- Local Maximum: $800.00
- Overseas: 80% OF UCR
Note: (semi-private room)
Hospital & Surgical (Subject to Co-Insurance & UCR unless noted)
Hospital Daily Room & Board Limit
Intensive Care Unit
- Local Maximum: 80% Up To $1600.00
- Overseas: 80% Up to $4,000.00
Surgical Benefit
- 80% of UCR
Anesthesia Benefit
- 25% of Surgical UCR