Plan Administrator: Tokio Marine HCC - Medical Insurance Services Group | AM Best Rating: A "Excellent" | Underwriter: Lloyd's
SCHEDULE OF BENEFITS AND LIMITS
All benefits, except Emergency Medical Evacuation, Repatriation of Remains, and Common Carrier Accidental Death and Dismemberment, are subject to deductible and are per injury or illness, up to the overall policy maximum, unless stated otherwise
DEDUCTIBLE | Plan A | Plan B | Plan C | Plan D |
---|---|---|---|---|
Ages 14 days -59 years | $0, $50, or $100 | |||
Ages 60- 69 years | $0, $50, or $100 | |||
Ages 70 – 79 years | $100 or $200 | |||
Ages 80 and above | $100 or $200 | |||
OVERALL POLICY MAXIMUM | ||||
Ages 14 days -59 years | $50,000 | $75,000 | $100,000 | $130,000 |
Ages 60- 69 years | $50,000 | $75,000 | $100,000 | |
Ages 70 – 79 years | $50,000 | $75,000 | ||
Ages 80 and above | $10,000 |
INPATIENT TREATMENT | ||||
---|---|---|---|---|
Plan A | Plan B | Plan C | Plan D | |
Hospital Room &Board, including miscellaneous unless specified |
$1,450 per day, 30 days max |
$1,725 per day, 30 days max |
$2,000 per day, 30 days max |
$2,585 per day, 30 days max |
Intensive Care Unit, including miscellaneous unless specified |
$2,200 per day, 8 days max |
$2,600 per day, 8 days max |
$3,000 per day, 8 days max |
$3,800 per day, 8 days max |
Surgery | $3,600 per session | $4,800 per session | $6,000 per session | $7,800 per session |
Consultant physician | $450 | $475 | $500 | $650 |
Private duty nurse | $550 | $550 | $550 | $700 |
Physician visits |
$60 per visit, 30 visits max |
$75 per visit, 30 visits max |
$90 per visit, 30 visits max |
$115 per visit, 30 visits max |
OUTPATIENT TREATMENT | ||||
Plan A | Plan B | Plan C | Plan D | |
Surgery | $3,300 per session | $4,400 per session | $5,500 per session | $7,150 per session |
Outpatient Surgical Facility | $1,100 | $1,150 | $1,200 | $1,500 |
Pre-admission Testing | $1,100 | $1,100 | $1,100 | $1,450 |
Diagnostic X-ray and Labs | $500, plus $400 for one CAT Scan, MRI or PET | $550, plus $450 for one CAT Scan, MRI or PET | $600, plus $500 for one CAT Scan, MRI or PET | $750, plus $650 for one CAT Scan, MRI or PET |
Emergency Room (all expenses incurred therein) | $375 | $485 | $600 | $785 |
Observation Room Services (all expenses incurred therein) | $355 | $465 | $575 | $750 |
Outpatient Prescription Drugs | $150 | $200 | $250 | $300 |
Office Visits, including Urgent Care |
$70 per visit, 10 visits max |
$85 per visit, 10 visits max |
$100 per visit, 10 visits max |
$130 per visit, 10 visits max |
MISCELLANEOUS INPATIENT & OUTPATIENT TREATMENT | ||||
Plan A | Plan B | Plan C | Plan D | |
Anesthesiologist | $825 | $1,110 | $1,375 | $1,775 |
Assistant Surgeon | $825 | $1,110 | $1,375 | $1,775 |
Local Ambulance | $500 | $500 | $500 | $500 |
Dental Accident | $550 | $550 | $550 | $550 |
Physical Therapy | $40 per visit, 1 visit per day, maximum 12 visits | |||
Mental & Nervous Disorder & Substance Abuse | Same as any Illness | Same as any Illness | Same as any Illness | Same as any Illness |
Durable Medical Equipment | $1,100 | $1,200 | $1,300 | $1,700 |
Acute Onset of Pre-existing Condition (only available to members under age 70) | $50,000 Lifetime Maximum for Eligible Medical Expenses | $75,000 Lifetime Maximum for Eligible Medical Expenses | $100,000 Lifetime Maximum for Eligible Medical Expenses | $100,000 Lifetime Maximum for Eligible Medical Expenses |
$25,000 Lifetime Maximum for Emergency Medical Evacuation | ||||
OTHER BENEFITS Not subject to deductible or overall policy maximum |
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Plan A | Plan B | Plan C | Plan D | |
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 | |||
Local Burial & Cremation | $5,000 | |||
Common Carrier Accidental Death & Dismemberment |
$25,000 Lifetime aximum Principal Sum Death or Loss of Two Limbs – Principal Sum Loss of One Limb – One-half the Principal Sum Subject to a maximum of $125,000 any one family or group |