Page 4 - Nationwide_Care Access Plan
P. 4
Other covered services (per event) Economy Value Superior
Ambulance (per trip) $100 $250 $500
$500 $1,000 $2,000
Ground or water $100 $100 $100
Air
$300 $600 $900
Second surgical opinion
Benefit payable for a second opinion prior to a surgery; not subject to the ››$0 ››$0 ››$0
per illness or injury deductible. ››$1,000 ›› $1,000 ›› $1,000
››$2,500 ›› $2,500 ›› $2,500
Chemotherapy and radiation (per treatment up to lifetime maximum of 100
treatments)
Covers outpatient chemotherapy treatment including chemotherapy
medication and radiation therapy, for the treatment of cancer.
Customize your plan options
Per injury or illness deductible
Critical illness benefit
Benefit payable for one of the following conditions: cancer-in-situ, major
organ transplant, severe burns, life threatening cancer, heart attack, stroke,
kidney (renal) failure, and coma. The covered person must be positively
diagnosed by a legally qualified physician as having a critical illness for the
first time following the coverage effective date.
Not available in all states. Applicant $10,000
Spouse $10,000
Child(ren) $2,500
Buy-up options:
Applicant $20,000 and $40,000
Spouse $20,000 and $40,000
Child(ren) $10,000
Additional Outpatient benefits $200 $200 $200
Wellness Preventive Care Rider (maximum one visit per person, per year) $50 $60 $60
Covered services include routine physical examination including diagnostic (maximum 2 (maximum 4 (maximum 4
tests that are performed during the exam, routine Pap smear, screening visits per year) visits per year)
mammography, immunizations and prostate and colorectal cancer visits per
screening; not subject to per injury or illness deductible. year) $300
Outpatient physician office visit or retail health clinic (per person) $150
Physician Office Visit Rider. Not subject to per injury or illness deductible.
Outpatient urgent care or emergency room visit $75
(maximum one visit per person, per year)
Not subject to per injury or illness deductible.
Optional diagnostic testing (each test covered twice per person, $100 $100 $100
per year) $500 $1,000
Benefit payable within 30 days following an inpatient confinement or outpatient
surgery for a covered illness or injury.
Outpatient diagnostic X-ray and lab
Covers X-rays and lab tests performed in an outpatient setting and not
done in conjunction with a wellness or preventive care examination; not
subject to per injury or illness deductible.
Outpatient advanced studies $250
Covers Angiogram, Arteriogram, Computed Tomography Scan (CT);
Electroencephalogram (EEG), Magnetic Resonance Imaging (MRI),
Myelogram, Positron Emission Tomography Scan (PET), Thallium Stress Test;
not subject to per injury or illness deductible.
Benefits listed are subject to the per injury or illness deductible, if applicable. Refer to page 7 for more information.
Benefits vary by state.
Brochure Care Access Plan L 0518 4
Ambulance (per trip) $100 $250 $500
$500 $1,000 $2,000
Ground or water $100 $100 $100
Air
$300 $600 $900
Second surgical opinion
Benefit payable for a second opinion prior to a surgery; not subject to the ››$0 ››$0 ››$0
per illness or injury deductible. ››$1,000 ›› $1,000 ›› $1,000
››$2,500 ›› $2,500 ›› $2,500
Chemotherapy and radiation (per treatment up to lifetime maximum of 100
treatments)
Covers outpatient chemotherapy treatment including chemotherapy
medication and radiation therapy, for the treatment of cancer.
Customize your plan options
Per injury or illness deductible
Critical illness benefit
Benefit payable for one of the following conditions: cancer-in-situ, major
organ transplant, severe burns, life threatening cancer, heart attack, stroke,
kidney (renal) failure, and coma. The covered person must be positively
diagnosed by a legally qualified physician as having a critical illness for the
first time following the coverage effective date.
Not available in all states. Applicant $10,000
Spouse $10,000
Child(ren) $2,500
Buy-up options:
Applicant $20,000 and $40,000
Spouse $20,000 and $40,000
Child(ren) $10,000
Additional Outpatient benefits $200 $200 $200
Wellness Preventive Care Rider (maximum one visit per person, per year) $50 $60 $60
Covered services include routine physical examination including diagnostic (maximum 2 (maximum 4 (maximum 4
tests that are performed during the exam, routine Pap smear, screening visits per year) visits per year)
mammography, immunizations and prostate and colorectal cancer visits per
screening; not subject to per injury or illness deductible. year) $300
Outpatient physician office visit or retail health clinic (per person) $150
Physician Office Visit Rider. Not subject to per injury or illness deductible.
Outpatient urgent care or emergency room visit $75
(maximum one visit per person, per year)
Not subject to per injury or illness deductible.
Optional diagnostic testing (each test covered twice per person, $100 $100 $100
per year) $500 $1,000
Benefit payable within 30 days following an inpatient confinement or outpatient
surgery for a covered illness or injury.
Outpatient diagnostic X-ray and lab
Covers X-rays and lab tests performed in an outpatient setting and not
done in conjunction with a wellness or preventive care examination; not
subject to per injury or illness deductible.
Outpatient advanced studies $250
Covers Angiogram, Arteriogram, Computed Tomography Scan (CT);
Electroencephalogram (EEG), Magnetic Resonance Imaging (MRI),
Myelogram, Positron Emission Tomography Scan (PET), Thallium Stress Test;
not subject to per injury or illness deductible.
Benefits listed are subject to the per injury or illness deductible, if applicable. Refer to page 7 for more information.
Benefits vary by state.
Brochure Care Access Plan L 0518 4
