Page 4 - FL_STM_Connect PLus
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 office 1 copay for 30–90 days of coverage
visit, including expenses for laboratory and diagnostic 2 copays for 91-180 days of coverage
tests will be subject to plan deductible and coinsurance. 3 copays for 180+ days of coverage
Based on your state of residence, you may be limited to a
certain number of copays.
Deductible • $5,000
• $10,000
The selected deductible maximum is an amount of
money that must be paid by the covered person before
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 deemed satisfied for the remainder of the coverage
period.
Coinsurance percentage and out-of- 30% coinsurance
pocket maximum Out-of-pocket: $6,000
After the deductible maximum amount has been met, 50% coinsurance
you pay the selected coinsurance percentage of covered Out-of-pocket: $10,000
expenses until the out-of-pocket maximum amount has
been reached.
The out-of-pocket maximum amount is specific to
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 $2,000,000
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
Pre-existing condition coverage period $25,000
maximum $25,000
$25,000
After maximum is reached, expenses due to pre-existing
conditions are not covered.
Primary insured
Covered spouse
Covered child(ren)
Eligibility
Individuals, spouses and dependents may be covered. Connect Plus is available to the primary
applicant from age 18 to 64, his or her spouse age 18 to 64 and dependent children under the age of
26. A child-only plan is available for children age 2 up to age 18.
4 Brochure Connect Plus 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 office 1 copay for 30–90 days of coverage
visit, including expenses for laboratory and diagnostic 2 copays for 91-180 days of coverage
tests will be subject to plan deductible and coinsurance. 3 copays for 180+ days of coverage
Based on your state of residence, you may be limited to a
certain number of copays.
Deductible • $5,000
• $10,000
The selected deductible maximum is an amount of
money that must be paid by the covered person before
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 deemed satisfied for the remainder of the coverage
period.
Coinsurance percentage and out-of- 30% coinsurance
pocket maximum Out-of-pocket: $6,000
After the deductible maximum amount has been met, 50% coinsurance
you pay the selected coinsurance percentage of covered Out-of-pocket: $10,000
expenses until the out-of-pocket maximum amount has
been reached.
The out-of-pocket maximum amount is specific to
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 $2,000,000
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
Pre-existing condition coverage period $25,000
maximum $25,000
$25,000
After maximum is reached, expenses due to pre-existing
conditions are not covered.
Primary insured
Covered spouse
Covered child(ren)
Eligibility
Individuals, spouses and dependents may be covered. Connect Plus is available to the primary
applicant from age 18 to 64, his or her spouse age 18 to 64 and dependent children under the age of
26. A child-only plan is available for children age 2 up to age 18.
4 Brochure Connect Plus 1018
