| Monthly Costs |
 |  |
| IS200 Plan Pays: | IS350 Plan Pays: | IS500 Plan Pays: |
| | |
|
Physician Office Visits
For medically necessary treatment of injury or sickness up to five visits per covered person per Plan Year*. |
| $40
Per Visit | $50
Per Visit | $65
Per Visit |
|
Outpatient Lab & X-ray
3 visits per Plan Year for diagnostic tests and x-rays which are ordered by a doctor and performed in an outpatient setting. |
| $40
Per Visit | $50
Per Visit | $65
Per Visit |
|
Wellness Visits
1 visit per Plan Year for a routine examination or well-child care. |
| $40
Per Visit | $50
Per Visit | $65
Per Visit |
|
| | | |
Regular Inpatient Accident & Sickness Stay
A maximum of 30 days per Plan Year. |
| $200
Per Day | $350
Per Day | $500
Per Day |
|
Intensive Care Unit/Critical Care Unit
Up to 10 days per Plan Year. |
| $400
Per Day | $700
Per Day | $1000
Per Day |
|
Mental/Nervous
A maximum of 10 days per Plan Year. |
| $100
Per Day | $175
Per Day | $250
Per Day |
Substance Abuse
A maximum of 10 days per Plan Year. |
| $100
Per Day | $175
Per Day | $250
Per Day |
|
Skilled Nursing Facility
A maximum of 20 days per Plan Year. Confinement must begin within 3 days of a hospital stay. |
| $100
Per Day | $175
Per Day | $250
Per Day |
|
| up to $500 | up to $1000 | up to $2000 |
| Inpatient surgery. Plan pays up to the indicated maximum surgery benefit per Plan Year. |
|
| Outpatient surgery. Plan pays up to the indicated maximum surgery benefit per Plan Year. |
| up to $200 | up to $400 | up to $800 |
|
Anesthesia
25% of surgery benefit paid, up to the indicated maximum per Plan Year. |
| up to $125 | up to $250 | up to $500 |
|
| up to $300
Per Accident | up to $500
Per Accident | up to $750
Per Accident |
|
| $100
Per Visit | $100
Per Visit | $250
Per Visit |
|
| $5,000 | $5,000 | $10,000 |
|
| $2,500 | $2,500 | $5,000 |
|
| $1,000 | $1,000 | $1,000 |
|
Vision Benefit
Benefits are $25 for 1 eye exam per Plan Year and $50 toward eyeglasses or contact lenses every 2 Plan Years. |
| $25 | $25 | $25 |
| $50 | $50 | $50 |
|
| Non-Insured Features Included In The Plan |
|
| Included | Included | Included |
|
24-hour Nurse Line
24-hour access to a toll-free number for health consultations and basic health information. |
| Included | Included | Included |
|
| Included | Included | Included |
|
| Optional Insured Benefit |
|
Insured Dental Plan Available
Scheduled amounts are payable up to $1,500 per covered person per Plan Year. Some services require a 12 month waiting period before benefits are available. Requires additional premium. |
| Option | Option | Option |
| |
| Monthly Costs |
| |
|
* Plan Year, wherever referenced, means the 12 consecutive month period beginning on the Policyholder’s (AEA) effective date and each anniversary date thereafter.
|
