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<br />Ronda Munlclpallnsur8nce Trust <br /> <br />Medical Master Plan of Benefits <br /> <br />approval must be obtained by the Trust for prosthetics and other devices <br />which exceeds $500 in cost. <br /> <br />(5) Initial Eye Glasses or Contact Lens - resulting only from cataract or glaucoma <br />surgery (including those surgically implanted). <br /> <br />(6) Hospital Charges - for emergency room care or for surgical service.s performed <br />in the outpatient department of a hospital. <br /> <br />(7) Alternative Housing - in close proximity to a medical facility located in the <br />state: <br /> <br />(a) If the Trust finds a bone marrow transplant otherwise covered under the <br />terms of this Plan has been performed on the participant at the medical <br />facility; <br /> <br />(b) Due to the special nature of the bone marrow transplant procedure, it <br />can be performed in no more than four medical facilities in the state the <br />participant does not reside within 45 minutes driving time to the medical <br />facility; <br /> <br />(c) Due to the special nature of the bone marrow transplant procedure, it is <br />medical necessary for the participant to remain over a prolonged period of <br />time in close proximity to the medical facility in which the procedure was <br />performed in order to closely monitor potential post-procedure <br />complications directly related to the procedure; <br /> <br />(d) The costs of the physician-directed inpatient hospital stay would far <br />outweigh the cost of outpatient services combined with the alternative <br />housing. <br /> <br />(e) The above findings and decisions to permit alternative housing, including <br />those related to medical necessity, and the type, location, cost, length of <br />stay and nature of the alternative housing, shall be within the sole <br />discretion of the Trust. The fact that a physician may prescribe, order, <br />recommend, or approve the alternative housing does not of itself make it <br />medically necessary or make the expense an allowable expense, <br /> <br />(f) Notwithstanding the other terms, conditions and limitations provided in <br />this subsection, the Lifetime Maximum under this section is $10,000**. <br /> <br />Supplemental Accident Benefit - Services under this Plan will be provided, as stated <br />in the Schedule of Benefits, for each accident when expenses are incurred, as the <br />result of an accident for medical, surgical, and hospital care and treatment, <br />within ninety (90) days subsequent to an accident not connected with <br />employment and when such treatment has been prescribed by a physician. <br /> <br />Expenses which are incurred after the ninety (90) day period or after the <br />maximum for each accident has been reached, will be paid as regular Plan <br />benefits, subject to the deductible and/ or coinsurance provisions of this Plan. <br /> <br />Diagnostic X-ray. Laboratorv and Patholopcal Services - Services for outpatient <br />hospital ~d physician charges for diagnostic x-ray, laboratory and pathology <br />required for the treatment of an illness shall be paid in accordance with the <br />schedule. of benefits. <br /> <br />Chiropractic Services - The reasonable fees for chiropractic services shall be <br />covered, subject to all Plan provisions, deductibles and coinsurance. <br />