Benefits

Plan 100

Plan 300

Plan 500

Plan 1000

Physician Office Visit
Hospital Emergency Room Visit

$25
(max 6 visits per year)

$50
(max 6 visits per year)

$50
(max 6 visits per year)

$75
(max 6 visits per year)

Hospital Confinement (per day-max 30 days)

$100

$300

$500

$1,000

Hospital Admission (per admission)

$100

$300

$500

$1,000

Hospital Intensive Care
(per day-max 30 days)

$200

$600

$1,000

$2,000

Surgical Benefit
(per procedure)

Up to $1,000

Up to $1,000

Up to $1,000

Up to $2,000

Anesthesia
(25% of Surgical Benefit)

Up to $250

Up to $250

Up to $250

Up to $500

Wellness Benefits
 (per calendar year)

$150

$150

$150

$150

Diagnostic Test

Up to $250

Up to $250

Up to $250

Up to $250

Outpatient Accident Expense
(per accident)

Up to $200

Up to $300

Up to $500

Up to $500

Outpatient Diagnostic Lab
(per test - max 3 test per calendar year)

$20

$30

$35

$50

Well Baby
(per visit - max 4 visits per calendar year)

$50

$50

$50

$50

Plan 100

Plan 300

Plan 500

Plan 1000

Employee

$132.25

$162.25

$182.25

$222.25

Employee + Child

$162.25

$202.25

$232.25

$292.25

Employee + Spouse

$172.25

$212.25

$242.25

$322.25

Family

$202.25

$252.25

$282.25

$382.25