A Limited Medical Income Plan
A Limited Medical Income Plan
designed to pay covered Hospital and Doctor Charges. The Insured
can assign his or her benefits to the Doctor or Hospital or get
reimbursed directly. If you utilize our PPO
network of
Beechstreet with your plan you are eligible for a discount by
the Network Providers.
The Plan is offered in
four options: a Bronze option, with lower coverage amounts (and
lower premium cost), a Silver option, with higher coverage
amounts (and higher premium cost), and a Gold or Diamond option, with the
highest coverage amounts (and premium costs).
ScriptSave Rx
All four options include a
ScriptSave Prescription Discount Card and brochure, which
explains how the discounted tiers work for all prescribed drugs.
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BENEFITS |
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Lifetime
Maximum
Pays
full benefits for each covered claim depending
on the number of days or visits and/or the
schedule of surgery. |
Bronze |
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Silver |
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Gold |
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Diamond |
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No limits |
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No limits |
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No limits |
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No Limits |
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INPATIENT BENEFITS |
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Daily Hospital
Confinement
($/day)
Pays a daily
amount for hospital confinement as an inpatient due to a
covered accident or sickness up to a maximum of 180 days
per confinement. |
Bronze |
Silver |
Gold |
Diamond |
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$250 |
$500 |
$750 |
$1000 |
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Mental/Emotional Disorder
Will pay up to a maximum of 30
days per confinement for a covered mental or emotional
disorder. |
$250 |
$500 |
$750 |
$1000 |
| Annual First Occurrence Hospital
($/year) Confinement
Rider
Pays a lump sum amount the first time an insured is
confined to a hospital as an inpatient. Payable only
once per calendar year. |
$1000 |
$1000 |
$1500 |
$1500 |
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Intensive Care/Coronary Care Rider ($/day)
Pays a daily amount for
confinement in a Hospital Intensive Care Unit or
Hospital Coronary Care Unit due to a covered accident or
sickness up to a maximum of 20 days per confinement.
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$400 |
$1000 |
$1000 |
$1000 |
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Surgical & Anesthesia
Rider* (maximum)
Pays actual
charges, not to exceed the scheduled amount for Surgery
performed due to a covered accident or sickness by a
physician. Scheduled amounts are based upon a $1,000
surgical schedule multiplied by the number of units
selected. Also pays an additional 25% of
the surgery amount paid for anesthesia administered by a
physician in connection with the surgery |
$5000 |
$10000 |
$10000 |
$10000
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OUTPATIENT BENEFITS
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Outpatient Surgical Facility Benefit*
When an insured person has a surgical
procedure due to a covered
illness or injury as an outpatient in a
hospital or at an Ambulatory Surgical
Facility. We will pay the actual
expenses incurred up to the amount shown
for the facility fee charged by such
hospital or facility. (Benefit is only
paid on outpatient procedures). |
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$0 |
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$500 |
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$500 |
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$500 |
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Surgical & Anesthesia
Rider* (maximum)
Pays actual
charges, not to exceed the scheduled amount for Surgery
performed due to a covered accident or sickness by a
physician. Scheduled amounts are based upon a $1,000
surgical schedule multiplied by the number of units
selected. Also pays an additional 25% of
the surgery amount paid for anesthesia administered by a
physician in connection with the surgery |
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$5000 |
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$10000 |
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$10000 |
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$10000
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Emergency Accident Rider ($/accident)
Pays the actual charges, not to
exceed the maximum amount selected, for treatment of a
covered accident by a Physician in the Physician's
Office, Clinic, Urgent Care Facility or Hospital
Emergency Room, subject to a 2 visit annual maximum per
person, except for Dependent Children. |
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$300 |
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$300 |
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$300 |
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$300 |
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Outpatient Sickness
Rider ($/visit)
Pays $50/$75
for treatment of a covered sickness by a Physician in
the Physician's Office, Clinic, Urgent Care Facility, or
Emergency Room subject to a 5 visit annual maximum per
person, except for Dependent Children. The maximum
number of visits for all Dependent Children combined is
5 visits per calendar year. The maximum number of visits
is 10 per calendar year |
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$50 |
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$50 |
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$75 |
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$75 |
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Wellness & Diagnostic : |
Bronze |
Silver |
Gold |
Diamond |
Wellness Rider**
($/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. Examinations and tests that are covered by this
rider are Mammography, Pap Smear, Flexible
Sigmoidoscopy, Colonoscopy, Cholesterol and Diabetes
Screening, PSA, EKG, and Chest X-ray.
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$75 |
$75 |
$75 |
$75 |
Diagnostic Testing**
($/year)
Pays actual
charges up to $250 per year for diagnostic tests not
covered under the Wellness Benefit in conjunction with a
covered accident or sickness. Coverage is payable once
per person per calendar year and two times per family
per calendar year.
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$250 |
$250 |
$250 |
$250 |
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ScriptSave Card
The
ScriptSave Card provides discounts for all prescribed
drugs. You will receive your ScriptSave card and plan
details via a separate mailing.
ScriptSave benefit summary:
| First tier drugs |
$10 or less |
| Second tier drugs |
$20 or less |
| Third tier drugs |
$50 or less |
| Fourth tier drugs |
Discount |
*Refer to the policy for specific amounts and schedules.
** The maximum amounts payable for all coverage under this rider
form is $250 per person, per calendar year |
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