| 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 |
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