| Diamond Elite Plus | Platinum Elite | Gold Classic Plus | Silver Classic | ||
| Inpatient Hospital Confinement (per inpatient day) $1,000,000 per calendar year limit | $5,000 | $3,000 | $2,000 | $1,500 | |
| Building Benefit Injury Reimbursement Inpatient Hospitalization benefits increase 25% each year, years 2-5 for injury related hospital stays | year 2 | $6,250 | $3,750 | $2,500 | $1,875 |
| year 3 | $7,500 | $4,500 | $3,000 | $2,250 | |
| year 4 | $8,750 | $5,250 | $3,500 | $2,625 | |
| year 5 | $10,000 | $6,000 | $4,000 | $3,000 | |
| Hospital Admission Benefits (for the first inpatient day per calendar year) | $3,000 | $2,000 | $1,000 | $1,000 | |
| Emergency Room or Urgent Care | $375 | $250 | $250 | $125 | |
| Surgery Benefit Limit of 1 daily benefit per calendar year, daily surgical benefits for both inpatient and outpatient surgery. The reimbursement schedule for 1 unit is similar to what is payable under the Medicare Physician Fee Schedule for surgeries. (Maximum Benefit per calendar year) | 3 X Policy Fee Schedule | 2.5 X Policy Fee Schedule | 2 X Policy Fee Schedule | 1 X Policy Fee Schedule | |
| Ambulatory Surgical Benefit If outpatient surgery is performed in an Ambulatory Surgery Center or Outpatient Hospital facility, the benefits payable include the surgical and anesthesia benefit in addition to per day ambulatory/outpatient facility benefit. | $3,000 | $2,500 | $2,000 | $1,000 |
| Assistant Surgeon | Pays a daily amount per day of surgery |
| Anesthesiologist | Pays a daily amount per day of surgery |
| Diamond Elite Plus | Platinum Elite | Gold Classic Plus | Silver Classic | |
| Doctor’s Office Visit (Per day/calendar year) | $100/4 days | $75/4 days | $75/3 days | $50/3 days |
| Prescription Benefit (Per day – $750 calendar year maximum) | $75 | $50 | $50 | $25 |
| Outpatient Medical Benefits Preventive Services (per Colonoscopy, Pap, PSA) | $300/$100/$100 | $300/$100/$100 | $300/$100/$100 | $300/$100/$100 |
| Laboratory Services (per day for surgical pathology/other laboratory services) | $100/$50 | $100/$25 | $100/$25 | $100/$25 |
| Therapy Services (per day for physical, occupational, speech) | $25 | $25 | $25 | $25 |
| Radiology Services (per day: MRI/PET scan/CT scan/mammogram/ other radiology tests) | $500/$250/$200 /$150/$75 | $250/$250/$200 /$100/$50 | $250/$250/$200 /$100/$50 | $250/$250/$200 /$100/$50 |
| Calendar Year Limit for all Outpatient Benefits | $25 | $25 | $25 | $25 |
| Ground and Air Ambulance Limit of 2 daily benefits per calendar year for all ambulance transportation (per day for ground, per day for air) | $150/$1000 | $100/$1000 | $100/$1000 | $100/$500 |
| Allergy Shots and Immunization (child only) | $10/$25 | $10/$25 | $10/$25 | $10/$25 |
| Cancer Benefit Pays for Radiation, Chemotherapy, & Immunotherapy (per day/40 days per calendar year) | $2,000 | $2,000 | $1,000 | $1,000 |
| Lifetime Maximum | $5 million | $5 million | $5 million | $5 million |