Page 4 - FL_STM_Connect STM
P. 4
Plan selection
All benefits listed apply per covered person, per coverage period. The amount of benefits provided
depends on the plan selected and the premium will vary with the amount of benefits selected.
Physician office visit copay $50 copay, not to exceed one
visit per coverage period
After the copay, the balance of the doctor office visit
charge is covered at 100 percent.
Additional covered expenses incurred during the 1 copay for 30–90 days of coverage
office visit, including expenses for laboratory and
diagnostic tests will be subject to plan deductible and 2 copays for 91-180 days of
coinsurance. coverage
3 copays for 180+ days of coverage
Based on your state of residence, you may be limited
to a certain number of copays.
Deductible • $2,500
The selected deductible maximum is an amount of • $5,000
money that must be paid by the covered person before • $10,000
coinsurance benefits begin.
Family deductible maximum: When three covered
persons in a family each satisfy their deductible,
the deductibles for any remaining covered family
members are considered satisfied for the remainder of
the coverage period.
Coinsurance percentage and out-of-pocket 20% coinsurance
maximum Out-of-pocket maximum: $4,000
After the deductible maximum amount has been met, 30% coinsurance
you pay the selected coinsurance percentage of Out-of-pocket maximum: $6,000
covered expenses until the out-of-pocket maximum
amount has been reached. 50% coinsurance
Out-of-pocket maximum: $5,000 or
The out-of-pocket maximum amount is specific to $10,000
expenses applied to the coinsurance percentage;
it does not include covered expenses applied to
the deductible, precertification penalty amounts, or
expenses not covered under the policy.
Once the deductible and out-of-pocket maximum
amounts have been satisfied, additional covered
expenses within the coverage period are paid at 100
percent, not to exceed the coverage period maximum
benefit amount. Benefit-specific maximums may also
apply.
Coverage period maximum benefit $2,000,000
4 Brochure Connect STM 1018
All benefits listed apply per covered person, per coverage period. The amount of benefits provided
depends on the plan selected and the premium will vary with the amount of benefits selected.
Physician office visit copay $50 copay, not to exceed one
visit per coverage period
After the copay, the balance of the doctor office visit
charge is covered at 100 percent.
Additional covered expenses incurred during the 1 copay for 30–90 days of coverage
office visit, including expenses for laboratory and
diagnostic tests will be subject to plan deductible and 2 copays for 91-180 days of
coinsurance. coverage
3 copays for 180+ days of coverage
Based on your state of residence, you may be limited
to a certain number of copays.
Deductible • $2,500
The selected deductible maximum is an amount of • $5,000
money that must be paid by the covered person before • $10,000
coinsurance benefits begin.
Family deductible maximum: When three covered
persons in a family each satisfy their deductible,
the deductibles for any remaining covered family
members are considered satisfied for the remainder of
the coverage period.
Coinsurance percentage and out-of-pocket 20% coinsurance
maximum Out-of-pocket maximum: $4,000
After the deductible maximum amount has been met, 30% coinsurance
you pay the selected coinsurance percentage of Out-of-pocket maximum: $6,000
covered expenses until the out-of-pocket maximum
amount has been reached. 50% coinsurance
Out-of-pocket maximum: $5,000 or
The out-of-pocket maximum amount is specific to $10,000
expenses applied to the coinsurance percentage;
it does not include covered expenses applied to
the deductible, precertification penalty amounts, or
expenses not covered under the policy.
Once the deductible and out-of-pocket maximum
amounts have been satisfied, additional covered
expenses within the coverage period are paid at 100
percent, not to exceed the coverage period maximum
benefit amount. Benefit-specific maximums may also
apply.
Coverage period maximum benefit $2,000,000
4 Brochure Connect STM 1018
