Hospital Room & board | Average semi-private room rate, including nursing services |
Outpatient Treatment | Usual, Reasonable and Customary charges |
Outpatient prescription drugs | 50% of actual charge |
Mental health disorders | Outpatient:$50 maximum per day, $500 maximum lifetime |
Inpatient: Usual, reasonable, and customary charges to $5,000 maximum lifetime |
Emergency Medical Evacuation | $50,000 lifetime |
Emergency reunion | $1,000 lifetime maximum |
Repatriation of Mortal Remains | $25,000 maximum (not subject to deductible or coinsurance) |
Physical therapy and chiropractic care | Maximum $25 per day |
Pre-existing Conditions | $25,000 lifetime maximum for eligible medical expenses for the acute onset of pre-existing condition only |
Ambulance Service | Up to $300 per injury / illness if hospitalized as inpatient |
Hospital pre-certification penalty | 50% of eligible medical expenses |
Intensive Care Unit | Usual, Reasonable and Customary charges |
Therapeutic termination of pregnancy | $500 maximum per certificate period |