| Benefit Description | AWA AdvancedHealth Level 1 | AWA AdvancedHealth Level 2 | AWA AdvancedHealth Level 3 | AWA AdvancedHealth
Level 4 |
| Hospital Confinement Benefit |
| Pays a daily benefit if a Covered Person incurs charges for and is Confined in a Hospital for a period of no less than 20 continuous hours due to injuries received in a Covered Accident or due to a Covered Sickness. This benefit is not payable for emergency room or outpatient treatment. |
| Benefit per Day of Confinement | $250 | $500 | $750 | $1,000 |
| Maximum Days per Insured per Membership Year | 15 | 30 | 30 | 30 |
| Hospital Intensive Care Unit Confinement Benefit |
| Pays a daily benefit if a Covered Person incurs charges for and is Confined in a Hospital Intensive Care Unit due to injuries received in a Covered Accident or due to a Covered Sickness. This benefit is payable if the Hospital Confinement benefit is payable and is paid in addition to the Hospital Confinement Benefit. |
| Benefit per Day of Confinement | $250 | $500 | $750 | $1,000 |
| Maximum Days per Membership Year | 3 | 3 | 3 | 3 |
| Additional Hospital Admission Benefit |
| Pays a benefit for the first day of hospitalization if a Covered Person incurs charges for and is Confined in a Hospital for a period of no less than 20 continuous hours due to injuries received in a Covered Accident or due to a Covered Sickness. This benefit is not payable for emergency room treatment. |
| Benefit for the First Day of Hospitalization | $250 | $500 | $750 | $1,000 |
| Maximum Days per Insured per Membership Year 2 | 1 | 1 | 1 | 1 |
| Surgery Benefit (percentage of Surgical Fee Schedule)* |
| Pays a benefit for any day a Covered Person undergoes a surgical procedure due to a Covered Accident or Covered Sickness. The procedure must be performed by a board certified surgeon in a Hospital or an Ambulatory Surgical Center. Anesthesia must be administered by a licensed anesthesiologist or certified registered nurse anesthetist (CRNA). |
| % of Surgical Fee Schedule for Any Day in which Surgery is performed on an Inpatient Basis | N/A | 100% | 100% | 100% |
| % of Surgical Fee Schedule for Any Day in which Surgery is performed on an Outpatient Basis | N/A | 100% | 100% | 100% |
| Maximum Days in which Inpatient or Outpatient Surgery is Performed per Membership Year | N/A | 1 | 1 | 1 |
| Anesthesia Benefit - Percentage of Surgical Fee Schedule Per Day of Surgery | N/A | 25% | 25% | 25% |
| Outpatient Surgical Facility Benefit |
| Pays a daily benefit for any day a Covered Person incurs charges for a surgical procedure performed in an Ambulatory Surgical Center or in a Hospital on an outpatient basis. The charges must be incurred as a result of injuries received in a Covered Accident or due to a Covered Sickness. |
| Benefit Amount per Day | $200 | $300 | $400 | $500 |
| Maximum Days per Insured per Membership Year | 1 | 1 | 1 | 1 |
| Doctor Office Visit Benefit |
| Pays a daily benefit for any day a Covered Person incurs charges for and requires a Doctor's office visit due to injuries received in a Covered Accident or due to a Covered Sickness. Visits due to injuries received in a Covered Accident must occur within 72 hours after the date of the Covered Accident. Services must be rendered by a licensed Physician acting within the scope of their license. |
| Benefit Amount per Day | $60 | $70 | $75 | $85 |
| Maximum Days per Insured per Membership Year | 4 | 5 | 5 | 5 |
| Diagnostic X-Ray & Laboratory Tests Benefit (including interpretation)** |
| Pays a daily benefit for any day a Covered Person incurs charges for diagnostic x-ray and/or laboratory testing caused by a Covered Accident or Covered Sickness. The test must be ordered by a Physician because of a Covered Accident or Covered Sickness and must be performed in a Hospital, Ambulatory Surgical Center, Doctor's office or Diagnostic Center or Facility. This benefit is not payable if Hospital Confinement, Emergency Room or Doctor Office benefit is paid. |
| Benefit Amount per Day for Basic Pathology (laboratory tests) | $50 | $75 | $85 | $100 |
| Benefit Amount per Day for Basic Radiology (x-rays, ultrasounds and other medical imaging) |
| Benefit Amount per Day for Advanced Studies (MRI, CT, PET and other advanced scans) |
| Maximum Benefit for All Basic Pathology, Basic Radiology and Advanced Studies Combined per Insured per Year | 2 | 2 | 2 | 2 |
| Emergency Room Visits Benefit |
| Pays a daily benefit for any day a Covered Person incurs charges for and requires medical care from an emergency room due to injuries received in a Covered Accident or due to a Covered Sickness. Services must be rendered by a Physician. Visits due to injuries received in a Covered Accident must occur within 72 hours after the date of the Covered Accident. Benefit will not be payable if Covered Person is confined in a Hospital as a result of the injuries received in the Covered Accident or due to the Covered Sickness that caused the visit to the Emergency Room. |
| Benefit Amount per Day | $100 | $150 | $200 | $250 |
| Maximum Days per Insured per Membership Year | 1 | 1 | 1 | 1 |
| Ambulance Benefit |
| Pays a benefit for any day a licensed professional ambulance company transports a Covered Person by ground transportation to or from a Hospital or between medical facilities, where treatment is received as the result of a Covered Sickness or Accident. The ambulance transportation must be within 90 days after a Covered Sickness or Accident. Benefit is payable once per Covered Sickness or Accident. |
| Benefit Amount per Day | $100 | $150 | $200 | $250 |
| Maximum Days per Insured per Membership Year | 1 | 1 | 1 | 1 |
