Description of Benefits
Plan 4

Inpatient Hospital Benefit

Covered Expenses for inpatient hospital services are payable at a selected dollar per day of confinement up to a maximum number of days per calendar year.

Surgical Benefit

Covered expenses for surgeries performed by a doctor and incurred in connection with an illness or injury will be paid accordin gto the selected surgical schedule up to a calendar year maximum.

Doctors Office Visit, Urgent Care and Outpatient Hospital Benefit

Covered expenses for visits to doctor's office, urgent care or outpatient hospital facility are payable at a selected dollar benefit per visit, up to a calendar year maximum. Routine exams and injections are excluded.

Outpatient Diagnostic X-Ray and Lab Benefit

Diagnostic x-ray and lab tests ordered or performed by a doctor are payable at a selected dollar benefit per visit, up to a calendar year maximum when a hospital visit is not required. Must be medically necessary.

Preventative Care Benefit

Routine exams, medical treatment, and well childcare immunizations are payable at a selected dollar benefit per visit, up to a calendar year maximum.

Prescription Drug Benefit

Covered out-of-hospital prescription drugs will be paid up to the calendar year maximum, after the prescription drug co-payment has been paid. Prescription drugs must meet the three criteria: Must be ordered by a doctor, dispensed by a licensed pharmacist, and must be medically necessary for the care and treatment of the patient.

Pharmacy Discount Program

A discount off usual and customary charges may be given to the eligible person when prescriptions are purchased through a contracting pharmacy. There is no additional charge for this benefit.

Survivor Benefit

If an employee dies while insured, any coverd dependents will be extended benefits (other than dependent life) without premium payments for 2 years after the employee's death, as long as the employer's plan remains in force and the covered dependent meets the coverage requirements in the provision. Ther is no additional charge for this benefit.

Monthly Premium (Download Application)

Note: Employer must pay 50% - 100% of premium. Exclusions, limitations, definitions and benefits may vary by state. Please see the policy for details. The informtion on this page is for informational purposes only. Actual policy may differ. Rates are subject to change.