Deductible

The amount of covered expenses that the insured must pay before a plan or insurance contract starts to pay.

$0.0

Coinsurance

Most policies require the insured to pay some portion of the health care bills. A typical arrangement is that the insurer pays 80 percent and the insured 20 percent, up to $3,000 of covered expenses after the insured has paid the deductible. After the insured hits the maximum out-of-pocket limit, the insurance company pays 100 percent of covered expenses during the remainder of the calendar year, up to any applicable annual benefit or lifetime maximum of the policy.

None

Coinsurance Out-of-Pocket Maximum

The limit on the amount an individual is required to pay for health care services covered by his or her benefits plan after the deductibles and any copays are paid. Refers to care received from the network of participating physicians, hospitals, and health care professionals. Coinsurance Out-of-Pocket amounts are in addition to any Deductible amounts.

0.0

Network

A group of doctors, hospitals and other health care providers and facilities that have, either, (i) contracted with a health insurer or health plan to provide medical services at negotiated or discounted rates, or (ii) for limited benefits supplemental coverage, contracted directly or indirectly with an underwriter to agree to reduced fees for medical services.

MultiPlan

Wellness/Preventive Care (Includes immunizations)

$150 per Day (Maximum 1 day per Calendar Year)

Accidental Loss of Life: Primary and Spouse

$20,000

Accidental Loss of Life: Dependent

$5,000

Doctors Office/Urgent Care Visits-Illness or Injury

$100 per Day (Maximum 4 days per Calendar Year)

Lab

$50 per Day (Maximum 4 days per Calendar Year)

X-ray

$50 per Day (Maximum 4 days per Calendar Year)

MRI/PET/CT Scan

$300 per Day (Maximum 2 days per Calendar Year)

Outpatient Surgical Procedure

$1,500 per Day (Maximum 2 days per Calendar Year)

Anesthesiologist (When applicable to Outpatient Surgical Procedure)

$300 per Day

Emergency Room

$250 per Day for Illness $500 per Day for Injury (Combined Maximum 2 days per Calendar Year)

Ambulance

$500 per Day Ground/Water $5,000 per Day Air (Combined Maximum 2 days per Calendar Year)

Inpatient Hospital Confinement

$1,000 per Day (Maximum 31 days per Period of Confinement)

Intensive Care Unit (ICU) Confinement

$1,000 per Day (Maximum 31 days per Period of Confinement)

First Hospital Confinement

$2,000 per Day (Maximum 1 day per Calendar Year)

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