| Features/Benefits |
Specifics |
| Eligibility |
Ages 18-64
1/2 years* |
| Plan
Options |
PPO**
or Managed Indemnity |
| Annual Plan
Deductibles and Coinsurance |
Individual
$1,500
(80/20of the next $18,000)
$2,600
(80/20 of the next $12,000)
$1,500
(100%)
$2,600
(100%)
$5,000
(100%)
|
Family
$3,000
(80/20of the next $36,000)
$5,150
(80/20 of the next $24,000)
$3,000
(100%)
$5,150
(100%)
$10,000
(100%)
|
| Lifetime
Maximum |
$7,000,000
per person |
| Non-Preventive
office visits |
100% after
deductible |
|
Emergency
Room Deductible
(in
addition to annual plan deductible) |
$250
per visit (waived if admitted to hospital) |
| Prescription Drugs |
100% after
deductible |
| Preventive Care |
Eligible
expenses for medical services and supplies incurred for preventive
care in an asymptomatic individual are
covered up to $300 per person per calendar year, which includes $50
for routine eye exams. |
| Psychiatric
Care*** |
Inpatient
annual maximum of $2,500 per person, per calendar year.
Outpatient annual maximum of $1,000 per person per calendar year.
Lifetime maximum of $10,000 per person per inpatient and outpatient
combined. |
| Manipulative
Therapy*** |
$500
maximum per person, per calendar year. |
| Hospital |
Average
semi-private room rate. Intensive care at four times the
average semi-private room rate. |
| Home Health
Care |
30 visits per person,
per calendar year, one visit per day. |
| Rehabilitation
Facility |
Inpatient - up to 30
days confinement per person, per calendar year . |
| Rehabilitation
Therapy |
Outpatient
- up to 30 visits per person, per calendar year. |
| Extended Care
Facility |
Up to 12
days of confinement, per person, per calendar year. |
| Transplants |
Covered up to amount
negotiated by network if Transplant Network used; capped at $100,000
per procedure if insured goes out of network. |
| Ambulance |
$3,000 covered per
person, per calendar year for emergency air or ground ambulance
service. |
| Value-Added Features/Benefits |
Preferred
Rates - Preferred rates are available for qualifying
applicants. Applicants and/or their spouses who have not used
tobacco in the past 12 months will also receive additional premium
savings.
|
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