National Media Benefits - Indemnity Plan
Major Medical Plan, $300/80/20
Covered Benefits: $2,000,000 Lifetime Maximum Benefit Per Individual
| Benefit | Benefit Amount | |
| Financial | ||
| Deductible | $300 Individual / $900 Family | |
| Payment Percentage | 80% | |
| Payment Percentage Limit | $3,000 Individual / $6,000 Family | |
| Lifetime Max Benefit | $2,000,000 Per Individual | |
| Physician & Specialty Care | 80% After Deductible | |
| Office & Inpatient Visits; Surgery; 2nd Surgical Opinion; Allergy Services; Pre-Admission Testing; Referred Lab, X-Ray & Diagnostic Testing | ||
| Hospital Services | ||
| Room & Board - Semi-Private Room Rate | 80% After Deductible | |
| Intensive Care Unit | 80% After Deductible | |
| Skilled Nursing Facility | ||
| Semi-Private Room Rate | 80% After Deductible / Max 100 Days per Calendar Year | |
| Emergency Room | 80% After Deductible | |
| Ambulance Service | 80% After Deductible / Max $1,500 per Calendar Year | |
| Home Care | 80% After Deductible / Max $5,000 per Calendar Year | |
| Hospice Care | 80% After Deductible / Max $10,000 Lifetime | |
| Maternity | Treated as any other medical condition | |
| Routine Well Newborn Care | 80% After Deductible | |
| Mental Health & Substance Abuse | ||
| Inpatient | 50% After Deductible / Max 14 Days per Calendar Year | |
| Outpatient | 50% After Deductible / Max 30 Visits per Calendar Year | |
| Wellness Benefit | 80% After Deductible / Max $300 per Calendar Year | |
| Office visits; Routine Physicals; X-ray; Lab Tests; Immunizations; Flu Shots; Pap Smears; Gynecological exams; PSA/Prostate exams | ||
| Physical, Occupational, andSpeech Therapy | 80% After Deductible / $3,000 Combined Calendar Year Maximum | |
| Organ Transplant | 80% After Deductible / Max $100,000 Lifetime | |
| Chiropractic | 80% After Deductible / Max 30 Visits per Calendar Year | |
| Durable Medical Equipment | 80% After Deductible / Max $1,000 per Calendar Year | |
| Prosthetics | 80% After Deductible / Max $3,000 per Calendar Year | |
| Orthotics | 80% After Deductible / Max $1,000 per Calendar Year | |
| Prescription Drug | $10 Generic/ $25 Preferred Brand /$35 Non-Preferred BrandMax $2,500 per Individual per Calendar Year | |
| Medically Underwritten | The NMB Benefits Indemnity rates are subject to underwriting approval. | |
| Dependent Children covered to the end of the 18th year. Coverage will extend
through 23rd year with proof of enrollment at an accredited learning institution.
Pre-Certification required or benefits paid will be reduced. Emergency Room
notification is required within 48 hours. Pre-Certification determines medical
necessity only. It is not a commitment for payment of any incurred claims
expense. |
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| THE SCHEDULE OF BENEFITS SUMMARY DESCRIBED HEREIN IS FOR ILLUSTRATIVE PURPOSES ONLY.REFER TO THE PLAN DOCUMENT and SUMMARY PLAN DESCRIPTION FOR SPECIFIC BENEFITS AND EXCLUSIONS. Rev. 10-02 | ||