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Plan Detail

Plan Administrator: Tokio Marine HCC - Medical Insurance Services Group | AM Best Rating: A "Excellent" | Underwriter: Lloyd's

Benefits


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
  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