| Advantage Plan Pays: | Advantage Plus Plan Pays: |
| Doctor Office Visits - 5 visits per covered person per calendar year. One visit may be used for wellness care. |
| $50 Per Visit | $75 Per Visit |
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Diagnostic Testing or X-ray
For medically necessary diagnostic tests and x-rays performed in a doctor’s office or outpatient facility. (3 visits per covered person per calendar year. One visit may be used for wellness care) |
| $50 Per Visit | $100 Per Visit |
|
| Child Wellness Visits - Benefits payable for routine well-child care doctor visits at eleven specified age intervals, from birth through age five. Well-child care includes physical exams, laboratory tests, immunizations, vision screenings, and hearing screenings. |
| $50 Per Visit | $75 Per Visit |
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| Regular Inpatient Stay - Overnight stays in hospital. A maximum of 30 days per confinement. |
| $250 Per Day | $500 Per Day |
|
| ICU/CCU - A maximum of 10 days per confinement. |
| $500 Per Day | $1,000 Per Day |
|
| Mental Illness - A maximum of 10 days per confinement. |
| $125 Per Day | $250 Per Day |
|
| Alcohol and Substance Abuse - A maximum of 10 days per confinement. |
| $125 Per Day | $250 Per Day |
|
| Convalescent Facility - Confinement must begin within three days of a hospitalization stay of at least three days. A maximum of 20 days per confinement. |
| $125 Per Day | $250 Per Day |
|
 Emergency Room - Applicable for emergency room visits when patient is not confined to the hospital. (3 visits for injuries & 1 visit for sickness per person per calendar year) |
| $150 Per Visit | $300 Per Visit |
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| Inpatient - One inpatient surgery per covered person per calendar year. |
| $1,000
Per Procedure | $2,000
Per Procedure |
|
| Outpatient - One outpatient surgery (performed in a hospital or outpatient surgery center) per covered person per calendar year. |
| $400
Per Procedure | $800
Per Procedure |
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| included | included |
|
| Available | Available |
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| Important Note: The CUBS Health Solutions Plan is not comprehensive major medical insurance. It is a lower-cost alternative providing fixed amount, limited benefits directly to insureds for the most-used types of medical services. The plan pays in addition to any other medical insurance the member may have. Please note, also, that the CUBS Health Solutions Plan is not Medicare Supplement insurance. |
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