EasyShare25 member is $250,000.
vi. Per Medical Incident Sharing Limits.
There is a limit on the total amount of medical expenses that may be shared for each Member in
connection with any Medical Incident (as defined herein), inclusive of all inpatient and outpatient Facility
and Professional expenses related to that Medical Incident.
The per Medical Incident sharing limit applicable for the EasyShare50 Program is as follows:
Service
# of
visits/incidents
Eligible for Sharing Member Pays
Inpatient Hospitalization 10 days Up to $3,000 per day
for room and board
Any charge above
the sharable limit
Inpatient and Outpatient
Surgery
2 procedures per
year
Up to $3,000 per
incident
Any charge above
the sharable limit
Emergency Room 2 visits per year Up to $1,000 per
incident
Any charge above
the sharable limit
Ambulance 2 incidents per
year
Up to $500 per incident Any charge above
the sharable limit
CT Scan 2 imaging series
per year
Up to $400 per imaging
series
Any charge above
the $400 per
imaging series
MRI 2 imaging series
per year
Up to $400 per imaging
series
Any charge above
the $400 per
imaging series
X-Ray 2 imaging series
per year
Up to $250 per imaging
series
Any amount above
$250 per imaging
series
The per Medical Incident sharing limit applicable for the EasyShare25 Program is as follows:
Service
# of
visits/incidents
Eligible for Sharing Member Pays
Inpatient Hospitalization 10 days Up to $2,500 per day
for room and board
Any charge above
the sharable limit
Inpatient and Outpatient
Surgery
2 procedures per
year
Up to $2,500 per
incident
Any charge above
the sharable limit
Emergency Room 2 visits per year Up to $1,000 per
incident
Any charge above
the sharable limit
Ambulance 2 incidents per
year
Up to $500 per incident Any charge above
the sharable limit
CT Scan 2 imaging series
per year
Up to $400 per imaging
series
Any charge above
the $400 per
imaging series
MRI 2 imaging series
per year
Up to $400 per imaging
series
Any charge above
the $400 per
imaging seriesUHFR093021E100121 Page 105
X-Ray 2 imaging series
per year
Up to $250 per imaging
series
Any amount above
the $250 per
imaging series
The EasyShare Programs share the actual charges of Room and Board and procedures up to the
maximum per-day or per-incident limit, inclusive of any other eligible, sharable medical expenses incurred
that day.
Emergency Room and Ambulance cost sharing for the EasyShare Programs are subject to the 90-day
waiting period and are limited to a maximum of two incidents per year. Emergency Room and Ambulance
expenses are only available for sharing for medical conditions that are life threatening or could seriously
jeopardize the health of the individual by seriously impairing bodily functions or by causing serious
dysfunction of any bodily organ or part, and if the illne