| Benefit Summary | Physician | Value | Gold | Platinum |
|---|---|---|---|---|
| Doctor Office Visits Maximum number of visits |
$100 10 |
$110 10 |
$120 10 |
$125 10 |
| Doctor Office Visits Maximum number of visits |
$100 10 |
$110 10 |
$120 10 |
$125 10 |
| Hospital Semi-private room and board per day Intensive Care Unit (ICU) per day, 15 day max. Combined maximum number of days |
$250 $250 31 |
$500 $500 31 |
$1,000 $1,000 31 |
$1.500 $3,000 31 |
| Surgery Inpatient Outpatient Combined maximum number of days |
$500 $200 1 |
$1,000 $500 1 |
$1,000 $1,000 1 |
$1.500 $3,000 1 |