Our plan provides the following included benefits.
INPATIENT BENEFITS Covers inpatient hospital stays, inpatient surgeries, physician’s inpatient charges, if these expenses are covered under a Covered Person’s Medical plan.
Benefits are determined by the employer based on the employer’s major medical plan. Available coverage amounts for the employer to select from are: $500, $1,000, $1,250, $1,500, $2,000, $2,500, $3,000, $3,500, $4,000, $4,500, $5,000, $5,500, $6,000, $6,500, $7,000, $7,500 We will pay benefits for Covered Charges if a Covered Person: • incurs the Covered Charges while the Covered Person is an Inpatient due to an Injury or Sickness; and • the expenses are covered by the Covered Person’s Medical Plan Available coverage amounts are: $250, $300, $350, $400, $450, $500, $600, $700, $750, $800, $900, $1,000, $1,100, $1,200, $1,250, $1,300, $1,400, $1,500, $1,600, $1,700, $1,750, $1,800, $1,900, $2,000, $2,100, $2,200, $2,250, $2,300, $2,400, $2,500, $3,000, $3,500, $4,000, $4,500, $5,000, $5,500, $6,000, $6,500, $7,000, $7,500 We will pay benefits for Covered Charges if a Covered Person receives treatment on an Outpatient basis due to an Injury or Sickness.
OUTPATIENT BENEFITS Outpatient treatment of injury and sickness. Treatment must be performed in: • An Emergency Room • An Urgent Care Facility • A Free-Standing Facility • An Ambulatory Surgical Center and/or Outpatient Hospital Facility
OUTPATIENT PRESCRIPTIONS DRUGS
Generic Outpatient Prescription Drug Benefit: $10 - $50 in $10 Increments Brand Name Outpatient Prescription Drug Benefit: $10 - $50 in $10 Increments Plan Year Maximum: $100 - $500 in $100 Increments
AMBULANCE BENEFITS
Ground Ambulance Benefit: $150 - $1,000 per day Air Ambulance Benefit:
$300 - $2,000 per day Plan Year Maximum: 4 transports
DOCTOR’S OFFICE VISIT
Doctor’s Office Visit Benefit: $25 per visit Plan Year Maximum: 4 visits
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