ELITE PLUS

ELITE

CLASSIC PLUS

CLASSIC

Inpatient Hospital Confinement

(per Inpatient Day)

$5,000

$3,000

$2,000

$1,500

Building Benefit Injury Reimbursement Inpatient Hospitalization Benefits increase 25% each year, years 2-5, for injury-related hospital stays. (per day)

Year 2

$6,250

$3,750

$2,500

$1,875

Year 3

$7,500

$4,500

$3,000

$2,250

Year 4

$8,750

$5,250

$3,500

$2,625

Year 5

$10,000

$6,000

$4,000

$3,000

Hospital Admission Benefits

(for the first Inpatient Day per calendar year)

$3,000

$2,000

$1,000

$1,000

Emergency Room or Urgent Care

(Per day/limit of 1 daily benefit per calendar year)

$375

$250

$250

$125

Surgery Benefit

Daily surgical benefits for both inpatient and outpatient surgery. The reimbursement schedule for 1 unit is similar to what is payable under the Medicare Physician Fee Schedule for surgeries. (Maximum $50,000 benefit per calendar year)

3 X

the policy fee schedule

2.5 X

the policy fee schedule

2 X

the policy fee schedule

1 X

the policy fee schedule

Ambulatory Surgical Benefit

If outpatient surgery is performed in an Ambulatory Surgical Center or Outpatient Hospital facility, the benefits payable include the surgical and anesthesia benefits in addition to per day ambulatory/outpatient facility benefit.

$3,000

$2,500

$2,000

$1,000

Assistant Surgeon

Pays a daily amount per day of surgery.

Anesthesiologist

Pays a daily amount per day of surgery.

Doctor’s Office Visit

(Per day/per calendar year)

$100/4 days

$75/4 days

$75/3 days

$50/3 days

Prescription Benefit

(Per Day)

$75

$50

$50

$25

Outpatient Medical Benefits

$300/$100/$100

$300/$100/$100

$300/$100/$100

$300/$100/$100

Preventative Services: (per Colonoscopy/Pap/PSA)

Laboratory Services: (per day for surgical pathology/other laboratory services)

$100/$50

$100/$25

$100/$25

$100/$25

Therapy Services: (per day for physical, occupational, speech)

$25

$25

$25

$25

Radiology Services: (per day: MRI/PET scan/ CT scan/ mammogram/other radiology tests)

$500/$250/

$200/$150/$75

$500/$250/

$200/$150/$75

$250/$250/

$200/$100/$50

$250/$250/

$200/$100/$50

Calendar year limit for all Outpatient Benfits

$3,000

$2,000

$2,000

$1,000

Ground and Air Ambulance

Limit of 2 daily benefits per calendar year for all ambulance transportation

(per day for ground/per day for air)

$150/$1,000

$100/$1,000

$100/$1,000

$100/$500

Allergy Shots and Immunization (child only)

(per day allergy shots/immunizations)

$10/$25

$10/$25

$10/$25

$10/$25

Cancer Benefit

Pays for Radiation, Chemotherapy, & Immunotherapy (per day/40 days per calendar year)

$2,000

$2,000

$1,000

$1,000

Inpatient Hospital Confinement/

Building Benefit Injury Reimbursement

$1,000,000 calendar year limit

Prescription Benefit

$750 calendar year maximum

Allergy Shots and Immunization

$100 calendar year maximum

Lifetime Maximum

$5,000,000

Teladoc

Teladoc is a modern day house call with immediate access to a network of board-certified physicians. Physicians are available anytime, anywhere for personalized, secure, web or phone-base consultation that includes diagnosis and treatment of medical issues.

Karis 360

Karis360 helps policyholders save on out-of-pocket expenses, in finding doctors, assists in searching and comparing facilities, providers, and prescription costs, as well as many other services. Karis360 offers 3 services to policyholders.