Fundamental Care - Limited Medical Plan Summary of Benefits

For members of the Association for Better Health. IMPORTANT INFORMATION: Each insured member and each insured family member receives the following benefits each coverage year. Insurance benefits payable for sickness and accidents only. Pre-existing condition limitations apply only to Inpatient, Maternity Coverage and Critical Illness benefit*.

OUTPATIENT (1) FCLFCX07
Outpatient Only Plan
Physician office visit pre-pay (2)
Benefit amount per day
$10
$85 per day x 3 days
Accident maximum benefit amount per year up to;
Benefit % payable
$10,000 per year
80% U&C; $0 Deductible
Emergency Room (sickness) benefit amount per day
Surgery benefit amount per day
Anesthesia benefit amount per day
$400 per day x 1 day
$1,000/day x 1 day
$250/day x 1 day
Diagnostic, x-ray, lab benefit amount per day
Class I: Laboratory- Blood work, CMP, Lipid Panel, ECG, Pap/PSA, urinalysis and all other laboratory tests
$30 per day x 2 days
Class II: Radiology, Ultrasound, Mammogram, Sonogram, Angiogram $75 per day x 2 days
Class III: Imaging, CT, PET $150 per day x 1 day
Class IV: Other Diagnostic tests - Endoscopy, Bronchoscopy, Colonscopy without Biopsy, MRI $400 per day x 1 day
Additional Outpatient Non-Insurance Benefits(3) MDLIVE: $0 consult fee for unlimited telephonic doctor office visits. SupportLinc: Unlimited calls and 3 face-to-face no-cost sessions for mental health/substance abuse.
INPATIENT (1)
Day 1 hospital confinement benefit amount per day
Days 2+ hospital confinement benefit amount per day
Maximum benefit
N/A
N/A
N/A
Surgery benefit amount (incl. maternity) per day
Anesthesia benefit amount per day
N/A
N/A
ICU benefit amount per day N/A
Accident Medical - payable for accident only
Benefit % payable
N/A
N/A
PRESCRIPTION (3)
Retail - Generic Rx Copay $10
Retail - Preferred Brand Rx Copay $30
Mail Order - Generic Rx Copay $30
Mail Order - Preferred Brand Rx Copay $90
Monthly benefit maximum - MEMBER/FAMILY $200/$400
AD&D (4)
Accidental Death & Dismemberment Benefit Amount $25,000|$10,000|$5,000
CRITICAL ILLNESS (4)
Critical Illness Benefit Amount N/A
OTHER SERVICES (4)
First Health PPO Discounts Yes
MDLIVE Yes
SupportLinc Member Assistance Program Yes
Myewellness Yes
Association Member Benefits (ABH) Yes

* Expenses related to maternity are not covered within the first 9-months after effective date of coverage. Expenses related to Inpatient care are subject to a 12-month pre-existing condition limitation. The Critical Illness benefit is subject to a 24-month pre-existing condition limitation. (1)Fixed Hospital Indemnity, Accident Medical, Critical Illness and AD&D Plans are underwritten by First Continental Life and Accident Insurance Company. (2)The office visit pre-pay is offered through First Health PPO Network. (3) Non-insurance services not provided by First Continental Life and Accident Insurance Company. (4) AD&D benefit amount listed is for Member|Spouse|Child(ren). (5) Payable for 10 conditions: Cancer, Heart Attack, Renal Failure, Stroke, Major Organ Transplant, Multiple Sclerosis, Coronary Artery Bypass Surgery, Alzheimer’s, ALS, Terminal Illness. NOTICE: The insurance described in this summary provides limited benefits. Limited benefit plans are insurance products with reduced benefits and are not an alternative to or integrated with comprehensive coverage. This insurance does not coordinate with any other insurance plan. It does not provide major medical or comprehensive medical coverage and is not designed to replace major medical insurance. Further, this insurance is not minimum essential benefits as set forth under the Patient Protection and Affordable Care Act. Coverage is subject to exclusions and limitations and are not available in all US states. Product availability and plan design features, including eligibility requirements, descriptions of benefits, exclusions or limitations may vary depending on state laws. Full terms and conditions of coverage, including effective dates of coverage, benefits, limitations, and exclusions, are set forth in the policy. Please see full brochure for plan rates, exclusions, and limitations. In addition to the insurance premium for the Limited Benefit Medical Insurance products being offered, the total rate charged to you may include monthly fees for non-insurance products and services and $5.95 per month association dues. This page is a summary of the plans and benefits available under this program.

Monthly Rates** Outpatient Only Plan
Member Only $127
Member+Spouse $216
Member+Child(ren) $203
Member+Family $341

*Rates do not include Association dues of $5.95 or monthly service fee of $9.00 PMPM