| Company/Plan Name |
 Secure 12x3 STM |
| Deductible |
|
| In-Network |
$500
|
| Out-Network |
$500 Per Person, Per Coverage Period |
| Maximum Family Deductible |
Maximum 3 Per Family, Per Coverage Period |
| Coinsurance |
|
| In-Network |
80/20% to $10,000 |
| Out-Network |
80/20% to $10,000 |
| Maximum Out-Of-Pocket Coinsurance |
|
| In-Network |
$2,000 per person excluding deductible |
| Out-Network |
$2,000 per person excluding deductible |
| Maximum Benefit |
$750,000 per insured, per coverage period |
| Physician Office Visit |
|
| In-Network |
N/A
|
| Out-Network |
Coverage is up to $25 per visit up to four visits per coverage period. Over $25 is subject to Deductible and CoInsurance up to $1,000 per coverage period
|
| Outpatient Lab & X-Ray |
|
| In-Network |
N/A |
| Out-Network |
Up to $1000 per Coverage Period; Subject to Deductible and CoInsurance |
| Outpatient Preventive Care |
|
| In-Network |
N/A |
| Out-Network |
Not Covered |
| Prescription Drugs |
|
| Generic |
Not Covered (Discounts may be available) |
| Brand Name(formulary) |
Not Covered (Discounts may be available) |
| Brand Name(Non-formulary) |
Not Covered (Discounts may be available) |
| Outpatient Surgery |
|
| In-Network |
N/A |
| Out-Network |
Up to $1000 per day (including cost of operating room and all miscellaneous charges) See brochure for detailed explanation. |
| Emergency Room |
|
| In-Network |
N/A |
| Out-Network |
Up to $500 per day (including ER physician charge, 24 hour surveillance and all miscellaneous charges) See brochure for detailed explanation. |
| Maternity Prenatal/Post Natal |
|
| In-Network |
N/A |
| Out-Network |
Not Covered |
| Inpatient Benefits |
|
| Hospitalization |
|
| In-Network |
N/A |
| Out-Network |
Up to $1000 per day (including daily room and board and all miscellaneous charges) See brochure for detailed explanation |
| Surgical |
|
| In-Network |
N/A |
| Out-Network |
Up to $2500 per procedure; Up to $5000 maxiumum per Coverage Period |
| Maternity |
|
| In-Network |
N/A |
| Out-Network |
Not Covered |
| Rate Guarantee |
N/A |
| Optional Benefits |
|
| Supplemental Accident |
Not Available |
| 24 Hour Coverage |
Not Available |
| Other |
Not Available |