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Schedule of Medical Benefits Schedule of Medical Benefits
 
MAXIMUM LIFETIME BENEFIT UNLIMITED
ELIGIBLE MEDICAL EXPENSES:  
Ambulatory Surgical Center, per use $250 Co-Pay
Chiropractic Care, per visit
Limited to $1,000 per Calendar Year 		$30 Co-Pay
Diagnostic Lab & X-ray, Outpatient
MRI, CAT, PET Scan 		$50 Co-Pay
Other Diagnostic Services 100%
Home Health Care 100%
Limited to 100 visits per Calendar Year. Each visit by a nurse or by a therapist and each 4-hour period of home health aide services will count as 1 visit.
Hospice Care
Inpatient Care, per admission 		$250 Co-Pay
Home Care Services & Supplies 100%
Hospital Services
Inpatient Care, per admission 		$250 Co-Pay
Emergency Room, per use – see NOTE $150 Co-Pay
Outpatient Services, per use (surgery, etc.) – see NOTE $250 Co-Pay
Eligible coverage for Inpatient room and board are limited to a Semi-Private Room or for an Intermediate or Intensive Care Unit as medically required. A private room accommodation will be covered only when isolation of the patient is Medically Necessary and is ordered by the attending Physician to protect the health of the patient or others.

NOTE: The Co-Pay will be waived if patient is admitted to the Hospital directly following use of
Outpatient services.
Mental Health / Substance Abuse Care
Inpatient Care, per admission 		$250 Co-Pay
Day Treatment, per session $30 Co-Pay
Outpatient Visits & Day Treatment, per visit $30 Co-Pay
Inpatient mental health and substance abuse care is limited to a combined maximum of 30 days per Calendar Year. Day treatment sessions are subject to the Inpatient limit on a 2 for 1 basis
(i.e., 2 day treatment sessions will count as 1 Inpatient day). Outpatient visits for mental health and substance abuse care are limited to 30 per Calendar Year.
Physician Services
Inpatient Visits 		100%
Office Visits – see NOTE:
to a primary care Physician, per visit (visit charge ONLY) 		$30 Co-Pay
to a specialist (visit charge ONLY) $50 Co-Pay
NOTE: A “primary care Physician” will include only a doctor in: (1) family practice and general practice, (2) internal medicine, (3) pediatrics, or (4) obstetrics/gynecology. Any other Physician will be treated
as a specialist. 		100%
(see below for Prescription Drugs)
Prescription Drugs
Preventive Care
In-Office Services, per visit 		$30 Co-Pay
Out-of-Office Services (lab work, X-rays, etc.) 100%
Preventive Care includes up to $500 in benefits each Calendar Year for routine health care check-ups
and related routine lab work and X-rays that are not related to Sickness or Accidental Injury.
Such routine care includes but is not limited to: physicals, a routine newborn pediatric exam, periodic well-baby and well-child check-ups, mammograms, prostate exams, pap smears, chest X-rays, blood work, vision exams, etc.
Second (& 3rd) Surgical Opinion $30 Co-Pay
Skilled Nursing Facility, per admission $250 Co-Pay
Eligible Expenses for room and board are limited to the facility's Semi-Private Room Charge.
Coverage is limited to 60 days per Calendar Year.
Urgent Care Facility, per visit $75 Co-Pay
All Other Eligible Medical Expenses 100%
Schedule of Presciption Benefits Schedule of Presciption Benefits
 
Covered Person Pays
PRESCRIPTION PROGRAM
Retail Pharmacy Feature
Generic Drug		 $4 Co-Pay
Brand Drug $25 Co-Pay
To use the Retail Program, a Covered Person takes his drug ID card to a participating pharmacy to fill his prescription order. A retail prescription can be purchased in up to a 30-day supply for the Co-Pays shown.
Mail Order Option
Generic Drug 		$10 Co-Pay
Brand Drug $60 Co-Pay
The Mail Order Option is for maintenance (longer-term) drugs. A retail prescription can be purchased in up to a 90-day supply for the Co-Pays shown.