Hospital Room (average semi-private) & Board, and Miscellaneous | Plan 100k: Charges up to $1,750 a day, to 30 days Plan 150k: Charges up to $1,900 a day, to 30 days |
Hospital Intensive Care Unit | Plan 100k: Charges up to $750 maximum additional a day, to 8 days Plan 150k: Charges up to $850 maximum additional a day, to 8 days |
Surgeon | Plan 100k: Charges up to $5,000 maximum Plan 150k: Charges up to $6,000 maximum |
Anesthetist | Plan 100k: Charges up to $1,250 maximum Plan 150k: Charges up to $1,500 maximum |
Assistance Surgeon | Plan 100k: Charges up to $1,250 maximum Plan 150k: Charges up to $1,500 maximum |
Doctor’s Non-Surgical Visits | Plan 100k: Charges up to $1,250 maximum Plan 150k: Charges up to $1,500 maximum |
Consultant Doctor, when requested by attending Doctor | Plan 100k: Charges up to $450 maximum Plan 150k: Charges up to $500 maximum |
Pre-Admission Tests within 14 days before hospital admission | Plan 100k: Charges up to $1,100 maximum Plan 150k: Charges up to $1,200 maximum |
Surgical Room & Supply Expenses | Plan 100k: Charges up to $1,100 maximum Plan 150k: Charges up to $1,200 maximum |
Surgeon | Plan 100k: Charges up to $5,000 maximum Plan 150k: Charges up to $6,000 maximum |
Anesthetist | Plan 100k: Charges up to $1,250 Plan 150k: Charges up to $1,500 |
Assistance Surgeon | Plan 100k: Charges up to $1,250 Plan 150k: Charges up to $1,500 |
Doctor’s Non-Surgical Visits | Plan 100k: Charges up to $100 a visit maximum, 1 visit a day, to 10 visits Plan 150k: Charges up to $125 a visit maximum, 1 visit a day, to 10 visits |
Diagnostic X-rays & Lab Services | Plan 100k: Charges up to $650 maximum Plan 150k: Charges up to $750 maximum |
CAT Scan, PET Scan, or MRI | Plan 100k: Charges up to $650 additional Plan 150k: Charges up to $1,000 additional |
Hospital Emergency Room | Plan 100k: Charges up to $500 Plan 150k: Charges up to $750 |
Prescription Drugs | Plan 100k: Charges up to $150 maximum Plan 150k: Charges up to $200 maximum |
Ambulance Services | Plan 100k: Charges up to $450 maximum Plan 150k: Charges up to $500 maximum |
Rehabilitative Braces or Appliances | Plan 100k: Charges up to $1,100 maximum Plan 150k: Charges up to $1,200 maximum |
Dental Treatment injury to Sound, Natural teeth (Due to Accident) | Plan 100k: Charges up to $500 maximum. There are no benefits for dental services for immediate relief of pain. Plan 150k: Charges up to $550 maximum. There are no benefits for dental services for immediate relief of pain. |
Chemotherapy and/or Radiation Therapy | Plan 100k: Charges up to $1,150 Plan 150k: Charges up to $1,250 |
Physical & Occupational Therapy | Plan 100k: Charges up to $45 a visit maximum, 1 visit per day to 12 visits Plan 150k: Charges up to $50 a visit maximum, 1 visit per day to 12 visits |
Private Duty Nurse | Plan 100k: Charges up to $500 maximum Plan 150k: Charges up to $550 maximum |
Emergency Medical Treatment of Pregnancy | Plan 100k: Charges up to $5,000 maximum Plan 150k: Charges up to $5,500 maximum |
Medical Evacuation | Plan 100k: $25,000 maximum Plan 150k: $25,000 maximum |
Repatriation of Remains | Plan 100k: $15,000 maximum Plan 150k: $20,000 maximum |
Accidental Death & Dismemberment | Plan 100k: $25,000 maximum Plan 150k: $25,000 maximum |
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