Deductible | | | | |
Ages 14 days - 69 years | $0, $50, or $100 | $0, $50, or $100 | $0, $50, or $100 | $0, $50, or $100 |
Ages 70 - 79 | $100 or $200 | $100 or $200 | N/A | N/A |
Ages 80 and above | $100 or $200 | N/A | N/A | N/A |
Overall Policy Maximum | | | | |
Ages 14 days - 69 years | 50000 | 75000 | 100000 | 130000 |
Ages 70 - 79 | 50000 | 75000 | N/A | N/A |
Ages 80 and above | 10000 | N/A | N/A | N/A |
Inpatient Treatment | | | | |
Hospital room and board, including miscellaneous | $1,450 per day, maximum 30 days | $1,725 per day, maximum 30 days | $2,000 per day, maximum 30 days | $2,585 per day, maximum 30 days |
Intensive care unit, including miscellaneous | $2,110 per day, maximum 8 days | $2,480 per day, maximum 8 days | $2,850 per day, maximum 8 days | $3,690 per day, maximum 8 days |
Surgery | $3,300 per session | $4,400 per session | $5,500 per session | $7,150 per session |
Consultant physician | $450 maximum | $475 maximum | $500 maximum | $650 maximum |
Private duty nurse | $550 maximum | $550 maximum | $550 maximum | $700 maximum |
Physician visits | $60 maximum per visit, 30 visits maximum | $75 maximum per visit, 30 visits maximum | $90 maximum per visit, 30 visits maximum | $115 maximum per visit, 30 visits maximum |
Outpatient Treatment | | | | |
Surgery | $3,300 per session | $4,400 per session | $5,500 per session | $7,150 per session |
Outpatient surgical facility | $1,000 maximum | $1,050 maximum | $1,100 maximum | $1,400 maximum |
Pre-admission testing | $1,100 maximum | $1,100 maximum | $1,100 maximum | $1,450 maximum |
Diagnostic x-ray and labs | $450 maximum, plus $250 for one CAT Scan, MRI or PET | $475 maximum, plus$375 for one CAT Scan, MRI or PET | $500 maximum, plus$500 for one CAT Scan, MRI or PET | $650 maximum, plus$600 for one CAT Scan, MRI or PET |
Emergency room (all expenses incurred therein) | $355 maximum | $465 maximum | $575 maximum | $750 maximum |
Outpatient prescription drugs | $100 maximum | $125 maximum | $150 maximum | $200 maximum |
Office visits, including urgent care | $60 allowable per visit, 10 visitsmaximum | $75 allowable per visit, 10 visitsmaximum | $90 allowable per visit, 10 visitsmaximum | $115 allowable per visit, 10 visitsmaximum |
Miscellaneous Inpatient & Outpatient Treatment | | | | |
Anesthesiologist | 825 | 1110 | 1375 | 1775 |
Assistant surgeon | 825 | 1110 | 1375 | 1775 |
Local ambulance | $475 maximum | $475 maximum | $475 maximum | $475 maximum |
Dental accident | $550 maximum | $550 maximum | $550 maximum | $550 maximum |
Physical therapy | $40 maximum per visit, 1 visit per day, maximum 12 visits | $40 maximum per visit, 1 visit per day, maximum 12 visits | $40 maximum per visit, 1 visit per day, maximum 12 visits | $40 maximum per visit, 1 visit per day, maximum 12 visits |
Durable medical equipment | $1,100 maximum | $1,200 maximum | $1,300 maximum | $1,700 maximum |
Other Benefits (not subject to deductible or overall policy maximum) | | | | |
Emergency medical evacuation | $50,000 lifetime maximum, except as provided under acute onset of pre-existing condition. Available only to members under age 70. | $50,000 lifetime maximum, except as provided under acute onset of pre-existing condition. Available only to members under age 70. | $50,000 lifetime maximum, except as provided under acute onset of pre-existing condition. Available only to members under age 70. | $50,000 lifetime maximum, except as provided under acute onset of pre-existing condition. Available only to members under age 70. |
Repatriation of remains | $7,500 per member | $7,500 per member | $7,500 per member | $7,500 per member |
Common carrier accidental death & dismemberment | $25,000 lifetime maximum principal sum per member Not subject to deductibleDeath or loss of two limbs - principal sum Loss of one limb - one-half the principal sum | $25,000 lifetime maximum principal sum per member Not subject to deductibleDeath or loss of two limbs - principal sum Loss of one limb - one-half the principal sum | $25,000 lifetime maximum principal sum per member Not subject to deductibleDeath or loss of two limbs - principal sum Loss of one limb - one-half the principal sum | $25,000 lifetime maximum principal sum per member Not subject to deductibleDeath or loss of two limbs - principal sum Loss of one limb - one-half the principal sum |
Acute onset of pre-exiting condition (only available to mem- bers under age 70) | $50,000 lifetime maximum for eligible expenses. $25,000 lifetime maximum for emergency medical evacuation. | $75,000 lifetime maximum for eligible expenses. $25,000 lifetime maximum for emergency medical evacuation. | $100,000 lifetime maximum for eligible expenses. $25,000 lifetime maximum for emergency medical evacuation. | $100,000 lifetime maximum for eligible expenses. $25,000 lifetime maximum for emergency medical evacuation. |