Plan maximum per injury/sickness |
$50,000 |
$75,000 |
$100,000 |
$130,000 |
Inpatient |
Hospital Room & Board |
$1,450 per day, maximum 30 days |
$1,725 per day, maximum 30 days |
Up to $2,000/day, 30 day max |
Up to $2,585/day, 30 day max |
Hospital Intensive Care Unit |
$2,200 per day, maximum 8 days |
$2,600 per day, maximum 8 days |
$3,000 per day, maximum 8 days |
$3,800 per day, maximum 8 days |
Surgery |
$3,600 per session |
$4,800 per session |
$6,000 per session |
$7,800 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 max. |
$75 maximum per visit, 30 visits max. |
$90 maximum per visit, 30 visits max. |
$115 maximum per visit, 30 visits max. |
Outpatient |
Surgical |
$3,300 per session |
$4,400 per session |
Up to $5,500 per session |
Up to $7,150 per session |
Outpatient surgical facility |
$1,100 maximum |
$1,150 maximum |
$1,200 maximum |
$1,500 maximum |
Pre-admission testing |
$1,100 maximum |
$1,100 maximum |
$1,100 maximum |
$1,450 maximum |
Diagnostic x-ray and labs |
$500 maximum, plus $400 for one CAT Scan, MRI or PET |
$550 maximum, plus $450 for one CAT Scan, MRI or PET |
$600 maximum, plus $500 for one CAT Scan, MRI or PET |
$750 maximum, plus $650 for one CAT Scan, MRI or PET |
Emergency room (all expenses incurred therein) |
$375 maximum |
$485 maximum |
$600 maximum |
$785 maximum |
Observation room services |
$355 maximum |
$465 maximum |
$575 maximum |
$750 maximum |
Outpatient prescription drugs |
$150 maximum |
$200 maximum |
$250 maximum |
$300 maximum |
Office visits, including urgent care |
$70 allowable per visit, 10 visits max. |
$85 allowable per visit, 10 visits max. |
$100 allowable per visit, 10 visits max |
$130 allowable per visit, 10 visits max |
Other |
Anesthesiologist |
$825 |
$1,110 |
$1,375 |
$1,775 |
Assistant surgeon |
$825 |
$1,110 |
$1,375 |
$1,775 |
Local ambulance |
$500 maximum |
Dental accident |
$550 maximum |
Physical therapy |
$40 maximum per visit, 1 visit per day, maximum 12 visits |
Mental & nervous disorder & substance abuse |
Same as any illness |
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. |
Repatriation of remains |
$25,000 per member |
Local burial & cremation |
$5,000 per member |
Common carrier accidental death & dismemberment |
$25,000 lifetime maximum principal sum per member Death 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 members under age 70) $25,000 lifetime maximum for emergency medical evacuation |
$50,000 lifetime maximum for eligible expenses |
$75,000 lifetime maximum for eligible expenses |
$100,000 lifetime maximum for eligible expenses |