Example of Mini Medical Plan

Sample Limited Medical Plan “Benefit Ranges”

AVAILABLE LIMITED MEDICAL PLAN  BENEFIT OPTIONS

BENEFITRANGES

Overall Per Person Calendar Year Maximum

Up to $100,000

Physician Office Visits
General Office Visits - Up to 10 Visits Per Person Calendar Year Maximum

$40-$100 Per Visit

Emergency Room - Sickness
Included in Office Visit (or Separate Benefit)

$40-$100 Per Visit

Wellness Benefit
Maximum of $150 Per Person Per Calendar Year

$50-$150 Per Visit

Diagnostics, X-ray & Lab
Maximum of $300 Per Person Per Calendar Year

$20-$300 Per Visit

Emergency Room - Accident
For treatment in an emergency room if performed within 72 hours of the accident

$300-$10,000 Per Visit

Surgery and Anesthesia - Scheduled Benefit Indemnity
Surgical Scheduled Indemnity Benefit

$500-Unlimited

Surgical Indemnity Benefit

$500-$5,000

Anesthesiology

Up to 30% of Surgical Benefit

FirstDayHospital Occurrence

$100-$2,000

Hospital Confinement Indemnity for Bodily Sickness & Injuries
Requires 24 hours stay.  Payable from first day of confinement

$100-$1,500 Per Day

Intensive Care Confinement Indemnity
Paid in addition to Daily Hospital Confinement Benefit

$100-$3,000 Per Day

Hospital Confinement Benefit for Mental & Nervous and Substance Abuse
Mental & Nervous
Substance Abuse

$100-$1,000 Per Day
$100-$1,000 Per Day

Confinement Benefit for Skilled Nursing
Skilled Nursing Stay must follow a covered Hospital stay of at least 3 days

$50-$500 Per Day

Life/AD&D
Example:  $5,000 Employee ($2,500 Spouse, $1,500 Children, $150 Infants)

$5,000-$50,000

Outpatient Prescription Drug Benefit Options
$10 Generic Formulary Co-pay with $50 Brand Formulary Co-pay
$10 Generic Formulary Co-pay
Prescription Drug Card with $10/$20/$40 Tiered Formulary Discount Card
Prescription Drug Discount Card

$10 Generic/$50 Brand Co-pay
$10 Generic Co-pay
$10/$20/$40 Tiered Discounts
Discounts Only

Sample of Copay/Expense Incurred Limited-Medical “ Benefit Ranges”

AVAILABLE LIMITED MEDICAL PLAN BENEFIT OPTIONS

BENEFITRANGES

Overall Per Person Calendar Year Maximum

Up to $10,000

Physician Office Visits
General Office Visits

$20 Copay

Emergency Room

$50 Copay Per Visit

Wellness

$20 Copay

Diagnostics, X-ray & Lab

$20 Copay

Surgery and Anesthesia -

$250 Copay

Deductible

$200

Coinsurance

30%

Hospital Benefit

$200 Copay

Intensive Care

$200 Copay

Life/AD&D
Example:  $5,000 Employee ($2,500 Spouse, $1,500 Children, $150 Infants)

$5,000-$50,000

Outpatient Prescription Drug Benefit Options
$10 Generic Formulary Co-pay with $50 Brand Formulary Co-pay
$10 Generic Formulary Co-pay
Prescription Drug Card with $10/$20/$40 Tiered Formulary Discount Card
Prescription Drug Discount Card

$10 Generic/$50 Brand Co-pay
$10 Generic Co-pay
$10/$20/$40 Tiered Discounts
Discounts Only