PAYMENT

COMMENTS

ACCUPUNCTURE

80% TO $300.

AMBULANCE

$300.00

ANESTHETIST EXPENSES

80%  

DENTAL

$500.

INJURY

DENTAL

$100. PER TOOTH

EXTRACTION OF IMPACTED OR UNERUPTED

DURABLE MEDICAL EQUIPMENT

50.00 DEDUCTIBLE, THEN 80% UP TO $1,000.

INCLUDES. FIRST TIME ORTHOTICS, SPLINTS

HIGH COST PROCEDURES

80%  

HIGH COST THERAPY

80%  

HOSPITAL EXPENSES

80%

HOSPITAL ROOM AND BOARD

80%   

INCLUDES MENTAL HEALTH

INTENSIVE CARE

80%  

MATERNITY

80%

 BENEFITS ARE PAID ON THE SAME BASIS AS A SICKNESS

MENTAL HEALTH OUTPATIENT

80%  

MIS. DAY SURGURY EXP.

80%  

OUTPATIENT SERVICES

80%  

LABORATORY, X-RAY, EMERGENCY ROOM

PHYSICAL THERAPY

100%  OF FIRST VISIT THEN 80% UP TO A MAXIMUM OF $800.00

80% UP TO $500.

ONLY AT PATRICK GYM

ON REFERRAL FROM PATRICK GYM

PHYSICIAN EXPENSES

80%  

INCLUDES CHIROPRACTOR

PHYSICIAN HOSPITAL VISITS

80%  

PRESCRIPTIONS

$25. FOR NAME BRAND
$15. FOR GENERIC
Up to a maximum of $1500.

PATIENTS RESPONSIBILITY

SURGEON  EXPENSES

80%