Health Plan Form
Getting Started - Plan Comparison
Step 1 of 3
Step 1 of 3
Complete Choice Plus plans are not available in the following states:
AK, CO, CT, KS, ME, MD, MA, MN, MT, NV, NH, NJ, NY, ND, OR, RI, SD, UT, VT, WA, WY
AK, CO, CT, KS, ME, MD, MA, MN, MT, NV, NH, NJ, NY, ND, OR, RI, SD, UT, VT, WA, WY
| Doctor's Office Visits | 1100 | 3300 | 6600 |
| Outpatient doctor's office visits (including chiropractic office consultations) are covered at the indicated amount per visit at the indicated maximum per person during each calendar year. | $60 per visit $300 max |
$75 per visit $300 max |
$75 per visit $300 max |
| Preventive Care | 1100 | 3300 | 6600 |
| Routine exams, medical treatment and wellness injections are covered at the indicated amount per visit and up to $150 per person during each calendar year. | $50 per visit $150 max |
$75 per visit $150 max |
$100 per visit $150 max |
| Outpatient Diagnostic Benefits | 1100 | 3300 | 6600 |
| Coverage for lab tests, x-rays and advanced studies up to the indicated collective maximum amount per person during each calendar year, as follows: | $1,200 total max: | $1,305 total max: | $2,610 total max: |
| Lab Tests – diagnostic lab tests are covered at the indicated amount per test for up to the indicated number of tests per person during each calendar year. | $20 per test 3 tests $60 max |
$35 per test 3 tests $105 max |
$35 per test 6 tests $210 max |
| Advanced Studies – outpatient advanced diagnostic tests, up to the indicated maximum amount per person during each calendar year, are covered at specifically scheduled amounts.Examples of scheduled amounts for such advanced studies include the indicated amounts for the following tests: | $1,000 max Specific max per particular test: |
$1,000 max Specific max per particular test: |
$2,000 max Specific max per particular test: |
| - Angiogram/Arteriogram | $270 | $400 | $400 |
| - EEG | $50 | $80 | $80 |
| - Myelogram | $90 | $130 | $130 |
| - CT | $170 | $260 | $260 |
| - MRI scans | $220 | $330 | $330 |
| - PET | $400 | $600 | $600 |
| Hospitalization | 1100 | 3300 | 6600 |
| Hospitalization is covered up to the indicated amount per day and for up to 10 days per person during each calendar year.Covered stays also includes the following types of care at the indicated amounts per day: | $200 first day $100 each additional day Up to 10 days $1,100 max |
$600 first day $300 each additional day Up to 10 days $3,300 max |
$1,200 first day $600 each additional day Up to 10 days $6,600 max |
| Mental Illness | $50 per day 10 day max |
$150 per day 10 day max |
$300 per day 10 day max |
| Substance Abuse Treatment | $50 per day 10 day max |
$150 per day 10 day max |
$300 per day 10 day max |
| Skilled Nursing Facility - payable one time for any particular illness or injury and only following a hospital stay of at least 3 days. | $50 per day 10 day max |
$150 per day 10 day max |
$300 per day 10 day max |
| Inpatient Miscellaneous Hospital Expense | 1100 | 3300 | 6600 |
| Miscellaneous hospital expenses such as lab tests, x-rays, medications, crutches and bandages are covered at the indicated amount per day for up to 10 days per person during each calendar year.This coverage does not apply to mental illness, substance abuse and skilled nursing stays or ambulance and certain other charges. | n/a | $75 per day 10 day max $750 max |
$150 per day 10 day max $1,500 max |
| Surgery | 1100 | 3300 | 6600 |
| Surgical costs are payable according to the included Surgical Schedule for each person up to the indicated maximum per calendar year. |
$1,000 maximum per person |
$3,000 maximum per person |
$6,000 maximum per person |
| Anesthesia | 1100 | 3300 | 6600 |
| Anesthesia is covered at 25% of the covered amount paid by the surgical benefit. | Limited to $250 per surgery | Limited to $750per surgery | Limited to $1,500per surgery |
| Outpatient Surgical Facility | 1100 | 3300 | 6600 |
| Expenses are covered at the specified amount per surgery for up to 2 surgeries per person during each calendar year | n/a |
$75 per surgery $150 max |
$150 per surgery $300 max |
| Durable Medical Equipment | 1100 | 3300 | 6600 |
| Durable medical products such as canes, crutches, walkers, wheelchairs, slings, splints, nebulizers, respiratory equipment, knee/elbow/neck braces, etc. are covered up to the specified amount per person during each calendar year. | $50 | $100 | $100 |
| Emergency Room Visits | 1100 | 3300 | 6600 |
| Emergency room visits for illnesses (which do not result in hospital confinement) are covered at $75 per visit for up to 4 visits per person during each calendar year. |
$75 per visit $300 max |
$75 per visit $300 max |
$75 per visit $300 max |
| Accident Medical Expense | 1100 | 3300 | 6600 |
| This benefit is underwritten by Guarantee Trust Life Insurance Company. | $5,000 | $5,000 | $5,000 |
| Accidental Death & Dismemberment | 1100 | 3300 | 6600 |
| This benefit is underwritten by Guarantee Trust Life Insurance Company | $10,000 | $10,000 | $10,000 |
| Prescription Drug Coverage | 1100 | 3300 | 6600 |
| This benefit is underwritten by ACE American Insurance Company | $15 co-pay | $15 co-pay | $15 co-pay |
| Adult Annual Wellness Test | 1100 | 3300 | 6600 |
| This pre-paid health benefit is part of your "complete Choice" membership and is available AFTER 90 days of membership. |
$500 retail value $0 co-pay! |
$500 retail value $0 co-pay! |
$500 retail value $0 co-pay! |
The above-referenced benefits are underwritten by Pan-American Life Insurance Company: Doctor Office Visits; Preventative Care; Outpatient Diagnostic Benefits; Hospitalization; Surgery and Anesthesia; and Emergency Room. The Accident Medical Benefits and Accidental Death & Dismemberment Benefits are underwritten by Guarantee Trust and Life Insurance Company. The Prescription Drug Benefit is underwritten by Ace American Insurance Company. NOT AVAILABLE IN ALL STATES.
Complete Choice plans are not available in the following states:
AK, CO, CT, KS, ME, MD, MA, MN, MT, NV, NH, NJ, NY, ND, OR, RI, SD, UT, VT, WA, WY
AK, CO, CT, KS, ME, MD, MA, MN, MT, NV, NH, NJ, NY, ND, OR, RI, SD, UT, VT, WA, WY
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