Corresponding benefit in
sample plans document |
Benefit Description |
| Network |
First Health Network |
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The First Health Network provides access to one of the nation's largest and most respected networks. By going to a First Health provider members can reduce their out of pocket expenses and stretch benefit dollars. More than 490,000 provider locations across all 50 states. Visit www.yourmedbenefits.com to search providers online. |
Life/AD&D
Insurance |
Life/Accidental Death and Dismemberment Insurance |
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The Life Insurance Benefit is reduced by 35% of the original amount upon attainment of Age 65, and by an additional 35% each five year period thereafter. |
| Dependent Life Insurance |
Dependent Life Insurance |
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Spouse; Child (from 6 months to 19 years, 26 years if a Full Time Student); and Child (from 10 days to 6 months). |
| Critical Illness |
Critical Illness Benefit |
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Benefit payable on the first occurrence of End-Stage Renal Failure, Heart Attack, Life-Threatening Cancer, Major Organ Transplant, or a Stroke as defined by the plan. |
| Daily In-Hospital Indemnity |
Daily In-Hospital Indemnity Benefit |
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Benefit payable per day. Up to a Lifetime Maximum of 500 days of confinement (does not apply for Substance Abuse, Mental Illness Disorder, and In-patient Skilled Nursing Facility confinement). |
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Intensive Care Unit |
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Double the Daily In-Hospital Benefit will be paid, up to a maximum of 30 days per Calendar Year. |
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Mental Illness Disorder |
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50% of the Daily In-Hospital Benefit will be paid, up to a maximum $5,000 per Calendar Year. Lifetime Maximum $30,000. |
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Substance Abuse |
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50% of the Daily In-Hospital Benefit will be paid, up to a maximum of 30 days per Calendar Year. Lifetime Maximum $30,000. |
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In-Patient Skilled Nursing Facility |
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50% of the Daily In-Hospital Benefit will be paid. Maximum benefit per Covered Person per period of confinement is 60 days. The confinement is covered only if it follows a covered Hospital stay of at least 3 days. |
| Inpatient Miscellaneous |
Inpatient Miscellaneous Indemnity Benefit |
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Benefits payable per day. Up to 60 days per calendar year (reduced benefits apply to Mental Illness Disorder and Substance Abuse). Benefits include non-professional facility charges associated with a hospital inpatient stay and are paid in addition to the Daily In-Hospital Indemnity Benefit. |
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Mental Illness Disorder |
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50% of the daily Inpatient Miscellaneous Indemnity Benefit will be paid, up to a maximum $5,000 per Calendar Year. Lifetime Maximum $30,000. |
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Substance Abuse |
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50% of the daily Inpatient Miscellaneous Indemnity Benefit will be paid, up to a maximum of 30 days per Calendar Year. Lifetime Maximum $30,000. |
| Hospital Admission |
Hospital Admission Benefit - Single Sum |
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Benefit payable only once during any period of confinement. The amount is equal to the Daily In-Hospital Benefit for other than Intensive Care. |
| Doctor Office Visit |
Doctor's Office Visit Indemnity Benefit (due to Illness, Accident or Medical Emergency) |
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Benefit payable per visit per Covered Person. Routine exams, medical treatment, immunizations and injections are not covered under this benefit. |
| Outpatient Diagnostic X-Ray and Lab |
Outpatient Diagnostic X-Ray and Lab Indemnity Benefit |
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Benefit is payable per test per Covered Person, when hospital confinement is not required. Routine exams are not covered under this benefit. |
| Advanced Studies |
Outpatient Diagnostic Advanced Studies Indemnity Benefit |
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Benefit will be paid per Covered Person for tests ordered or performed by a Doctor, when hospital confinement is not required. Routine exams are not covered under this benefit. Covered procedures are limited to: Angiograms, Arteriograms, CT Scans, MRI’s and other advanced studies tests. Benefit includes the cost of reading the Advanced Studies. |
| IP/OP/OP Minor Surgical Indemnity |
Inpatient, Outpatient or Outpatient Minor Surgical Indemnity Benefit |
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Inpatient Surgical Indemnity Benefit |
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Benefit is payable only once per Calendar Year, per Covered Person for any covered Inpatient surgical procedure or for two or more Inpatient surgical procedures performed in the same surgical session. Calendar Year Maximum applies. |
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Outpatient Surgical Indemnity Benefit |
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Benefit is payable per Covered Person for any covered Outpatient surgical procedure, or two or more Outpatient surgical procedures performed in the same surgical session. |
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Outpatient Minor Surgical Indemnity Benefit |
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Benefit is payable per Covered Person for any covered Outpatient Minor Surgical Procedure or two or more Outpatient Minor Procedures performed in the same surgical session. |
| Anesthesia Benefit |
Anesthesia Indemnity |
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Benefit amount will equal 30% of the amount paid for the covered surgical procedure. Benefit is paid once per surgical session. |
| Outpatient Surgical Facility |
Outpatient Surgical Facility Indemnity Benefit |
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Benefit will be paid for a covered surgical procedure, per Covered Person, per Calendar Year. A covered surgery must be performed at a free-standing outpatient surgical center or a Hospital outpatient surgical facility. No benefits will be payable for surgeries performed in a doctor’s office. |
| Preventive Care |
Preventive Care Indemnity Benefit |
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Benefit payable per visit per Covered Person. Routine exams, medical treatment and immunizations are covered under this benefit. |
| Accident Expense |
Accident Expense Benefit |
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Up to 100% of charges incurred are payable within 90 days of an Accidental Bodily Injury. Benefit is per accident. |
Emergency Room Indemnity Benefit
for Illness Only |
Emergency Room Indemnity Benefit for Illness Only |
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Benefit is payable per visit. Maximum per person per Calendar Year is $300. |
| Health Savings Program |
Health Savings Program - this benefit is not underwritten by Nationwide Life Insurance Company |
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Discounts on Vision*, Hearing, Chiropractic*, Vitamins & Nutritional Supplements. Access to Counseling (EAP) and 24-Nurseline. *Not available to residents of Vermont. |
| Tier'd RX Program |
Prescription Program - this benefit is not underwritten by Nationwide Life Insurance Company |
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The Tier'd Pricing Pharmacy Plan saves money and takes the guess work out of paying for prescription medications. This program segments brand name and generic drugs into three price classifications making it easier for members to consult with their physician to find the most effective medication at the lowest cost. Discounts also apply to drugs not listed in one of the following tiers as well as maintenance medications purchased through the mail order program.
Preferred brand and generic drugs available for $10 or less (tier 1), $20 or less (tier 2), $40 or less (tier 3) for the scheduled quantity or dose. Mail order pharmacy included.
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