Coverage Information


Hospital services for in-patient and out-patient treatment which is determined as medically necessary to the patient.

Ambulance transportation (ground and air)

Primary Care Services

Behavioral Health



There is a $15,000.00 fiscal year limit for hospital services and a $5,000.00 fiscal limit for ambulance service. (This is per patient and amounts cannot be transferred from one patient to another.)

Primary Care/ Behavioral Health/Dental services to an eligible individual will be subject to a limit of $4,000.00 per patient per fiscal year and claims are paid at 65%.

(Primary Care co-pays are not eligible because they are considered reasonable and generally result after the Medicare reimbursement.)