Page 9 - MGM 2020 Benefits
P. 9
MEC
Inpatient
Day 1-3 Hospital Coninement (per day) $1,000
Days 4+ Hospital Coninement (per day) $500
Maximum Beneit 60 days per year
Intensive Care Unit (per day) $400
Surgery (per day, max 1 day per year) $500
Anesthesia (per day, max 2 days per year) $100
Outpatient
Physician Oice Visit (max 2 days per $75
individual, 4 days per family)
Accident Beneits
Medical Expense $250
Hospital Indemnity (per day) $100
Ground Ambulance $100
Fracture/Dislocation $200
up to $2,000
Blood and Plasma $300
Immediate Hospitalization $1,000
Paralysis/Quadriplegia $10,000/$20,000
Physical Therapy $30
Ruptured Disc/Tendon, Ligament, Rotator $500
Cuf, or Knee Cartilage
AD&D/Critical Illness
Accidental Death and Dismemberment* $20,000/$10,000/$5,000
Critical Illness $5,000
Prescription
Retail—Generic Rx Copay $10 max cost
Retail—Preferred Brand Rx Copay $20 max cost
Non-Preferred Brand Rx Copay $40 max cost
Specialty Rx Copay Discount only
Monthly Beneit Maximum— None
Individual/Family
Other Services (2)
Telephonic Doctor Oice Visits (unlimited) Yes
(1) The Minimum Essential Coverage option is provided by BayBridge Insurance Company
(2) These services are not insurance and are not provided by the underwriting companies shown
here
* Beneit amounts listed are for: employee/spouse/child(ren)
MGM Healthcare 9
Inpatient
Day 1-3 Hospital Coninement (per day) $1,000
Days 4+ Hospital Coninement (per day) $500
Maximum Beneit 60 days per year
Intensive Care Unit (per day) $400
Surgery (per day, max 1 day per year) $500
Anesthesia (per day, max 2 days per year) $100
Outpatient
Physician Oice Visit (max 2 days per $75
individual, 4 days per family)
Accident Beneits
Medical Expense $250
Hospital Indemnity (per day) $100
Ground Ambulance $100
Fracture/Dislocation $200
up to $2,000
Blood and Plasma $300
Immediate Hospitalization $1,000
Paralysis/Quadriplegia $10,000/$20,000
Physical Therapy $30
Ruptured Disc/Tendon, Ligament, Rotator $500
Cuf, or Knee Cartilage
AD&D/Critical Illness
Accidental Death and Dismemberment* $20,000/$10,000/$5,000
Critical Illness $5,000
Prescription
Retail—Generic Rx Copay $10 max cost
Retail—Preferred Brand Rx Copay $20 max cost
Non-Preferred Brand Rx Copay $40 max cost
Specialty Rx Copay Discount only
Monthly Beneit Maximum— None
Individual/Family
Other Services (2)
Telephonic Doctor Oice Visits (unlimited) Yes
(1) The Minimum Essential Coverage option is provided by BayBridge Insurance Company
(2) These services are not insurance and are not provided by the underwriting companies shown
here
* Beneit amounts listed are for: employee/spouse/child(ren)
MGM Healthcare 9
