Apex-PALIC Health Saver Plus Gold Edition

The 3 key Components of the Apex-PALIC Health Saver Plus Gold Edition solution pairs the Apex Advantage Plan with Indemnity Benefit Plans from Philadelphia American Life Insurance Company – (PALIC).

Component 1
Apex Advantage Plan
The Apex Advantage Plan Component satisfies the Minimum Essential Coverage requirement of the PPACA, and is designed to be utilized for preventative and day-to-day healthcare needs.

Component 2
PALIC Health Saver Plus Gold Edition
The PALIC Health Saver Plus Gold Edition component is for more serious and unforeseen healthcare needs.

Component 3 (Optional)
PALIC Optional Riders and Policies
PALIC Supplemental Benefits provide added protection for life’s unexpected expenses. Options include the highly recommended Specified Disease Policy and more.

By pairing Apex and PALIC products, employers and employees can benefit from significant health care cost reductions and savings. The PALIC Component of this health care solution provides generous defined benefit payments for treatment for various sickness, injury, and professional services provided. All 3 Component choices are efficiently enrolled and administered on one convenient platform.

At the employer level these plans are available to employer groups starting at low as 4 (four) employees with Full Underwriting. Guaranteed Issue plans start with employer groups as small as 10-15 employees with a minimum of 8 eligible employees participating in the plan. PALIC can supply the Employer Sponsored Enrollment Guide for further information regarding enrollment and underwriting guidelines.

At the employee level, the Apex and PALIC Health Saver Plus Gold Edition requires a minimum purchase of Components 1 and 2.

Component 1

Apex Advantage Plan Benefits Include:

  • ACA Compliance for employers of 50 or more
  • Four (4) Year "Rate Lock"
  • No waiting periods
  • Small Co-pays
  • Coverage for Primary Care, Specialist, Urgent Care, Lab, Imaging, and Prescription Drugs
Component 2

PALIC Health Saver Plus Gold Edition Benefits include:

  • $5,000,000 Lifetime Coverage
  • Three Annual Benefit Options to Select from
  • Seven Deductible Options to Choose from (Deductible only Applies to Inpatient)
  • Hospital Admission Benefit for First Inpatient Day (Reduces Out of Pocket Cost)
  • First Dollar Coverage for Outpatient Benefits up to Benefit Selected
  • Covers Inpatient and Outpatient Services
  • 20 Doctors Office Visits/year – 6 can be for Chiropractic
  • Covers Brand Name and Generic Prescriptions
  • Freedom of Choice – Any Doctor, Any Hospital, Nationwide
  • National PPO Network Available for Additional Cost Savings
  • Teledoc - Free Unlimited Doctor Consultations via phone or video chat
  • Karis 360 – Health Concierge Service and Bill Negotiator
  • Guaranteed Renewable to Age 65
Component 3

PALIC Optional Riders and Policies

  • Specified Disease Insurance Policy (Highly Recommended)
  • Catastrophic Accident Policy
  • Critical Illness Rider
  • 24 Hour Accident Expense Insurance Policy
  • 24 Hour Indemnity Accident Policy (CA Only)
  • Family Term Insurance Rider
  • Dental Insurance with Network Provider Discounts

NCBA Apex-PALIC Health Health Saver Plus Gold Edition is only available to NCBA members.

State Availability

State Availability: AL, AR, AZ, DE, FL, GA, IA, IL, KY, LA, ME, MI, MS, NC, NE, NM, NV, OK, PA*, SD, TN*, TX, UT, VA, WI, WY.
* Please note there is a separate brochure posted for PA and TN.

Riders and Policy availability can vary by State. Check with a licensed PALIC representative for State availability and specific policy and/or rider details.

The PALIC Specified Disease Insurance Policy (Component 3) is available in the above States except for KY, PA, WA

Full product features and benefits are listed below.

Component 1:Apex Advantage Plan

The Apex Advantage Plan: for Day-to-Day Health Care Issues

Preventive Benefits – Covers all mandated Preventive benefits required by PPACA
Note: This list will be updated from time to time and a current list of covered preventive services is available at healthcare.gov
Medical Benefits – Must utilize a PHCS Network provider or facility. PHCS is part of MultiPlan, Inc. Call to confirm.
All 21 Preventive Services for Adults
100% Coverage for Mandated Preventive Care Services
All 28 Preventive Services for Women
100% Coverage for Mandated Preventive Care Services
All 31 Preventive Services for Children
100% Coverage for Mandated Preventive Care Services
Telemedicine – Health Wallet
$0 Copay, unlimited use for all family members
Primary Care Office Visit
$20 Copay
(Max 3 visits per calendar year)
Specialists Office Visit
$50 Copay
(Max 3 visits per calendar year)
Urgent Care
$50 Copay
(Max 3 visits per calendar year)
Diagnostic X-Ray, Lab
$50 Copay
(Max 3 visits per calendar year)
CT Scan or MRI
$200 Copay
(Max 1 CT Scan or MRI per calendar year)
Hospital, Surgical, Ambulance, Emergency Room
Not Covered
Prescription Drug Benefits - CitizenRx
Tier 1 – Low Cost Generics
$1 Copay
Tier 2 - Generics
10% Coinsurance
Tier 3 - Preferred Brand
20% Coinsurance
Tier 4 – Non-Preferred Brand
40% Coinsurance
Tier 5 – Specialty, Generic and Preferred
10% Coinsurance
(Plan pays 90% up to a max of $150 per Rx)
Tier 6 – Non-Preferred Specialty
20% Coinsurance
(Plan pays 80% up to a max of $250 per Rx)
Contribution Schedule (Monthly Rates)
Four Year Rate Lock: Increase in years 2 through 4 cannot exceed 3% on an accumulative basis.
EE Only
$143.00
EE Plus Child(ren)
$216.40
EE Plus Spouse
$233.50
EE Plus Family
$313.75

 

Component 2: PALIC Health Saver Plus Gold Edition

PALIC Health Saver Plus Gold Edition - Policy Options

Lifetime Maximum Per Policy is $5,000,000
Calendar Year Maximum Benefit per Insured Person $250,000 $500,000 $1,000,000
Benefit Level Gold Value (One Unit) Gold Plus (Two Unit) Gold Preferred (Three Unit)
Calendar Year Confinement Deductible Per insured person with a maximum of three (3) deductibles per Policy $10,000 - $7,500 - $5,000 - $2,500 - $1,000 - $500 - $100

Hospital Indemnity Benefits - Facility Fees

FIRST DAY INPATIENT Choose a Calendar Year Inpatient Deductible per Insured person. Higher deductible plans will pay a First Day Hospital Admission Benefit.
Hospital Admission Benefit for the First Inpatient Day
One benefit per Insured person per Calendar Year.
$10,000
Deductible

Per Year
$3,000
$7,500
Deductible

Per Year
$3,000
$5,000
Deductible

Per Year
$2,000
$2,500
Deductible

Per Year
$1,000
$1,000
Deductible

Per Year
$0
$500
Deductible

Per Year
$0
$100
Deductible

Per Year
$0

  Deductible Applies VALUE (One Unit) PLUS (Two Unit) PREFERRED (Three Unit)
Hospital Confinement
The plan will pay the daily Indemnity benefit selected if any Covered Person incurs charges for and is confined in a Hospital as a result of a covered Sickness or Injury.
Deductible Applies:YES VALUE (One Unit)
Per Day
Sickness: $1,500
Injury: $2,250
PLUS (Two Unit)
Per Day
Sickness: $3,000
Injury: $4,500
PREFERRED (Three Unit)
Per Day
Sickness: $4,500
Injury: $6,750
Confinement in a Hospital's Intensive Care Unit (ICU)
Indemnity Benefit Up to twenty (20) days per Calendar Year as a result of a covered Sickness or Injury.
Deductible Applies:YES VALUE (One Unit)
Per Day
Sickness: $2,250
Injury: $2,500
PLUS (Two Unit)
Per Day
Sickness: $4,500
Injury: $5,000
PREFERRED (Three Unit)
Per Day
Sickness: $6,750
Injury: $7,500
Confinement in a Hospital for Mental Illness, Alcohol and/or Substance Abuse Dependency Indemnity Benefit   VALUE (One Unit)
Per Day $200
PLUS (Two Unit)
Per Day $400
PREFERRED (Three Unit)
Per Day $600

Confinement in a Rehabilitation Facility or a Skilled Nursing Facility Indemnity Benefit
Does not include Mental Illness, Alcohol and/or Substance Abuse Dependency.

  VALUE (One Unit)
Per Day $750
PLUS (Two Unit)
Per Day $1,500
PREFERRED (Three Unit)
Per Day $2,250

Outpatient Hospital or Ambulatory Surgical Center Services When Surgery is Performed

Indemnity Benefit
:
Benefit for Surgery Performed Under General Anesthesia
Benefit for Surgery Performed not Requiring General Anesthesia

  VALUE (One Unit)

Per Day $2,000
Per Day $750
PLUS (Two Unit)

Per Day $3,500
Per Day $1,500
PREFERRED (Three Unit)

Per Day $5,000
Per Day $2,250
Outpatient Radiation Therapy, Chemotherapy and Immunotherapy Indemnity Benefit   VALUE (One Unit)
Per Day $750
PLUS (Two Unit)
Per Day $1,500
PREFERRED (Three Unit)
Per Day $2,250

Professional Services

  VALUE (One Unit) PLUS (Two Unit) PREFERRED (Three Unit)
Inpatient Physicians Care Indemnity Benefit
When medical care is from a physician other than an operating surgeon.
VALUE (One Unit)
Per Day $50
PLUS (Two Unit)
Per Day $100
PREFERRED (Three Unit)
Per Day $150
Surgery Indemnity Benefit for Covered Services When Performed in a Hospital or in an Ambulatory Surgical Center
Per procedure for your provider location.
VALUE (One Unit)
Per Day 1X RBRVS
PLUS (Two Unit)
Per Day 2X RBRVS
PREFERRED (Three Unit)
Per Day 3X RBRVS
Inpatient Pathology/Radiology Indemnity Benefit for Covered Services
Per procedure for your provider location.
VALUE (One Unit)
Per Day 1X RBRVS
PLUS (Two Unit)
Per Day
2X RBRVS
PREFERRED (Three Unit)
Per Day 3X RBRVS
Assistant Surgeon Surgical Services Indemnity Benefit for Covered Services VALUE (One Unit)
Per Day
20% of Surgical Benefits Payable
PLUS (Two Unit)
Per Day
20% of Surgical Benefits Payable
PREFERRED (Three Unit)
Per Day
20% of Surgical Benefits Payable
Anesthesia Indemnity Benefit for Covered Services VALUE (One Unit)
Per Day
20% of Surgical Benefits Payable
PLUS (Two Unit)
Per Day
20% of Surgical Benefits Payable
PREFERRED (Three Unit)
Per Day
20% of Surgical Benefits Payable

Additional Outpatient Benefits

  VALUE (One Unit) PLUS (Two Unit) PREFERRED (Three Unit)
Aggregate Calendar Year Maximum for Outpatient Benefits
Per Insured person.
VALUE (One Unit)
Per Year $4,000
PLUS (Two Unit)
Per Year $6,000
PREFERRED (Three Unit)
Per Year $8,000
Physician Indemnity Benefit
For each day an Insured person sees a Physician in office or at an outpatient clinic. Maximum of twenty (20) benefit days including six (6) chiropractor and two (2) Specialist Physician visits per Insured person per Calendar Year.
VALUE (One Unit)
Per Day $80
PLUS (Two Unit)
Per Day $120
PREFERRED (Three Unit)
Per Day $200
Specialist Physician Indemnity Benefit
Maximum of two (2) benefit days paid at the Specialist Physician rate per Insured person per Calendar Year. After the first two Specialist Physician Benefits are paid at this rate, you will be paid the Physician Indemnity Benefit amount, assuming that you have not met your maximum of twenty (20) benefit days per Insured person per Calendar Year.
VALUE (One Unit)
Per Day $100
PLUS (Two Unit)
Per Day $150
PREFERRED (Three Unit)
Per Day $160
Surgery Benefit in a Physicians/Specialists Office or Outpatient Clinic
Maximum of two (2) benefits per Insured person per Calendar Year.
VALUE (One Unit)
Per Day $100
PLUS (Two Unit)
Per Day $200
PREFERRED (Three Unit)
Per Day $300
MRI, PET, CAT Scan or Nuclear Testing Indemnity Benefit VALUE (One Unit)
Per Day $300
PLUS (Two Unit)
Per Day $500
PREFERRED (Three Unit)
Per Day $700
X-rays or Other Diagnostic Testing Indemnity Benefit VALUE (One Unit)
Per Day $80
PLUS (Two Unit)
Per Day $160
PREFERRED (Three Unit)
Per Day $240
Laboratory Indemnity Benefit VALUE (One Unit)
Per Day $40
PLUS (Two Unit)
Per Day $80
PREFERRED (Three Unit)
Per Day $120
Injection Indemnity Benefit VALUE (One Unit)
Per Day $30
PLUS (Two Unit)
Per Day $60
PREFERRED (Three Unit)
Per Day $90
Emergency Department Indemnity Benefit
Maximum of one (1) benefit per Insured person per Calendar Year. Maximum of two (2) benefits combined Emergency Department Benefit/Urgent Care Center Benefit per Insured person per Calendar Year.

Facility Fee / Charges
Professional Services

VALUE (One Unit)
Per Day
$200
$200

PLUS (Two Unit)
Per Day
$300
$300
PREFERRED (Three Unit)
Per Day
$400
$400

Urgent Care Center Indemnity Benefit
Maximum of two (2) benefits per Insured person per Calendar Year. Maximum of two (2) benefits combined Emergency Department Benefit/Urgent Care Center Benefit per Insured person per Calendar Year.

VALUE (One Unit)
Per Day $200
PLUS (Two Unit)
Per Day $300
PREFERRED (Three Unit)
Per Day $400
Ambulance Indemnity Benefit
Maximum of two (2) ground benefit payments and one (1) air benefit payment per Insured person per Calendar Year.
VALUE (One Unit)
Per Day
1,000 (Ground) / $2,500 (Air)
PLUS (Two Unit)
Per Day
1,000 (Ground) / $2,500 (Air)
PREFERRED (Three Unit)
Per Day
1,000 (Ground) / $2,500 (Air)
Generic Prescription Indemnity Benefit
Per Insured person per prescription filled.
VALUE (One Unit)
Per Day $10
PLUS (Two Unit)
Per Day $20
PREFERRED (Three Unit)
Per Day $30
Brand Name Prescription Indemnity Benefit
Per Insured person per prescription filled.
VALUE (One Unit)
Per Day $20
PLUS (Two Unit)
Per Day $40
PREFERRED (Three Unit)
Per Day $60

Preventive Care Indemnity Benefits
Coverage starts sixty (60) days after the Effective Date of each Insured person. Limit of one (1) benefit per Insured person per Calendar Year. Not subject to the Pre-Existing Conditions Exclusion.

Mammograms VALUE (One Unit)
Per Calendar Year $250
PLUS (Two Unit)
Per Calendar Year $250
PREFERRED (Three Unit)
Per Calendar Year $250
Colonoscopy Without Finding Any Polyps
Policy Years One (1) Through Three (3) / Beginning the Fourth (4th) Policy Year
VALUE (One Unit)
Every Three Years
$500 / $750
PLUS (Two Unit)
Every Three Years
$500 / $750
PREFERRED (Three Unit)
Every Three Years
$500 / $750

All Other Preventive Care Services
Including but not limited to pap smears, PSA tests, chest X-rays and cholesterol testing. Coverage starts sixty (60) days after the Effective Date of each Insured person.

VALUE (One Unit)
Per Calendar Year $250
PLUS (Two Unit)
Per Calendar Year $250
PREFERRED (Three Unit)
Per Calendar Year $250
Regardless of the charge for the inpatient, professional, or outpatient medical services you receive, we pay the listed benefit amount for eligible services.

Daily time periods are twenty-four (24) or more consecutive hours.

 

Component 3: PALIC Optional Riders & Policies

PALIC Optional Riders & Policies

SPECIFIED DISEASE POLICY

Covered Diseases, Conditions & Procedure
Heart Attack, Stroke, Cancer (Internal Cancer), Angioplasty, Coronary Artery Bypass Surgery, Pacemaker Implant or Insertion of Implantable Cardiac Defibrillator, Heart Valve Surgery, Amputation, Joint Replacement, End Stage Renal Failure, Amyotrophic Lateral Sclerosis (ALS), Major Organ Failure/Major Organ, Transplant (Bone marrow, heart, kidney, liver, lung, pancreas)*, Ruptured Aneurysm (Ruptured Cerebral, Carotid or Aortic Aneurysm)

*The Maximum Lifetime transplant benefit for all transplant benefit for all transplants is $100,000 per insured person per policy.

Lifetime Maximum Benefit $2,000,000

Calendar Year Maximum Benefit – Choice of

$250,000
$500,000

Deductible

Specified Disease Deductible Levels

Per Insured Person with a maximum of three (3) deductibles per Calendar Year under this policy.

After the deductible, the plan will pay the Actual Charges up to the Usual, Customary and Reasonable amount for expenses incurred for a Covered Condition or Procedure.

Actual Charges are defined as the actual amount paid by You or any other entity for services, treatment, or material rendered.

Benefits are subject to the Covered Condition or Procedure definitions that can be found in the Specified Disease Insurance Policy Outline of Coverage or Policy Form.

  • $100,000

  • $75,000

  • $50,000

  • $25,000

Other Benefits

  • Provides Full Access to the PHCS PPO Network
  • Guaranteed Renewable until age 65
  • Permanent Solution
  • Plan Pays in Addition to Health Saver Plus Gold Edition Policy


CATASTROPHIC ACCIDENT POLICY:
Provides catastrophic accident coverage and pays 100% of the usual, customary and reasonable charges for covered expense. Plus, an accidental death benefit of $50,000 due to an accidental death.

CRITICAL ILLNESS RIDER: Select from $10,000 to $50,000 to help cover out-of-pocket medical expenses and other cost associated with a covered medical illness. Critical Illness insurance is designed to ease the financial pressure by providing a lump sum cash benefit paid directly to you upon diagnosis of a covered illness. Maximum amount of Critical Illness Insurance available is $50,000 for any one person.

24 HOUR ACCIDENT EXPENSE INSURANCE POLICY: Accident Expense insurance provides you with up to $4,000 for accidental injury; up to $100,000 for an accidental death and up to $10,000 for ground or air ambulance. The accident plan also has an optional accident disability benefit and pays in addition to other insurance you may have and is guaranteed renewable to age 80.

24 HOUR INDEMNITY ACCIDENT POLICY (CA ONLY): Indemnity Accident Insurance pays a fixed benefit amount of up to $2,000 for an accidental injury. Also covers air and ground ambulance. A daily hospital confinement benefit if an injured is hospitalized for an accidental injury and a dismemberment benefit.

FAMILY TERM LIFE INSURANCE RIDER: Protect your family with inexpensive term life insurance coverage that pays a death benefit depending on age of up to $50,000 for the principle insured, $10,000 for the spouse and $3,000 on each child.

DENTAL CHOICE: A unique "hybrid" dental insurance plan combining traditional dental insurance with network provider’s discounts.

Note: Riders and Policy availability can vary by State. Check with a licensed PALIC representative for State availability and specific policy and/or rider details.

 

Value Added Benefits

Taking charge of your healthcare spending has never been easier! As our policyholder, many resources and value added benefits are available for you to use with your Gold Plan at no additional charge.

TELADOC
The quality of care you need, in the convenience of your home!
Feeling a bit under the weather? If you are feeling unwell, you can receive convenient, quality care from a large network of health professionals 24 hours a day, 365 days a year, by web, phone or mobile app. www.teladoc.com

PHCS NETWORK
An additional opportunity to save healthcare dollars!
You will have access to doctors, hospitals, labs, imaging centers and home healthcare centers at discounted rates through MultiPlan’s PHCS Limited Benefit Network at no additional charge.

KARIS 360
Patient advocacy before, during and after a healthcare event!

Members gain a resource and concierge-style service to help them navigate through the chaos and confusion often associated with the healthcare marketplace. This includes services such as finding providers and healthcare facilities, scheduling appointments, pricing for non-emergency surgeries, and a personal advocate to help lower the patient’s portion of medical bills to something more manageable. www.thekarisgroup.com

SCRIPTSAVE WELLRX
ScriptSave allows you to locate the lowest discounted price for your medication!
At no extra cost you have access to use the prescription savings card, or app, to receive instant savings on both brand name and generic prescription medication. ScriptSave WellRX is accepted at over 62,000 pharmacies! Philadelphia American’s group number is 2242. www.scriptsave.com

 

IMPORTANT: Product Pricing and Agent Contracting Inquiries

Unlike other Apex Management Group offerings, our agreement with PALIC requires that PALIC Plan Pricing and/or Contracting Inquiries to be addressed directly by a PALIC representative.

To get started, please fill out the website form so a representative can contact you to discuss the process for working with Apex-PALIC health care solutions. Please note that in order to reach you quickly and to schedule adequate time for discussion, we ask that you also provide three (3) days/times as options for a representative to schedule with you. You will receive a confirmation for one of the pre-scheduled times that you propose.

Following this initial meeting, arrangements for contracting and training on Apex-PALIC heath care solutions will be made.

Apex-PALIC health care offerings provide Agents numerous options and flexibility to meet client needs and budgets. It is our goal to ensure that Agents are provided thorough training to gain an understanding of how the pairing of Apex and PALIC products can provide outstanding health care coverage at very affordable prices. Use the link below to get started.