BENEFITS
|
Bronze |
Silver |
Gold |
Signature |
| Physician Office Visits |
$50 per office visit
up to 5 per year for a total of 15 per family |
$60 per office visit
up to 5 per year for a total of 15 per family |
$75 per office visit
up to 5 per year for a total of 15 per family |
$100 per office visit
up to 5 per year for a total of 15 per family |
| Hospital Admission and
Confinement Benefit |
$500 1st day, $250
per day thereafter |
$500 1st day, $500
per day thereafter |
$750 1st day, $750
per day thereafter |
$1,250 1st day,
$1,000
per day thereafter |
| Diagnostic Testing & Lab Benefit |
$50 per visit, up to
3 per year. |
$60 per visit, up to
3 per year. |
$75 per visit, up to
3 per year. |
$100 per visit, up to
3 per year. |
| Surgical Benefit |
$50 x RVU schedule |
$100 x RVU schedule |
$200 x RVU schedule |
$300 x RVU schedule |
| Accident Rider |
$1,000 per accident
/ $50 deductible |
$1,000 per accident
/ $50 deductible |
$2,500 per accident
/ $100 deductible |
$5,000 per accident
/ $150 deductible |
| Substance Abuse and Mental
Illness |
3 visits annually |
3 visits annually |
3 visits annually |
3 visits annually |
| Term Life Insurance |
No Benefit |
$2,500 per insured
$750 per insured spouse
$500 per insured child |
$2,500 per insured
$750 per insured spouse
$500 per insured child |
$5,000 per insured
$1,250 per insured spouse
$500 per insured child |
| Accidental Death Benefit |
No Benefit |
$5,000 per insured |
$5,000 per insured |
$5,000 per insured |
| Discount
Benefits |
|
|
|
|
| Hospital PPO |
X |
X |
X |
X |
| Physician Network |
X |
X |
X |
X |
| Laboratory Services |
X |
X |
X |
X |
| Radiology & Imaging |
X |
X |
X |
X |
| Chiropractic |
X |
X |
X |
X |
| Alternative Medicine |
X |
X |
X |
X |
| Dental |
X |
X |
X |
X |
| Vision |
X |
X |
X |
X |
| 24 Hour Nurse |
X |
X |
X |
X |
| Durable Medical |
X |
X |
X |
X |
| Hearing Aids |
X |
X |
X |
X |
| Prescriptions - Walk in |
X |
X |
X |
X |
| Prescriptions - Mail order |
X |
X |
X |
X |
