Coverage & BenefitsPlan benefits summary

Disclaimers about this plan (3)

This is only a summary. If there is a difference between this summary and your plan documents, the terms of your plan documents will apply.
These costs are estimates only. The costs provided here are estimates only and are not a guarantee of payment or benefits. The estimates are based on the selected provider’s contract rates/fee schedule or claims averages. Your actual cost may be higher or lower than the estimate for various reasons.
You may have received a letter saying that your coverage request was denied. InterQual guidelines may have been used to make that decision. View the InterQual guidelines⁠(Opens new window).