This is not a guarantee of payment. The information provided is
real-time. Data shown may change as member files are updated.
| Member: | Member Name - XYZ 3000512345 |
| Group Number: | USA DRAGON BOATING LLC |
| As of Date: | 2/1/2009 |
|---|
Example Subheading
Example block. This is here only for a reverence to the structure of this container.
| Medical Benefit Accumulations |
| Item |
Requirement |
Paid to Date |
Amount Remaining |
| Individual Deductible |
$ 500.00 |
$ 250.00 |
$ 250.00 |
| Family Deductible |
$ 1500.00 |
$ 1000.00 |
$ 500.00 |
| Individual Out of Pocket Max |
$ 3000.00 |
$ 0.00 |
$ 3000.00 |
| Family Out of Pocket Max |
$ 3000.00 |
$ 0.00 |
$ 3000.00 |
|
|
Note:
The information shown is for the current date. No accumulation and/or
usage information is provided for dates in the past or into the future.
|
|
|
| Dental Limits |
| Item |
Product Maximum |
Used to Date |
| Oral Exam |
2 per benefit year |
1 |
| Bitewing X-ray |
2 per benefit year |
1 |
| Periodontal Cleanings |
1 per 2 benefit years |
1 |
| Panorex X-ray |
1 per 3 benefit years |
0 |
| Full Mouth X-rays |
1 per 5 benefit years |
1 |
|
|
| Dental Accumulations |
| Item |
Requirement |
Paid to Date |
Amount Remaining |
| Individual Deductible |
$ 500.00 |
$ 250.00 |
$ 250.00 |
| Family Deductible |
$ 1500.00 |
$ 1000.00 |
$ 500.00 |
| Individual Out of Pocket Max |
$ 3000.00 |
$ 0.00 |
$ 3000.00 |
| Family Out of Pocket Max |
$ 3000.00 |
$ 0.00 |
$ 3000.00 |
|
|
| Vision Accumulations and Limits |
| Item |
Product Maximum |
Used to Date |
| Routine Eye Exam |
2 per benefit year |
1 |
| Lenses |
2 per benefit year |
1 |
| Frames |
1 per 2 benefit years |
1 |
|
|
Note: No deductible on vision benefits.
|
|
|
