Defined Solutions

Covered service DS 500 DS 750 DS 1000
Physician office visit $50 per visit,
maximum of 2 visits		 $60 per visit,
maximum of 4 visits		 $75 per visit,
maximum of 4 visits
Wellness
Calendar-year maximum 		$50 $100 $150
Inpatient hospital confinement $500 per day, inpatient maximum of 30 days $750 per day, inpatient maximum of 30 days $1000 per day, inpatient maximum of 30 days
Surgery
Calendar-year maximum		 $500 inpatient
$250 outpatient 		$1,000 inpatient
$500 outpatient 		$1,500 inpatient
$750 outpatient
Emergency room No benefit $75 per visit,
maximum of 2 visits		 $100 per visit,
maximum of 2 visits
Generic prescription drugs No benefit $15 copay per generic
prescription, benefit
maximum of $100 per month		 $10 copay per generic
prescription, benefit
maximum of $200 per month

This is a brief description of some important features of the coverage. The product is not available in all states and benefits may vary based on state of residence. Please refer to the product brochure (IHC DS 6000 0209) for additional information. For a full explanation of benefits, exclusions and limitations, refer to the insurance policy (MMP 2250). The Defined Solutions plan is underwritten by Companion Life Insurance Company, Columbia, S.C.