligible, sharable inpatient stay and for an inpatient surgical
procedure.
viii. Sharing Amounts/Percentages.
Sharing Percentages are not applicable to the EasyShare Programs. Sharing amounts/limits are shown
above in section V, subsection vii, Per Medical Incident Limits.
II. Medical Expense Sharing
Medical costs are shared on a per person per Medical Incident basis for illnesses or injuries incurring
medical expenses after your Effective Date that were medically necessary and provided by or under the
direction of licensed Physicians, Hospitals or other licensed medical Facilities, or approved Practitioners.
A Medical Incident means a medically diagnosed condition and all medical treatment(s) received andUHFR093021E100121 Page 107
medical expenses incurred relating to such diagnosis. All medical bills of any nature relating to the same
diagnosis are part of the same Medical Incident. Medical expenses eligible for sharing include, but are not
limited to, physician and hospital services, emergency medical care, medical testing, x-rays, emergency
medical transportation and prescription medications provided by a Hospital during an admission, unless
otherwise limited or excluded by these Guidelines. Total bills incu