Doctor's office visits are payable at $75 per Covered Person per Doctor's Office Visit up to a Calendar Year maximum of $300. Routine exams, medical treatment, and injections are not covered under this benefit.

Routine exams, medical treatment, and wellness injections are payable at $100 per Covered Person per visit up to a Calendar Year maximum of $150.

An Emergency Room Visit as a result of an Illness is payable in the amount of $75 per visit up to a $300 maximum per calendar year, for services Medically Necessary and provided on an Emergency basis that do not result in Hospital Confinement.

Diagnostic lab (DXL) tests ordered or performed by a Doctor are payable at $35 per Covered Person with a six (6) test limit as the Calendar Year maximum when Hospital Confinement is not required. Routine exams are not covered under this benefit. This benefit is defined as those procedures in the CPT code range of 80000 excluding preventive care testing.

Diagnostic x ray tests ordered or performed by a Doctor are payable at $100 per Covered Person with a Calendar Year maximum of four (4) x-ray tests per year, when Hospital Confinement is not required. Benefit includes costs for reading of the x-ray. Routine exams are not covered under this benefit. This benefit is defined as those procedures in the CPT code range of 70000 excluding preventive care testing and advanced studies.

Diagnostic Advanced Studies ordered or performed by a Doctor are payable as shown in the schedule below up to the Calendar Year maximum of $2000 per Covered Person per Calendar Year when Hospital Confinement is not required. Routine exams are not covered under this benefit.

$600 per day, up to a Calendar Year Maximum of 10 days. First Day Hospital Admission Indemnity Benefit of $600 for the first day of hospital admission. This is payable only once per admission. If you are confined to the hospital because of the same or related injury or sickness, we will not pay this benefit again.

$300 per day for treatment of Substance Abuse or Mental Illness (up to a Calendar Year Maximum of 10 days).

$300 per day for stays in a Skilled Nursing Facility (up to a maximum of 10 days per stay. The stay is only covered if it is following a covered Hospital stay of at least 3 days).

Surgeries performed by a Doctor are payable according to the Surgical Schedule per Covered Person for a per surgery maximum of $6,000.

We will pay an Anesthesia Indemnity Benefit when a surgery is performed that is covered and paid under the Surgical Indemnity Benefit of Your Plan. The Anesthesia Indemnity Benefit amount will equal 25% of the amount paid for the surgical procedure which is paid according to our Schedule of Surgical Procedures

$5,000 Accident Medical Expense coverage paid after $100 deductible per occurrence for all medical expenses incurred as a result of a covered accident. This coverage is payable in addition to your doctor and hospital medical benefit.

Up to $10,000 paid in the event of accidental dismemberment, which is paid in addition to amounts covered under the accident medical expense benefit.

Generic drugs can be purchased for a $15 or less co-payment for a 30-day supply at more than 51,000 participating pharmacies nationwide, or a $45 co-payment for a 90-day supply through mail order. This benefit includes an annual deductible of $50 per person per calendar year and a monthly maximum benefit of $200 per person and $400 per family. Annual maximum benefit is $2,400 per person per calendar year.

Doctor's office visits are payable at $75 per Covered Person per Doctor's Office Visit up to a Calendar Year maximum of $300. Routine exams, medical treatment, and injections are not covered under this benefit.

Routine exams, medical treatment, and wellness injections are payable at $75 per Covered Person per visit up to a Calendar Year maximum of $150.

An Emergency Room Visit as a result of an Illness is payable in the amount of $75 per visit up to a $300 maximum per calendar year, for services Medically Necessary and provided on an Emergency basis that do not result in Hospital Confinement.

Diagnostic lab (DXL) tests ordered or performed by a Doctor are payable at $35 per Covered Person with a three (3) test limit as the Calendar Year maximum when Hospital Confinement is not required. Routine exams are not covered under this benefit. This benefit is defined as those procedures in the CPT code range of 80000 excluding preventive care testing.

Diagnostic x ray tests ordered or performed by a Doctor are payable at $100 per Covered Person with a Calendar Year maximum of two (2) x-ray tests per year, when Hospital Confinement is not required. Benefit includes costs for reading of the x-ray. Routine exams are not covered under this benefit. This benefit is defined as those procedures in the CPT code range of 70000 excluding preventive care testing and advanced studies.

Diagnostic Advanced Studies ordered or performed by a Doctor are payable as shown in the schedule below up to the Calendar Year maximum of $1000 per Covered Person per Calendar Year when Hospital Confinement is not required. Routine exams are not covered under this benefit.

$300 per day, up to a Calendar Year Maximum of 10 days. First Day Hospital Admission Indemnity Benefit of $300 for the first day of hospital admission. This is payable only once per admission. If you are confined to the hospital because of the same or related injury or sickness, we will not pay this benefit again.

$150 per day for treatment of Mental Illness or Substance Abuse (up to a maximum of 10 days per Calendar Year).

$150 per day for stays in a Skilled Nursing Facility (up to a maximum of 10 days per stay. The stay is only covered if it is following a covered Hospital stay of at least 3 days).

Surgeries performed by a Doctor are payable according to the Surgical Schedule per Covered Person for a per surgery maximum of $3,000.

We will pay an Anesthesia Indemnity Benefit when a surgery is performed that is covered and paid under the Surgical Indemnity Benefit of Your Plan. The Anesthesia Indemnity Benefit amount will equal 25% of the amount paid for the surgical procedure which is paid according to our Schedule of Surgical Procedures.

$5,000 Accident Medical Expense coverage paid after $100 deductible per occurrence for all medical expenses incurred as a result of a covered accident. This coverage is payable in addition to your doctor and hospital medical benefit.

Up to $10,000 paid in the event of accidental dismemberment, which is paid in addition to amounts covered under the accident medical expense benefit.

Generic drugs can be purchased for a $15 or less co-payment for a 30-day supply at more than 51,000 participating pharmacies nationwide, or a $45 co-payment for a 90-day supply through mail order. This benefit includes an annual deductible of $50 per person per calendar year and a monthly maximum benefit of $200 per person and $400 per family. Annual maximum benefit is $2,400 per person per calendar year.

Doctor's office visits are payable at $60 per Covered Person per Doctor's Office Visit up to a Calendar Year maximum of $300. Routine exams, medical treatment, and injections are not covered under this benefit.

Routine exams, medical treatment, and wellness injections are payable at $50 per Covered Person per visit up to a Calendar Year maximum of $150.

An Emergency Room Visit as a result of an Illness is payable in the amount of $75 per visit up to a $300 maximum per calendar year, for services Medically Necessary and provided on an Emergency basis that do not result in Hospital Confinement.

Diagnostic Advanced Studies ordered or performed by a Doctor are payable as shown in the schedule below up to the Calendar Year maximum of $1000 per Covered Person per Calendar Year when Hospital Confinement is not required. Routine exams are not covered under this benefit.

$100 per day, up to a Calendar Year Maximum of 10 days and a First Day Hospital Admission Indemnity Benefit of $100 for the first day of hospital admission. This is payable only once per admission. If you are confined to the hospital because of the same or related injury or sickness, we will not pay this benefit again.

$50 per day for treatment of Mental Illness or Substance Abuse (up to a maximum of 10 days per Calendar Year).

Diagnostic lab (DXL) tests ordered or performed by a Doctor are payable at $20 per Covered Person with a three (3) test limit as the Calendar Year maximum when Hospital Confinement is not required. Routine exams are not covered under this benefit. This benefit is defined as those procedures in the CPT code range of 80000 excluding preventive care testing.

$50 per day for stays in a Skilled Nursing Facility (up to a maximum of 10 days per stay. The stay is only covered if it is following a covered Hospital stay of at least 3 days).

Surgeries performed by a Doctor are payable according to the Surgical Schedule per Covered Person for a per surgery maximum of $1,000.

We will pay an Anesthesia Indemnity Benefit when a surgery is performed that is covered and paid under the Surgical Indemnity Benefit of Your Plan. The Anesthesia Indemnity Benefit amount will equal 25% of the amount paid for the surgical procedure which is paid according to our Schedule of Surgical Procedures.

$5,000 Accident Medical Expense coverage paid after $100 deductible per occurrence for all medical expenses incurred as a result of a covered accident. This coverage is payable in addition to your doctor and hospital medical benefit.

Diagnostic x ray tests ordered or performed by a Doctor are payable at $70 per Covered Person with a Calendar Year maximum of two (2) x-ray tests per year, when Hospital Confinement is not required. Benefit includes costs for reading of the x-ray. Routine exams are not covered under this benefit. This benefit is defined as those procedures in the CPT code range of 70000 excluding preventive care testing and advanced studies.

Up to $10,000 paid in the event of accidental dismemberment, which is paid in addition to amounts covered under the accident medical expense benefit.

Generic drugs can be purchased for a $15 or less co-payment for a 30-day supply at more than 51,000 participating pharmacies nationwide, or a $45 co-payment for a 90-day supply through mail order. This benefit includes an annual deductible of $50 per person per calendar year and a monthly maximum benefit of $200 per person and $400 per family. Annual maximum benefit is $2,400 per person per calendar year.