Hospital Room (average semi-private) & Board, and Miscellaneous | Plan 50k: Charges up to $1,300 a day maximum Up to 30 days Plan 100k: Charges up to $1,750 a day maximum Up to 30 days Plan 150k: Charges up to $1,900 a day maximum Up to 30 days |
Hospital Intensive Care Unit | Plan 50k: Charges up to $525 maximum additional a day | Up to 8 Days Plan 100k: Charges up to $750 maximum additional a day | Up to 8 Days Plan 150k: Charges up to $850 maximum additional a day | Up to 8 Days |
Surgeon | Plan 50k: Up to $3,000 maximum Plan 100k: Up to $5,000 maximum Plan 150k: Up to $6,000 maximum |
Anesthetist | Plan 50k: Up to $750 maximum Plan 100k: Up to $1,250 maximum Plan 150k: Up to $1,500 maximum |
Assistance Surgeon | Plan 50k: Up to $750 maximum Plan 100k: Up to $1,250 maximum Plan 150k: Up to $1,500 maximum |
Doctor’s Non-Surgical Visits | Plan 50k: Up to $60 a visit maximum | 1 visit a day Up to 10 visits Plan 100k: Up to $100 a visit maximum | 1 visit a day Up to 10 visits Plan 150k: Up to $125 a visit maximum | 1 visit a day Up to 10 visits |
Consultant Doctor, when requested by attending Doctor | Plan 50k: Up to $400maximum Plan 100k: Up to $450 maximum Plan 150k: Up to $500 maximum |
Pre-Admission Tests within 14 days before hospital admission | Plan 50k: Up to $1,000 maximum Plan 100k: Up to $1,100 maximum Plan 150k: Up to $1,200 maximum |
Surgical Room & Supply Expenses | Plan 50k: Up to $1,000 maximum Plan 100k: Up to $1,100 maximum Plan 150k: Up to $1,200 maximum |
Surgeon | Plan 50k: Up to $3,000 maximum Plan 100k: Up to $5,000 maximum Plan 150k: Up to $6,000 maximum |
Anesthetist | Plan 50k: Up to $750 maximum Plan 100k: Up to $1,250 maximum Plan 150k: Up to $1,500 maximum |
Assistance Surgeon | Plan 50k: Up to $750 maximum Plan 100k: Up to $1,250 maximum Plan 150k: Up to $1,500 maximum |
Doctor’s Non-Surgical Visits | Plan 50k: Up to $60 a visit maximum | 1 visit a day Up to 10 visits Plan 100k: Up to $100 a visit maximum | 1 visit a day Up to 10 visits Plan 150k: Up to $125 a visit maximum | 1 visit a day Up to 10 visits |
Diagnostic X-rays & Lab Services | Plan 50k: Up to $400 maximum Plan 100k: Up to $650 maximum Plan 150k: Up to $750 maximum |
CAT Scan, PET Scan, or MRI | Plan 50k: Up to $400 additional Plan 100k: Up to $650 additionalbr> Plan 150k: Up to $1,000 additional |
Ambulance Services | Plan 50k: Up to $400 additional Plan 100k: Up to $450 maximum Plan 150k: Up to $500 maximum |
Rehabilitative Braces or Appliances | Plan 50k: Up to $1,200 maximum Plan 100k: Up to $1,100 maximum Plan 150k: Up to $1,200 maximum |
Dental Treatment injury to Sound, Natural teeth (Due to Accident) | Plan 50k: Up to $450. There are no benefits for dental services for immediate relief of pain. Plan 100k: Up to $500. There are no benefits for dental services for immediate relief of pain. Plan 150k: Up to $550. There are no benefits for dental services for immediate relief of pain. |
Chemotherapy and/or Radiation Therapy | Plan 50k: Up to $1,000 maximum Plan 100k: Up to $1,150 maximum Plan 150k: Up to $1,250 maximum |
Physical & Occupational Therapy | Plan 50k: Up to $1,000 maximum Plan 100k: Up to $1,150 maximum Plan 150k: Up to $1,250 maximum |
Private Duty Nurse | Plan 50k: Up to $400 maximum Plan 100k: Up to $500 maximum Plan 150k:Up to $550 maximum |
Emergency Medical Treatment of Pregnancy | Plan 50k: Up to $4,500 maximum Plan 100k: Up to $5,000 maximum Plan 150k: Up to $5,500 maximum |
Medical Evacuation | Plan 50k:$15,000 maximum Plan 100k: $20,000 maximum Plan 150k: $25,000 maximum |
Repatriation of Remains | Plan 50k: $10,000 maximum Plan 100k: $15,000 maximum Plan 150k: $20,000 maximum |
Accidental Death & Dismemberment | Plan 50k: $25,000 Principal Sum Plan 100k: $25,000 Principal Sum Plan 150k: $25,000 Principal Sum |
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