OptiMed Limited Medical Plans

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13 Plans, scroll left to right (scroll bar below) and up and down (scroll bar at right)

Standard Plans	Select 20	Select 20 Rx	Select 30	Select 30 Rx	Med-Choice 40	Med-Choice 40 Rx	Premier 50 Rx	Premier 60 Rx	Preferred 70 Rx+	Preferred 80 Rx+	Executive 80 Rx+	Executive 90 Rx+	Executive 100 Rx+
Outpatient Physician Office Vists - Both General & Specialist	$20 Per Day (6 Days)	$20 Per Day (6 Days)	$30 Per Day (6 Days)	$30 Per Day (6 Days)	$40 Per Day (6 Days)	$40 Per Day (6 Days)	$50 Per Day (8 Days)	$60 Per Day (8 Days)	$70 Per Day (10 Days)	$80 Per Day (12 Days)	$80 Per Day (12 Days)	$90 Per Day (12 Days)	$100 Per Day (12 Days)
ER- Sickness - 3 day max per benefit period	$50 Per Day	$50 Per Day	$50 Per Day	$50 Per Day	$50 Per Day	$50 Per Day	$50 Per Day	$50 Per Day	$50 Per Day	$75 Per Day	$75 Per Day	$100 Per Day	$100 Per Day
Wellness Benefit - Under age 1 - 4 day benefit period max Age 1 and older - 3 day benefit period max	$50 Per day	$50 Per day	$50 Per day	$50 Per day	$50 Per day	$50 Per day	$50 Per day	$50 Per Day	$50 Per Day	$100 Per Day	$150 Per Day	$150 Per Day	$150 Per Day
Hearing Exam Beneft - Benefit is payable one time per 24 consecutive month period per insured and dependent spouse and one time per 12 consecutive month period per dependent child	N/A	N/A	$70 Exam	$70 Exam	$70 Exam	$70 Exam	$70 Exam	$70 Exam	$70 Exam	$70 Exam	$70 Exam	$70 Exam	$70 Exam
Outpatient Diagnostic Laboratory Test - 3 Day Max	N/A	N/A	N/A	N/A	N/A	N/A	$20 Per Day	$30 Per Day	$40 Per Day	$40 Per Day	$60 Per Day	$80 Per Day	$100 Per Day
Outpatient Diagnostic Test - 3 Day Max	N/A	N/A	N/A	N/A	N/A	N/A	$50 Per Day	$50 Per Day	$50 Per Day	$50 Per Day	$60 Per Day	$80 Per Day	$100 Per Day
Outpatient Advanced Diagnostic Testing Level 1 Ultrasound, Mammogram, Stress Test, Electroencephalogram(EEG) test, Electrocardiogram(EKG) test, Echocardiogram Level 2 CT(CAT) Scan, Magnetic Resonance Imaging(MRI) Scan, Magnetic Resonance Angiogram(MRA) Scan, Positron Emmission Tomography (PET) Scan - 3 Days per person per benefit period (Level 1 & Level 2 combined	N/A	N/A	N/A	N/A	N/A	N/A	$50 Per Day $150 Per Day	$100 Per Day $300 Per Day	$100 Per Day $300 Per Day	$150 Per Day $450 Per Day	$150 Per Day $450 Per Day	$200 Per Day $600 Per Day	$200 Per Day $600 Per Day
AmbulanceTrip - Groud/Water 3 days per benefit period Air - 3X the ground/water benefit	N/A	N/A	N/A	N/A	$150 per day	$150 per day	$150 per day	$150 per day	$150 Per Day	$150 Per Day	$150 Per Day	$150 Per Day	$150 Per Day
ER Injury - For treatment in ER if preformed within 72 hours of the accident / 3 Day benefit period Max	N/A	N/A	$300 Per Day	$300 Per Day	$300 Per Day	$300 Per Day	$500 Per Day	$500 Per Day	$1,000 Per Day	$1,000 Per Day	$1,000 Per Day	$1,000 Per Day	$1,000 Per Day
In-Patient Surgery - 2 day per person max	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	$500 Per Day	$1,000 Per Day	$1,500 Per Day	$2,000 Per Day	$2,500 Per Day
Out-Patient Surgery - 2 day per person max	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	$250 Per Day	$500 Per Day	$750 Per Day	$1,000 Per Day	$1,250 Per Day
Anesthesia - Inpatient and Outpatient	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	20% of surgical benefit	20% of surgical benefit	20% of surgical benefit	20% of surgical benefit	20% of surgical benefit
Hospital Confinement Indemnity - Requires 24 hour stay - payable from first day of confinement	$100 Per Day	$100 Per Day	$100 Per Day	$100 Per Day	$100 Per Day	$100 Per Day	$200 Per Day	$500 Per Day	$500 Per Day	$800 Per Day	$1,000 Per Day	$1,000 Per Day	$1,000 Per Day
Intensive Care Confinement Indemnity - Paid in addition to Daily Hospital Confinement. 30 Days Calendar Max - Per Person.	$100 Per Day	$100 Per Day	$100 Per Day	$100 Per Day	$100 Per Day	$100 Per Day	$200 Per Day	$500 Per Day	$500 Per Day	$800 Per Day	$1,000 Per Day	$1,000 Per Day	$1,000 Per Day
Confinement Benefit for Skilled Nursing- after a 3+ hospital stay/ up to 60 days per stay/120 day lifetime max	$50 Per Day	$50 Per Day	$50 Per Day	$50 Per Day	$50 Per Day	$50 Per Day	$100 Per Day	$250 Per Day	$250 Per Day	$400 Per Day	$500 Per Day	$500 Per Day	$500 Per Day
Life & AD&D (Employee Only)	N/A	N/A	N/A	N/A	5000	5000	5000	5000	5000	5000	5000	10000	20000
OutPatient Prescription Drug - Average tier Insured Cost Generic $10 / Brand $50 Annual Maximums $3,000 per insured subject to drug formulary. Cost may vary by Formulary Tier and Pharmacy. Member pays 100% of discounted price for drugs not covered under the formulary Note: RX is not available in IL, ME and MD	Discount Card	Generic Only	Discount Card	Generic Only	Discount Card	Generic Only	Generic Only	Generic Only	Generic/Brand	Generic/Brand	Generic/Brand	Generic/Brand	Generic/Brand
Guaranteed Issue	Included	Included	Included	Included	Included	Included	Included	Included	Included	Included	Included	Included	Included
PPO Networks	Multiplan, First Health	Multiplan, First Health	Multiplan, First Health	Multiplan, First Health	Multiplan, First Health	Multiplan, First Health	MultiPlan, First Health	MultiPlan, PHCS, First Health	MultiPlan, PHCS, First Health	MultiPlan, PHCS, First Health	MultiPlan, PHCS, First Health	MultiPlan, PHCS, First Health	MultiPlan, PHCS, First Health
Assignment of Benefits	Included	Included	Included	Included	Included	Included	Included	Included	Included	Included	Included	Included	Included
Patient Advocacy Program	Included	Included	Included	Included	Included	Included	Included	Included	Included	Included	Included	Included	Included
Enhanced Customer Care	Included	Included	Included	Included	Included	Included	Included	Included	Included	Included	Included	Included	Included
WorkPlace Wellness	Included	Included	Included	Included	Included	Included	Included	Included	Included	Included	Iincluded	Included	Included
Telemedicine	Included	Included	Included	Included	Included	Included	Included	Included	Included	Included	Included	Included	Included
Cobra Administration	Included	Included	Included	Included	Included	Included	Included	Included	Included	Included	Included	Included	Included
Section 125 Premium Only Plans	Included	Included	Included	Included	Included	Included	Included	Included	Included	Included	Included	Included	Included

Rates: EE	$34.58	$44.92	$42.89	$53.23	$48.95	$59.29	$77.42	$100.39	$133.53	$170.96	$196.77	$219.23	$240.11
Rates: EE+1	$52.98	$69.16	$69.18	$85.36	$80.13	$96.31	$131.92	$177.03	$241.99	$315.50	$366.19	$409.35	$448.46
Rates: Family	$70.32	$92.35	$92.87	$114.90	$107.95	$129.98	$179.58	$242.43	$334.67	$437.08	$507.70	$567.66	$621.78
Standard Plans	Select 20	Select 20 Rx	Select 30	Select 30 Rx	Med-Choice 40	Med-Choice 40 Rx	Premier 50 Rx	Premier 60 Rx	Preferred 70 Rx+	Preferred 80 Rx+	Executive 80 Rx+	Executive 90 Rx+	Executive 100 Rx+