Benefits
Value Plan Pays:
Standard Plan Pays:
Enhanced Plan Pays:
Option 1
Option 2
Doctor Office Visits - 5 visits per covered person per calendar year. One visit may be used for wellness care.
$30Per Visit
$40Per Visit
$45Per Visit
$50Per Visit
$55Per Visit
$65Per Visit
Diagnostic Testing or X-rayFor medically necessary diagnostic tests and x-rays performed in a doctor’s office or outpatient facility. (3 visits per covered person per calendar year. One visit may be used for wellness care)
Child Wellness Visits - Benefits payable for routine well-child care doctor visits at eleven specified age intervals, from birth through age five. Well-child care includes physical exams, laboratory tests, immunizations, vision screenings, and hearing screenings.
Hospitalization
Regular Inpatient Stay - Overnight stays in hospital. A maximum of 100 days per confinement.
$100Per Day
$200Per Day
$250Per Day
$350Per Day
$400Per Day
$500Per Day
ICU/CCU - A maximum of 30 days per confinement.
$700Per Day
$800Per Day
$1,000Per Day
Mental Illness - A maximum of 30 days per confinement.
$50Per Day
$125Per Day
$175Per Day
Alcohol and Substance Abuse - A maximum of 30 days per confinement.
Convalescent Facility - Confinement must begin within three days of a hospitalization stay of at least three days. A maximum of 60 days per confinement.
Emergency Room - Applicable for emergency room visits when patient is not confined to the hospital. (3 visits for injuries & 1 visit for sickness per person per calendar year)
$75Per Visit
$100Per Visit
$150Per Visit
$250Per Visit
$300Per Visit
Surgery
Inpatient - One inpatient surgery per covered person per calendar year.
n/a
$500Per Procedure
$1,000Per Procedure
$1,500Per Procedure
$2,000Per Procedure
Outpatient - One outpatient surgery (performed in a hospital or outpatient surgery center) per covered person per calendar year.
$200Per Procedure
$400Per Procedure
$600Per Procedure
$800Per Procedure
Benefit Upgrades
Available
Monthly Rates:
Value Plan
Standard Plan
Enhanced Plan
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
Notes: