INPATIENT | | | | |
Hospital Room & Board including Laboratory Tests, X-rays, Prescription Medical and other miscellaneous | Up to $1,400/day, 30 day max | Up to $1,675/day, 30 day max | Up to $1,950/day, 30 day max | Up to $2,535/day, 30 day max |
Hospital Intensive Care Unit | Additional $660/day, 8 day max | Additional $755/day, 8 day max | Additional $850/day, 8 day max | Additional $1,105/day, 8 day max |
Surgical Treatment | Up to $3,300 | Up to $4,400 | Up to $5,500 | Up to $7,150 |
Anesthetist | Up to $825 | Up to $1,100 | Up to $1,375 | Up to $1,775 |
Assistant Surgeon | Up to $825 | Up to $1,100 | Up to $1,375 | Up to $1,775 |
Physician’s Non-Surgical Visits | Up to $55/visit, 1/day, 30 visits max | Up to $70/visit,1/day, 30 visits max | Up to $85/visit, 1/day, 30 visits max | Up to $110/visit, 1/day, 30 visits max |
Consulting Physician, when requested by attending Physician | Up to $450 | Up to $475 | Up to $500 | Up to $650 |
Private Duty Nurse | Up to $550 | Up to $550 | Up to $550 | Up to $700 |
Pre-Admission Tests w/in 7 days before Hospital admission | Up to $1,100 | Up to $1,100 | Up to $1,100 | Up to $1,450 |
OUTPATIENT | | | | |
Surgical Treatment | Up to $3,300 | Up to $4,400 | Up to $5,500 | Up to $7,150 |
Anesthetist | Up to $825 | Up to $1,100 | Up to $1,375 | Up to $1,775 |
Assistant Surgeon | Up to $825 | Up to $1,100 | Up to $1,375 | Up to $1,775 |
Physician’s Non-Surgical / Urgent Care Visits | Up to $55/visit, 1/day, 10 visits max | Up to $70/visit, 1/day, 10 visits max | Up to $85/visit, 1/day, 10 visits max | Up to $110/visit, 1/day, 10 visits max |
Diagnostic X-rays & Lab Services | Up to $450 - Additional $250 - One CAT scan, PET scan or MRI | Up to $475 – additional $375 - One CAT scan, PET scan or MRI | Up to $500 - Additional $500 - One CAT scan, PET scan or MRI | Up to $650 - Additional $600 - One CAT scan, PET scan or MRI |
Hospital Emergency Room (all expenses incurred therein) | Up to $330 | Up to $440 | Up to $550 | Up to $700 |
Prescription Drugs | Up to $100 | Up to $125 | Up to $150 | Up to $200 |
Outpatient Surgical Facility | Up to $1,000 | Up to $1,050 | Up to $1,100 | Up to $1,400 |
OTHER TREATMENT & SERVICES | | | | |
Ambulance Services | Up to $450 | Up to $450 | Up to $450 | Up to $450 |
Initial Orthopedic Prosthesis/brace | Up to $1,100 | Up to $1,200 | Up to $1,300 | Up to $1,700 |
Chemotherapy and/or Radiation Therapy | Up to $1,100 | Up to $1,225 | Up to $1,350 | Up to $1,750 |
Dental Treatment for Injury to Sound, Natural Teeth | Up to $550 | Up to $550 | Up to $550 | Up to $550 |
Mental & Nervous Disorder & Substance Abuse | Same as any Sickness | Same as any Sickness | Same as any Sickness | Same as any Sickness |
Physiotherapy | Up to $40/visit, 1/day, 12 visits max | Up to $40/visit, 1/day, 12 visits max | Up to $40/visit, 1/day, 12 visits max | Up to $40/visit, 1/day, 12 visits max |
Emergency Evacuation | 50000 | 50000 | 50000 | 50000 |
Repatriation of Remains | 7500 | 7500 | 7500 | 7500 |
AD&D Principal Sum | $25,000 Common Carrier | $25,000 Common Carrier | $25,000 Common Carrier | $25,000 Common Carrier |
Acute Onset of a Pre-existing Condition (the above maximum schedule still applies) | $50,000 per policy period for medical expense benefits (subject to the sublimits for each benefit shown above) & $25,000 per policy period for 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 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 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 medical evacuation |