Essential StaffCARE Plans
| | 5k Plan | 10k Plan | 15k Plan | 20k Plan | | Annual Maximum (in or out-of-network) | $5,000 | $10,000 | $15,000 | $20,000 | | Annual Deductible - Individual / Family | $200 / $500 | $200 / $500 | $200 / $500 | $200 / $500 | | Outpatient Medical Expense Benefit | $2,000 | $1,500 | $2,250 | $3,000 | | Doctors' Office Visits (Lab and X-ray on same bill) | | | | | | Per visit co-pay 1. | $15 | $15 | $15 | $15 | | Co-insurance | 100% | 100% | 100% | 100% | | Diagnostic, Surgical, & Emergency Room Visit 1.2. | 80% | 80% | 80% | 80% | | Prescription Coverage Benefit 1.2.3. | 80% | 80% | 80% | 80% | | Inpatient Medical Expense Benefit | | | | | | Co-insurance | 80% | 80% | 80% | 80% | Inpatient Physician Services
(surgeon, anesthesiologist, doctor visits in hospital, etc.) | 80% | 80% | 80% | 80% | | Other Hospital Services Annual Maximum | $1,000 | $1,500 | $2,250 | $3,000 | | Daily Room & Board Maximum | $200 | $400 | $400 | $500 | | Daily ICU Room & Board Maximum | $400 | $800 | $800 | $1,000 | | Accidental Death and Dismemberment | | | | | | Included in the Medical Benefit (Not available in some states.) | | | | | | Employee | $10,000 | $10,000 | $10,000 | $10,000 | | Spouse | $5,000 | $5,000 | $5,000 | $5,000 | | Child | $2,500 | $2,500 | $2,500 | $2,500 | | Optional Prescription Drug Co-pay Card | | | | | | Per Month Maximum (no carryover) | $50 | $50 | $50 | $50 | | Generic / Branded Co-pay | $10 / $30 | $10 / $30 | $10 / $30 | $10 / $30 | | | | | | |
1. Subject to Outpatient Maximum
2. After Plan Deductible
3. Reimburstment Method
Exclusions and Limitations »
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