|
Benefit |
Silver |
Gold |
Diamond |
Plus |
|
Physician
Office Visit:
The
Carrier will pay the Benefit Amount as shown if you seek
treatment for a covered illness or injury. |
$50 per
office visit up to 5 per year/ 5 per each person in family |
$75 per
office visit up to 5 per year/ 5 per each person in family |
$75 per
office visit up to 5 per year/ 5 per each person in family |
$100 per
office visit up to 7 per year/ 7 per each person in family |
Diagnostic Testing or X-ray:
Medically necessary diagnostic tests and x-rays performed in
a doctor's office or outpatient facility. E.g. MRI, CAT
Scan, EKG |
$50 per visit
3 per year |
$100 per visit
3 per year |
$150 per visit
3 per year |
$400 per visit
3 per year |
Preventative Care Benefit:
Covers one preventative test per policy year. |
$100 per visit
1 per year |
$100 per visit
1 per year |
$150 per visit
1 per year |
$150 per visit
1 per year |
Regular Inpatient Stay:
A maximum of 100 days per year. |
$750 per day |
$1,000 per day |
$1,000 per day |
$1,000 per day |
ICU/CCU:
An extra daily benefit,
paid per day. |
None |
None |
$1,000
5 days |
$1,000
15 days |
|
Hospitalization
To Lookup a Provider
Click Here |
Hospital Admission:
An extra benefit
for the first day admitted in the hospital. |
None |
None |
None |
$2,000 per
stay |
Critical Illness Included:
Primary insured only |
$2,500 |
$5,000 |
$10,000 |
$5,000 for
primary & spouse |
Surgery:
Inpatient/Outpatient
Plan pays as a % of Medicare
reimbursement. |
50% |
80% |
100% |
100% |
Surgery Maximum:
Maximum annual benefit for surgery. |
Unlimited |
Unlimited |
Unlimited |
Unlimited |
Anesthesia Benefit:
As % of surgery benefit |
None |
20% |
20% |
25% |
Accident Coverage:
One accident covered per person per policy year. Costs must
be incurred within 90 days of accident or injury. |
$2,500 per year / $100 Ded. / 80% coinsurance |
$5,000 per year / $100 Ded. / 80% coinsurance |
$5,000 per year / $100 Ded. / 80% coinsurance |
Optional Rider
Available |
Plan Network
Physician and provider lookup. |
Muiltiplan PPO Network |
Muiltiplan PPO Network |
Muiltiplan PPO Network |
Muiltiplan PPO Network |
Dental Benefit1
Members enjoy
the savings and predictability of a dental program that provides preventive and
restorative care on a monthly, capitated basis. There's no paperwork, no maximum
or deductible, and no co-payment for diagnostic and preventive services. |
Included in FL |
Included in FL |
Included in FL |
Included in FL |
|
Rates |
|
Single |
$206.05 |
$257.16 |
$299.07 |
$368.98 |
|
Single + 1 |
$312.88 |
$407.07 |
$476.97 |
– |
|
Single + 2 + |
$420.22 |
$557.48 |
$656.47 |
– |
|
Single + Spouse |
– |
– |
– |
$680.33 |
|
Single + Child(ren) |
– |
– |
– |
$609.47 |
|
Family |
– |
– |
– |
$892.04 |
|
Optional Riders at
Additional Cost |
|
Critical Illness |
$2.500 or $25,000 |
$5,000 or $25,000 |
$10,000 or $25,000 |
$10,000 or $25,000 |
|
Dependant $2,500 |
$4.80 |
|
|
|
|
Dependent $5,000 |
|
$9.60 |
|
|
|
Dependent $10,000 |
|
|
$19.20 |
|
|
Increase to $25,000 |
$43.30 |
$38.50 |
$28.90 |
|
|
Dependent increase to $25,000 |
$91.40 |
$86.60 |
$77.00 |
|
|
Primary increase to $10,000 |
|
|
|
$9.60 |
|
Primary increase to $25,000 |
|
|
|
$38.50 |
|
Pri+Spouse increase to $10.000 |
|
|
|
$19.20 |
|
Pri+Spouse increase to $25,000 |
|
|
|
$77.00 |
|
Accident |
$5,000 |
$5,000 |
$5,000 |
$5,000 |
|
Single |
$16.15 |
$16.15 |
$16.15 |
$16.15 |
|
Single + Spouse |
$21.50 |
$21.50 |
$21.50 |
$19.00 |
|
Single + Child(ren) |
$21.50 |
$21.50 |
$21.50 |
$21.50 |
|
Family |
$24.00 |
$24.00 |
$24.00 |
$24.00 |
|
Rx 4-tier Plan Rider
Tier 1 $10 or less, Tier 2 $20 or less, Tier 3 $40 or less,
Tier 4 low contracted rates with no caps, no waiting periods |
Optional rider available |
Optional rider available |
Optional rider available |
Optional rider available |
|
Single |
$19.95 |
$19.95 |
$19.95 |
$19.95 |
|
Single + Spouse |
$26.95 |
$26.95 |
$26.95 |
$24.95 |
|
Single + Child(ren) |
$26.95 |
$26.95 |
$26.95 |
$26.95 |
|
Family |
$28.95 |
$28.95 |
$28.95 |
$28.95 |
Max