|
| Value Plan Pays: | Standard Plan Pays: | Enhanced Plan Pays: |
| Doctor Office Visits - 5 visits per covered person per calendar year. One visit may be used for wellness care. |
| $30
Per Visit | $50
Per Visit | $65
Per Visit |
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) |
| $30
Per Visit | $50
Per Visit | $65
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. |
| $30
Per Visit | $50
Per Visit | $65
Per Visit |
|
| Regular Inpatient Stay - Overnight stays in hospital. A maximum of 100 days per confinement. |
| $100
Per Day | $350
Per Day | $500
Per Day |
| ICU/CCU - A maximum of 30 days per confinement. |
| $200
Per Day | $700
Per Day | $1,000
Per Day |
| Mental Illness - A maximum of 30 days per confinement. |
| $50
Per Day | $175
Per Day | $250
Per Day |
| Alcohol and Substance Abuse - A maximum of 30 days per confinement. |
| $50
Per Day | $175
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 60 days per confinement. |
| $50
Per Day | $175
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) |
| $75
Per Visit | $250
Per Visit | $300
Per Visit |
|
| Inpatient - One inpatient surgery per covered person per calendar year. |
| n/a | $1,500
Per Procedure | $2,000
Per Procedure |
| Outpatient - One outpatient surgery (performed in a hospital or outpatient surgery center) per covered person per calendar year. |
| n/a | $600
Per Procedure | $800
Per Procedure |
| BeneScript Prescription Drug Discount Card |
| included | included | included |
| Available | Available | Available |