| 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.
|
| 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 |
