Lifetime Maximum	$500,000	$5,000,000
Deductible Options, per person per Injury/Sickness	$70, $100, $150, $250, $500, $1000 After the per Injury/Sickness Deductible, the program will pay up to the amount listed below for each Injury / Sickness.

inpatient

Private or semi-private room, per day (maximum of 240 consecutive days)	$600	$900
Intensive care, room, per day (maximum of 180 consecutive days)	$1,500	$2,000
Surgical Treatment	$3,000	$5,000
Anesthetist’s charges	$600	$1,000
Assistant Surgeon	$600	$1,000
Physician’s Non-Surgical / Urgent Care Visit	$60/visit, max 10	$75/visit, max 10
Laboratory Tests and X-Rays	$450	$600
Prescription medication	$100	$125
Chemotherapy and radiation therapy	$1,000	$1,250
Organ Transplant	$100,000	$130,000
Durable Medical Equipment	$100	$200

maternity

Normal and complicated child delivery maximum, including pre and postnatal care is reimbursed according to the other medical treatment benefit schedule. Waiting period of 12-months before maternity benefit begins.	$2,500	$4,000
Professional service related to hospitalization, per day	$200	$250

outpatient

Surgical Treatment	$3,000	$5,000
Anesthetist’s charges	$600	$1,000
Assistant Surgeon	$600	$1,000
Physician’s Non-Surgical / Urgent Care Visit	$60/visit, max 10	$75/visit, max 10
Hospital Emergency Room (all expenses incurred therein)	$350	$500
Prescription medication	$100	$125
Chemotherapy and radiation therapy	$1,000	$1,250

other treatment

Dental treatment for Injury to sound, natural teeth	$500	$500
Psychiatrist	$60/visit, max 10	$$75/visit, max 10
Laboratory Tests and X-Rays	$450	$600
Endoscopy (i.e. Gastroscopy, Colonoscopy, Cystroscopy)	$450	$600
Various Scans (i.e. MRI, CAT, Echocardiography)	$450	$600
Chiropractors	$60/visit, max 3	$75/visit, max 3
Well Child Care (not subject to Deductible) 12-month waiting period	$60/visit, max 3	$75/visit, max 3
Preventative Benefit (females and males, age 30 and over for checkups, routine physical exams, female preventative exams and mammograms, not subject to Deductible) 12-month waiting period	$60/visit, max 3	$75/visit, max 3

newborn coverage

Lifetime maximum for the first 31 days after birth, per limits as stated in the Certificate of Coverage

$5,000

$10,000

transportation

Local ground ambulance	$1,500	$2,000
Emergency Evacuation, when treatment not available locally, pre-approved transportation to a location where appropriate treatment is available. Includes cost of return trip.	$25,000	$50,000
Return of Mortal Remains	$20,000	$25,000

accidental death & dismemberment

	Principal Sum	Principal Sum
24 Hour Accidental Death and Dismemberment
- Insured and Spouse	$10,000	$10,000
- Dependent Children	$2,000	$2,000

Common Carrier Accidental Death and Dismemberment

- Insured and Spouse	$40,000	$40,000
- Dependent Children	$8,000	$8,000