| Annual Plan Maximum1 |
5k |
10k |
Outpatient Medical Benefit Maximum2 |
|
|
| Physician Office Visit (per visit) |
|
$100 |
$100 |
| |
|
|
| Diagnostic (Lab) (per testing day) |
$100 |
$100 |
| |
|
|
| Diagnostic (X-ray) (per testing day) |
$200 |
$200 |
| |
|
|
| Ambulance Services (per trip) |
$300 |
$300 |
| |
|
|
| Emergency Room Benefit – Sickness (per visit) |
$150 |
$150 |
| |
|
|
| Emergency Room Benefit - Accident3 (per visit) |
$500 |
$500 |
| |
|
|
| Surgery4 (per day) |
$500 |
$500 |
| Anesthesiology4 (per day) |
$100 |
$100 |
| |
|
|
| Physical Therapy/Occupational Therapy/Speech Therapy (per visit) |
$50 |
$50 |
| |
|
|
|
Prescription Drugs5 |
|
|
| Monthly Maximum |
$50 |
$50 |
| Generic (per script) |
$10 |
$10 |
| Brand (per script) |
$30 |
$30 |
|
|
|
| |
Inpatient Hospital Benefit6 |
| Standard Care (per day) |
$600 |
$800 |
| |
|
|
| Intensive Care (per day) 7 |
$600 |
$800 |
| |
|
|
| Surgery (per day) 8 |
$1,500 |
$2,500 |
| Anesthesiology (per day) |
$300 |
$500 |
| |
|
|
| Skilled Nursing9 (per day) |
$100 |
$100 |
| |
WELLNESS BENEFIT10 |
$75 |
$75 |
| |
Accidental Loss of Life, Limb or Sight Benefit11 |
|
|
| Employee |
$10,000 |
$10,000 |
Spouse |
$5,000 |
$5,000 |
| |
|
|
- The annual outpatient max and inpatient coverages are subject to the overall plan maximum. All benefits reflect a per covered person, per policy year basis.
- All outpatient benefits are subject to the outpatient maximum.
- Covers treatment in an emergency room for off the job accidents.
- Payable per outpatient surgical day.
- Not subject to outpatient maximum (Reverse co-pay method).
- Payable benefits require a minimum 24 hour stay.
- Paid in addition to standard care benefit.
- Payable per inpatient surgical day.
- For stays in a skilled nursing facility after a 3+ day hospital stay.
- One time lump sum benefit for a routine examination or other preventive testing per covered person per policy year.
- Accidental loss of life, limb, or sight benefit is not available as a rider to medical in CA, FL, MN, or NC.
|
