Inpatient Treatment | | | |
Hospital room and board | Up to $825 per day, 30 day maximum per period of coverage | Up to $1,400 per day, 30 day maximum per period of coverage | Up to $1,950 per day, 30 day maximum per period of coverage |
Intensive care | Up to an additional $400 per day, 8 day maximum per period ofcoverage | Up to an additional $660 per day, 8 day maximum per period of coverage | Up to an additional $850 per day, 8 day maximum per period of coverage |
Surgical treatment | Up to $2,000 per surgical session | Up to $3,300 per surgical session | Up to $5,500 per surgical session |
Physician consult | Up to $350 per period of coverage | Up to $450 per period of coverage | Up to $500 per period of coverage |
Pre-admission tests | Up to $750 per period of coverage | Up to $1,100 per period of coverage | Up to $1,100 per period of coverage |
Private duty nurse | Up to $400 per period of coverage | Up to $550 per period of coverage | Up to $550 per period of coverage |
Physician visits | Up to $40 per visit, 30 visits per period of coverage | Up to $55 per visit, 30 visits per period of coverage | Up to $85 per visit, 30 visits per period of coverage |
Outpatient Treatment | | | |
Surgical treatment | Up to $2,000 per surgical session | Up to $3,300 per surgical session | Up to $5,500 per surgical session |
Surgical facility fee | Up to $750 per surgical session | Up to $900 per surgical session | Up to $1,000 per surgical session |
Diagnostic x-ray & lab | Up to $650 per period of coverage, ($325 per procedure) | Up to $800 per period of coverage, ($400 per procedure) | Up to $950 per period of coverage, ($475 per procedure) |
Hospital emergency room | Up to $200 per visit | Up to 75% of URC to $330 per visit | Up to 75% of URC to $550 per visit |
Prescription drugs | Up to $150 per period of coverage | Up to $250 per period of coverage | Up to $250 per period of coverage |
Physician visits | Up to $50 per visit, 10 visits per period of coverage | Up to $55 per visit, 10 visits per period of coverage | Up to $85 per visit, 10 visits per period of coverage |
Miscellaneous Inpatient & Outpatient Treatment | | | |
Anesthetist | Up to $450 per surgical session | Up to $825 per surgical session | Up to $1,375 per surgical session |
Assistant surgeon | Up to $450 per surgical session | Up to $825 per surgical session | Up to $1,375 per surgical session |
Other Coverages | | | |
Local ambulance | Up to $250 per period of coverage | Up to $450 per period of coverage | Up to $450 per period of coverage |
Dental for accident to sound natural teeth | Up to $350 per period of coverage | Up to $550 per period of coverage | Up to $550 per period of coverage |
Physical therapy | Up to $25 per visit per day, 12 visits per period of coverage | Up to $40 per visit per day, 12 visits per period of coverage | Up to $40 per visit per day, 12 visits per period of coverage |
Extended care facility | Up to $150 per day, 15 day maximum per period of coverage | Up to $200 per day, 15 day maximum per period of coverage | Up to $250 per day, 15 day maximum per period of coverage |