S P O U S E

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*Product Variation for TN

_____

Monthly Premium

_________

$372

Monthly Premium

MaXX-1

Actual rates may vary by Zip Code. 

______________

_____

Monthly Premium

_________

$372

Monthly Premium

MaXX-1

$470

Monthly Premium

($250,000 Annual Max)

LIST BILL 10+

TESTIMONIAL OR EXAMPLE

TIMELINE / PROCESS

HEALTH BENEFITS SUMMARY

2018-2019

Type

Network Access

Lifetime Maximum - Per Covered Person

Annual Maximum - Per Covered Person

Critical Event Benefit - Per Covered Person*

Unlimited Services

Permanent

National/Unrestricted

$5 Million

$100,000

Up to $50,000

Teladoc, GoodRX, LabCorp, Karis360

Outpatient Maximum - Per Covered Person - Per Year

$4,000

Outpatient Physician - 20 Visits - Per Covered Person - Per Year

Prescription Benefits - Per Covered Person - Per Day

Name Brand
Generic

Urgent Care Center Benefit - Per Covered Person - Per Year

Outpatient Services - Per Covered Person - Per Day

MRI, CAT Scan or Nuclear Testing
X-Rays & Other Diagnostic Tests
Labs
Injections

Preventive Care - Per Covered Person - Per Year

Colonoscopy Benefit Every 3 Years (Benefit Doubles Year 4)
Mammograms & All Other Preventive (Including Physicals)

$300
$125

VALUE

MaXX-1

MaXX-2

$2,000

$4,000

$80

$60

$80

$20

$10

$10

$5

$20

$10

$125

$100

$125

$350
$80
$40
$20

$175
$40
$20
$10

$350
$80
$40
$20

C
O
V
E
R
A
G
E

E
V
E
R
Y
D
A
Y

Emergency Department - Per Covered Person - Per Year

Facility Fees
Professional Services

$150

$150

$100

$100

$150

$150

Ground Ambulance Benefit - Per Covered Person - 2 Per Year

$500

Air Ambulance Benefit - Per Covered Person - Per Year

$1,500

Accident Benefit - Per Covered Person - Per Day

Day 1
Day 2+

Preventive Care - Per Covered Person - Per Year

Colonoscopy Benefit Every 3 Years (Benefit Doubles Year 4)
Mammograms & All Other Preventive (Including Physicals)

$1,200

$6,000

$600

$3,000

$1,200

$6,000

Emergency Department - Per Covered Person - Per Year

Facility Fees
Professional Services

$150

$150

$100

$100

$150

$150

$150

$150

$100

$100

$150

$150

WHO WE ARE

COVERAGE

QUOTE SUMMARY:

GENDER: AGE, TOBACCO

GENDER: AGE, TOBACCO

DEPENDENTS: #

STATE: ZIP

Coverage Includes:

____________

_____________________________________

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UNLIMITED SERVICES

EXpected

BENEFITS

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COVERAGE

Benefits You EXpect At Prices You Can Afford

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