AFFORDABLE CHOICE PLAN COMPARISON CONTINUED Surgical and Hospitalization Benefits PLAN 1 PLAN 2 PLAN 3 PLAN 4 PLAN 5 Outpatient Medical Benefits
Wellness Benefit: (1 day per calendar year)
$100
N/A
Surgical Pathology: $200 Preventative Pap:$250 Preventative PSA: $250 All other Labs: $50
Surgical Pathology: $300 Preventative Pap:$300 Preventative PSA: $300 All other Labs: $50
Surgical Pathology: $400 Preventative Pap:$350 Preventative PSA: $350 All other Labs: $50
Surgical Pathology: $500 Preventative Pap:$400 Preventative PSA: $400 All other Labs: $50
Surgical Pathology: $250 Preventative Pap:$250 Preventative PSA: $250 All other Labs: $100
Laboratory Test (Per day)
Therapy Services: (Per day for physical, occupational, speech)
$50
$75
$100
$125
$100
MRI: $300 PET Scan: $300 CT Scan: $300 Mammogram: $250/ Other: $200
MRI: $600 PET Scan: $600 CT Scan: $600 Mammogram: $300 Other: $250
MRI: $900 PET Scan: $900 CT Scan: $900 Mammogram: $350 Other: $300
MRI: $1,000 PET Scan: $1,000 CT Scan: $1,000 Mammogram: $400 Other: $350
MRI: $300 PET Scan: $300 CT Scan: $300 Mammogram: $300 Other: $300
Radiology Services: (per day: MRI/PET scan/ CT scan/mammogram/ other radiology tests)
Calendar year limit for all Outpatient Benefits
$4,000
Ground and Air Ambulance (Limit of 2 trips per calendar year for all ambulance transportation.)
Ground: $500 Air: $1,500
N/A
Allergy Shots and Immunization (child only) (per day allergy shots/ immunizations)
Allergy Shots: $10 Immunizations: $25 Calendar year Maximum: $100
Health Care Practitioner Visit during Confinement
$50/day ; 1 day per year
$50/day ; 2 days per year
$50/day ; 3 days per year
$50/day ; 4 days per year
$50/day ; 4 days per year
Lifetime Maximum
$5,000,000
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