Medical Plan Maximums

This plan provides you with up to $325,000 of coverage for covered medical expenses each calendar year. Included within the $325,000 maximum are the following benefit maximums. If expenses exceed these maximums, this plan will not pay the additional costs.

• Allergy testing—Annual maximum of $600.
• Autism spectrum disorders (children age twelve and under)—Annual maximum of $1,500.
• Bariatric Surgery—Annual maximum of $15,000.
• Chemical dependency—Lifetime maximum of $10,000.
• Chiropractic care—Annual maximum of $750.
• Hearing aids—Maximum of $1,000 per ear paid in any three consecutive year period. ? Home health care—Annual maximum of $5,000.
• Hospice care—Maximum of 14 inpatient days for hospice care. Skilled care in the home is limited to 60 visits. Respite care is limited to 120 hours per three-month period.
• Mental health (inpatient)—Annual maximum of 15 days.
• Mental health (outpatient)—Annual maximum of 30 visits.
• Neurodevelopmental therapy (children age six and under)—Annual maximum of $1,500.
• Neuropsychological or psychological assessments or tests—Lifetime maximum of $1,200.
• Orthognathic surgery—Lifetime maximum of $5,000.
• Orthotics (foot)—Maximum of $400 paid in any two consecutive year period.
• Physical Examination (participant)—Annual maximum of $400.
• Physical Examination (participant's spouse or domestic partner)—Annual maximum of $300.
• Physical Examination (children)—$550 maximum during first year of life (0 months through 11 months), $300 maximum during second year of life (12 months through 23 months) and $200 maximum during third through eighteenth year of life (24 months through 18 years).
• Rehabilitation (inpatient)—Annual maximum of $24,000.
• Rehabilitation (outpatient)—Annual maximum of $2,000.
• Skilled nursing facility—Annual maximum of $10,000.
• TMJ and MPDS—Lifetime maximum of $2,500.
• Transplants (donor organ procurement costs)—Maximum of $25,000 per transplant.