(For Those Who are Not Eligible for U.S. Medicare)
Following is a brief summary of your Indemnity Medical Benefit Plan. These benefits are subject to inpatient hospital pre-admission certification. This is not a complete description of all of your Indemnity Medical benefits, limitations and exclusions.

 

Benefits	If You Use PPO Provider	If You Use Non-PPO Provider
Lifetime Maximum	$1,000,000
Calendar Year Deductible	$300 per person
Out-of-Pocket Maximum	$1,500 per person*	$2,500 per person**
Inpatient Hospital Services	90% of PPO Allowed Amount after deductible pre-authorization required	75% of UCR charges after deductible pre-authorization required
Outpatient Hospital Services	90% of PPO Allowed Amount after deductible	75% of UCR charges after deductible
Surgery Primary Surgeon Assistant Surgeon Anesthesiologist	90% of PPO Allowed Amount after deductible	75% of UCR charges after deductible
Physician Services Hospital Visits Office Visits	90% of PPO Allowed Amount after deductible	75% of UCR charges after deductible
Outpatient X-ray and Laboratory	90% of PPO Allowed Amount after deductible	75% of UCR charges after deductible

Benefits for mental health and chemical dependency are covered in a separate program by Health Management Center. Please refer to pages 30 to 40 for a complete description of these benefits.

Benefits for prescription drugs are covered in a separate program by NBN/Rx and Merck-Medco Rx Services.

^*  Covered PPO services are paid at 90% until $1,500 in eligible out-of-pocket expenses have been accumulated for an individual during a calendar year. Then the Plan pays 100% of eligible expenses for the remainder of the calendar year for that individual. Eligible out-of-pocket expenses do not include your deductible.