|
Statewide Hospital Surgical Plan |
|
Benefits
Limited
to
coverage
stated
in
policy.
|
| Benefits | Hospital Surgical Plan | |
| Lifetime Maximum |
$2,000,000.00 | |
| Deductible choice |
$100, $250, $500, $750 | |
|
$1,000,$2,500,even $5,000 | ||
| Maximum Out of Pocket |
$1,000 + deductible | |
|
| ||
| Hospital/Surgery % |
80% In Net Work/ | |
| Diagnostic Services/Outpatient Surgery | Instead of or before inpatient stay | |
| Radiation Therapy/Hemodialysis | Covered after deductible | |
|
Chemotherapy/Ultra Sound/ Blood Transfusions |
Covered after deductible | |
|
| ||
| Doctor Office Visits |
No Coverage | |
|
State
Mandated
Benefits |
Routine Pap Smear; Mammogram PSA; covered with no Deductible | |
| Other State Mandated Benfits | Covered Subject to Deductible | |
|
| ||
| Emergency Room |
80% InNetWork/60% OutofNetWork | |
|
| ||
| Rx Card |
No Coverage | |
|
| ||
| Maternity |
No Coverage | |
|
| ||
| Ambulance |
No Coverage | |
| Request a personalized quote! | ||