TransAmerica Limited Benefit Medical Insurance Plan with PPO network
A group
voluntary limited benefit medical plan that helps pay
basic medical expenses related to illnesses or
emergences from covered accidents. This plan will allow
you get the medical attention you need -when you need
it. Includes a PPO network discount from
NPPN Healthcare.
Prescription Card Included
INPATIENT BENEFITS
Daily In-Hospital Confinement
Benefits are paid for each day an insured is confined in
a hospital up up to a maximum of 30 days.
Standard
Enhanced
Premier
$500
$1000
$1200
In-Hospital and Surgical additional
Benefit pays an additional benefit for each covered
person when he/she receives treatment or surgery
while confined to a hospital as an inpatient as a
result of a covered accident or sickness.
$1000
$1000
$1000
Critical Illness Indemnity
Pays benefit when the insured is diagnosed with a
covered critical illness.
$5000
$5000
$10000
Surgical and Anesthesia Benefit
Pays when a covered person undergoes a surgical
procedure listed in the schedule of benefits as a result
of a covered accident or sickness.
$1500
$2500
$2500
OUTPATIENT BENEFITS
Standard
Enhanced
Premier
Outpatient Physician Office visit
Pays per visit as a result of covered sickness or
accident up to a maximum of 6 visits per covered person
per year.
$50
$80
$80
Outpatient Diagnostic X-ray and Lab
Pays
per day for tests performed for the purpose of diagnosis
of a covered sickness or accident.
$50
$100
$100
Surgical and Anesthesia Benefit
Pays when a covered person undergoes a surgical
procedure listed in the schedule of benefits as a result
of a covered accident or sickness.
$1500
$2500
$2500
Off-the-job Accidental Injury
Pays benefit on the actual charges for
outpatient treatment incurred for each covered
accident, with a maximum of
five occurrences per covered per calendar year.
$500
$1,000
$1,000
Wellness Rider **
($/visit)
This amount is payable for
routine examinations or other preventative testing and
is payable once per person per calendar year and two
times per family per calendar year.
$100
$100
$100
BENEFITS INCLUDED
Group Term Life Policy with AD& D Rider
Member,
Spouse and Children are eligible.
$5,000 member, $2,500 spouse and $1,500 child
$5,000 member, $2,500 spouse and $2,500 child
$10,000 member, $5,000 spouse and $2,500 child
Prescription Drug Benefit
Pays per per
prescription when an insured incurs expenses for
prescription drugs prescribed by a physician as a result
of an accident or sickness.
$20 per prescription
$20 per prescription
$20 per prescription
*Refer to the policy for specific amounts and schedules.
** 6 month waiting period for this benefit. Please see
Limitations and Exclusions for details.
Please note this is a brief summary of benefits.
Contact UTBA for details of specific
plans. Limitations and exclusions may apply.
