Plan A $50,000 max per injury/sickness | Plan B $75,000 max per injury/sickness | Plan C $100,000 max per injury/sickness | Plan D $130,000 max per injury/sickness | |
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INPATIENT | ||||
Hospital Room & Board including Laboratory Tests, X-rays, Prescription Medical and other miscellaneous | Up to $1,500/day, 30 day max | Up to $2,000 per day, 30 day max | Up to $2,500/day, 30 day max | Up to $3,000/day, 30 day max |
Hospital Intensive Care Unit | Additional $500/day, 8 day max | Additional $500/day, 8 day max | Additional $500/day, 8 day max | Additional $800/day, 8 day max |
Surgical Treatment | Up to $2,100 | Up to $4,800 | Up to $5,800 | Up to $7,200 |
Anesthetist | Up to $500 | Up to $750 | Up to $1,000 | Up to $1,650 |
Assistant Surgeon | Up to $500 | Up to $750 | Up to $1,000 | Up to $1,650 |
Physician’s Non-Surgical Visits | Up to $38/visit, 1/day, 30 visits | Up to $56/visit, 1/day, 30 visits | Up to $75/visit, 1/day, 30 visits | Up to $100/visit, 1/day, 30 visits |
Consultant Physician, when requested by attending Physician | Up to $250 | Up to $325 | Up to $500 | Up to $575 |
Pre-Admission Tests w/in 7 days before Hospital admission | Up to $650 | Up to $975 | Up to $1,300 | Up to $1,300 |
Private Duty Nurse | Up to $650 | Up to $650 | Up to $650 | Up to $650 |
OUTPATIENT | ||||
Surgical Treatment | Up to $2,100 | Up to $4,800 | Up to $5,800 | Up to $7,200 |
Anesthetist | Up to $500 | Up to $750 | Up to $1,000 | Up to $1,650 |
Assistant Surgeon | Up to $500 | Up to $750 | Up to $1,000 | Up to $1,650 |
Physician’s Non-Surgical /Urgent Care Visits | Up to $38/visit, 1/day, 10 visits | Up to $56/visit, 1/day, 10 visits | Up to $75/visit, 1/day, 10 visits | Up to $100/visit, 1/day, 10 visits |
Diagnostic X-rays & Lab Services | Up to $250; Additional $325 - One CAT scan, PET scan or MRI | Up to $375; Additional $325 - One CAT scan, PET scan or MRI | Up to $500; Additional $975 - One CAT scan, PET scan or MRI | Up to $575; Additional $975 - One CAT scan, PET scan or MRI |
Hospital Emergency Room | Up to $200 max | Up to $300 max | Up to $400 max | Up to $650 max |
Prescription Drugs | Up to $68 | Up to $101 | Up to $135 | Up to $200 |
Outpatient Surgical Facility | Up to $600 | Up to $900 | Up to $1,200 | Up to $1,400 |
OTHER SERVICES | ||||
Ambulance Services | Up to $500 | Up to $500 | Up to $500 | Up to $500 |
Initial Orthopedic Prosthesis/Brace | Up to $663 | Up to $994 | Up to $1,325 | Up to $1,600 |
Chemotherapy and/or Radiation Therapy | Up to $663 | Up to $994 | Up to $1,325 | Up to $1,600 |
Dental Treatment for Injury to Sound, Natural Teeth | Up to $650 | Up to $650 | Up to $650 | Up to $650 |
Mental & Nervous Disorder & Substance Abuse | Same as any Sickness | Same as any Sickness | Same as any Sickness | Same as any Sickness |
Physiotherapy | Up to $45/visit, 1/day, 12 visits | Up to $45/visit, 1/day, 12 visits | Up to $45/visit, 1/day, 12 visits | Up to $45/visit, 1/day, 12 visits |
Emergency Evacuation | $50,000 | $50,000 | $50,000 | $50,000 |
Return of Remains | $7,500 | $7,500 | $7,500 | $7,500 |
Common Carrier AD&D Principal Sum | $25,000 | $25,000 | $25,000 | $25,000 |
Acute Onset of a Pre-existing Condition | $50,000 per policy period for Medical Expense Benefits (subject to the sublimits for each benefit shown above) & $25,000 per policy period for Emergency Medical Evacuation. | $75,000 per policy period for Medical Expense Benefits (subject to the sublimits for each benefit shown above) & $25,000 per policy period for Emergency Medical Evacuation. | $100,000 per policy period for Medical Expense Benefits (subject to the sublimits for each benefit shown above) & $25,000 per policy period for Emergency Medical Evacuation. | $130,000 per policy period for Medical Expense Benefits (subject to the sublimits for each benefit shown above) & $25,000 per policy period for Emergency Medical Evacuation. |