| | Major Medical |
Subpart of part 2740.9964 | Benefit | Basic | Superimposed | Comprehensive |
1. | Hospital room and board | 128 | -26 | |
2. | Hospital extras | 290 | | |
3. | Surgery | 114 | | |
4. | Physician care; home, office | | | |
5. | Physician care; hospital | | | |
6. | Maternity | | | |
7. | Diagnostic X-ray and lab | | | |
8. | Drugs and medicine | | | |
9. | Radioactive therapy | | | |
10. | Nursing/convalescent facility | | -13 | |
11. | Home health care | | -6 | |
12. | Physical therapy | | | |
12. | Oxygen | | | |
12. | Prostheses | | | |
12. | Durable medical equipment | | | |
12. | Second opinion surgery | | | |
12. | Private duty nursing | | | |
12. | Ambulance | | | |
13. | Hospital room and board in full | | | |
14. | All hospital expenses in full | | | |
15. | Major medical maximums | | | |
Subtotal reasonable and customary medical services | 532 | | |
16. | Deductible | | | |
16. | Coinsurance | | | |
Subtotal net of deductible and coinsurance | | | |
17. | Adjust (comb. medical/dental ded.) | | | |
18. | COB/No-fault | 21 | | |
19. | Limit on "out-of-pocket" expenses | | | |
20. | Well baby care | | | |
21. | Emergency and supplemental accident | | | |
22. | Student dependents | | | |
23.-25. | Superimposed major medical | | 681 | |
Grand Total | 511 | 636 | |
Combined basic and superimposed | 1147 | XXX | XXX |