| Benefits |
Plan A |
Plan B |
Plan C |
Plan D |
| INPATIENT |
Policy Maximum |
$50,000 |
$75,000 |
$100,000 |
$130,000 |
| Deductible |
$0, $50, or $100 |
$0, $50, or $100 |
$0, $50, or $100 |
$0, $50, or $100 |
| Hospital Room/ Board |
Up to $1,400/day, 30 day max |
Up to $1,675/day, 30 day max |
Up to $1,950/day, 30 day max |
Up to $2,535/day, 30 day max |
| Hospital ICU |
Additional $660/day, 8 day max |
Additional $755/day, 8 day max |
Additional $850/day, 8 day max |
Additional $1,105/day, 8 day max |
| Surgical Treatment |
Up to $3,300 |
Up to $4,400 |
Up to $5,500 |
Up to $7,150 |
| Anesthetist |
Up to $825 |
Up to $1,100 |
Up to $1,375 |
Up to $1,775 |
| Assistant Surgeon |
Up to $825 |
Up to $1,100 |
Up to $1,375 |
Up to $1,775 |
| Physician’s Non-Surgical Visits |
Up to $55/visit, 1/day, 30 visits max |
Up to $70/visit, 1/day, 30 visits max |
Up to $85/visit, 1/day, 30 visits max |
Up to $110/visit, 1/day, 30 visits max |
| A Consulting Physician, when requested by attending Physician |
Up to $450 |
Up to $475 |
Up to $500 |
Up to $650 |
| Private Duty Nurse |
Up to $550 |
Up to $550 |
Up to $550 |
Up to $700 |
| Pre-Admission Tests w/in 7 days before Hospital admission |
Up to $1,100 |
Up to $1,100 |
Up to $1,100 |
Up to $1,450 |
| OUTPATIENT |
| Surgical Treatment |
Up to $3,300 |
Up to $4,400 |
Up to $5,500 |
Up to $7,150 |
| Anesthetist |
Up to $825 |
Up to $1,100 |
Up to $1,375 |
Up to $1,775 |
| Assistant Surgeon |
Up to $825 |
Up to $1,100 |
Up to $1,375 |
Up to $1,775 |
| Physician’s Non-Surgical / Urgent Care Visits |
Up to $55/visit, 1/day, 10 visits max |
Up to $70/visit, 1/day, 10 visits max |
Up to $85/visit, 1/day, 10 visits max |
Up to $110/visit, 1/day, 10 visits max |
| Diagnostic X-rays & Lab Services |
Up to $450
Additional $250 - One Cat scan, PET scan or MRI |
Up to $475
Additional $375 – One Cat scan PET or MRI |
Up to $500
Additional $500 - One Cat scan, PET scan or MRI |
Up to $650 -
Additional $600 - One Cat scan, PET scan or MRI |
| Hospital Emergency Room (all expenses incurred therein) |
Up to $330 |
Up to $440 |
Up to $550 |
Up to $700 |
| Prescription Drugs |
Up to $100 |
Up to $125 |
Up to $150 |
Up to $200 |
| Outpatient Surgical Facility |
Up to $1,000 |
Up to $1,050 |
Up to $1,100 |
Up to $1,400 |
| OTHER TREATMENT AND SERVICES |
| Ambulance Services |
Up to $450 |
Up to $450 |
Up to $450 |
Up to $450 |
| Initial Orthopedic Prosthesis/brace |
Up to $1,100 |
Up to $1,200 |
Up to $1,300 |
Up to $1,700 |
| Chemotherapy and/or radiation therapy |
Up to $1,100 |
Up to $1,225 |
Up to $1,350 |
Up to $1,750 |
| Dental Treatment for Injury to Sound, Natural Teeth |
Up to $550 |
Up to $550 |
Up to $550 |
Up to $550 |
| Mental & Nervous Disorder & Substance Abuse |
Same as any Sickness |
Same as any Sickness |
Same as any Sickness |
Same as any Sickness |
| Physiotherapy |
Up to $40/visit, 1/day, 12 visits max |
Up to $40/visit, 1/day, 12 visits max |
Up to $40/visit, 1/day, 12 visits max |
Up to $40/visit, 1/day, 12 visits max |
| Emergency Evacuation |
$50,000 |
$50,000 |
$50,000 |
$50,000 |
| Repatriation of Remains |
$7,500 |
$7,500 |
$7,500 |
$7,500 |
| AD&D Principal Sum |
$25,000 |
$25,000 |
$25,000 |
$25,000 |
| OPTIONAL PRE-EX BENEFIT |
Pre-existing Conditions
(the above maximum schedule still applies) |
Up to $5,000 in coverage for Myocardial Infarction (heart attack) or Stroke |
Up to $5,000 in coverage for Myocardial Infarction (heart attack) or Stroke |
Up to $5,000 in coverage for Myocardial Infarction (heart attack) or Stroke |
Up to $5,000 in coverage for Myocardial Infarction (heart attack) or Stroke |
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| PLEASE READ PLAN PDF FOR ADDITIONAL PLAN LANGUAGE, DEFINITIONS AND EXCLUSIONS |
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