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Plans and Rates
 
 

 

Value Plan Pays:

Standard Plan Pays:

Enhanced Plan Pays:

Option 1

Option 2

Option 1

Option 2

Option 1

Option 2

$30
Per Visit

$40
Per Visit

$45
Per Visit

$50
Per Visit

$55
Per Visit

$65
Per Visit

 

$30
Per Visit

$40
Per Visit

$45
Per Visit

$50
Per Visit

$55
Per Visit

$65
Per Visit

 

$30
Per Visit

$40
Per Visit

$45
Per Visit

$50
Per Visit

$55
Per Visit

$65
Per Visit

 

 

 

 

 

 

 

$100
Per Day

$200
Per Day

$250
Per Day

$350
Per Day

$400
Per Day

$500
Per Day

 

$200
Per Day

$400
Per Day

$500
Per Day

$700
Per Day

$800
Per Day

$1,000
Per Day

 

$50
Per Day

$100
Per Day

$125
Per Day

$175
Per Day

$200
Per Day

$250
Per Day

 

$50
Per Day

$100
Per Day

$125
Per Day

$175
Per Day

$200
Per Day

$250
Per Day

 

$50
Per Day

$100
Per Day

$125
Per Day

$175
Per Day

$200
Per Day

$250
Per Day

 

$75
Per Visit

$100
Per Visit

$150
Per Visit

$250
Per Visit

$250
Per Visit

$300
Per Visit

 

 

 

 

 

 

 

n/a

$500
Per
 Procedure

$1,000
Per
 Procedure

$1,500
Per
 Procedure

$1,500
Per
 Procedure

$2,000
Per
 Procedure

 

n/a

$200
Per
 Procedure

$400
Per
 Procedure

$600
Per
 Procedure

$600
Per
 Procedure

$800
Per
 Procedure

 

 

Available

Available

Available

 

 

Monthly Rates:

Value Plan

Standard Plan

Enhanced Plan

 

Option 1

Option 2

Option 1

Option 2

Option 1

Option 2

Employee Only

$22.73

$39.92

$52.77

$70.07

$75.79

$93.94

 

Employee & Spouse

$40.47

$71.38

$94.47

$125.53

$135.74

$168.31

 

Employee & Child(ren)

$52.29

$87.12

$113.51

$148.64

$160.51

$197.75

 

Family

$70.05

$118.56

$155.22

$204.10

$220.47

$272.11

 

 

 

Note:

 - Minimum Employer Contribution Is 50% Of Employee-Only Rate (Not Applicable To Dental Plan)

 - Employer Chooses To Include Or Exclude Dental

 - Employer Chooses Waiting Period - 0, 30, 60 Or 90 Days
   And Whether Or Not It Applies To Active Employees On The Plan Start Date

 - Employer Chooses Monthly Premium By Class of Employee

 

- Use Monthly Rates For Permanent Full Time Employees

 - Payroll Deduction Required For Employee-Paid Premiums

 - Multiple Plans And Payment Modes Available On A Class Basis