|
Income Protection Benefit for You |
| Maximum benefit |
55% of weekly earnings
up to $250 per week |
| Maximum payment period |
26 weeks |
| Benefits begin |
1st day of an accident
1st day of hospitalization
1st day of outpatient surgery
8th day of sickness |
|
Life Insurance & AD&D Benefit |
| For You |
$15,000 |
| For your
dependents |
| Spouse |
$2,500 |
| Child |
|
| 15 days but less than 1
year old |
$100 |
| 1 year but less than 18
years old |
$2,500 |
|
Accidental Death & Dismemberment (AD&D) |
| For you |
Up to $7,500
determined by the severity of the injury |
|
Comprehensive Medical Benefit for You and Your Dependents |
| Lifetime maximum |
$1,000,000 per person |
|
Annual Deductible |
| per person |
$250 |
per family |
$750 (3 persons must
each satisfy Annual Deductible) |
| Non-PPO Hospital Deductible |
$350 |
Non-Compliance Deductible |
$100 |
|
Percentage paid |
| PPO hospital |
Plan pays 85%,
you pay 15% |
| Non-PPO hospital |
Plan pays 65%,
you pay 35% |
| Out-of-area or
emergency hospital |
Plan pays 80%,
you pay 20% |
| Surgery when required
Second Opinion not obtained |
Plan pays 50%,
you pay 50% |
| Most other covered expenses |
Plan pays 80%,
you pay 20% |
| Annual out-of-pocket maximum |
$2,000 per person,
including Annual Deducible |
|
The following benefits are paid at 100% by the Plan and are not subject to the Annual Deductible |
| Well-child care
(child to age 2) |
Plan pays up to $500
per child, lifetime maximum |
| Preventive care for you
and your spouse |
Plan pays first $50 per
calendar year (expenses in excess of $50, paid at 80% after Annual Deductible) |
| Screening mammogram |
Plan pays up to $130
per person per calendar year within age limits (expenses in excess of $130, paid at 80% after Annual Deductible) |
|
Other Limits |
| Occupational therapy |
$2,500 per person per
calendar year |
| Physical therapy,
chiropractic therapy, prolo therapy, acupuncture |
Chiropractic therapy
maximum of $1,500 per person per calendar year; combined maximum of $2,500 for all therapy per person per calendar
year |
| Speech therapy |
$2,500 per person per
calendar year |
| Cardiac rehabilitation |
$1,000 per event |
| Oxygen, outpatient or
portable |
$500 per calendar year
plus the one-time cost of an oxygen concentrator, if applicable |
| Home health care |
$10,000 per calendar
year plus the cost of durable medical equipment, if applicalbe |
| Mental health |
| inpatient |
Maximum of 10 days
per person per year |
| outpatient |
20 visits per person per
calendar year payable at 50% |
| Substance abuse |
$5,000 lifetime maximum
per person |
| Transplants |
$100,000 per transplant |
| Hearing aid |
$500 per person in any
5-consecutive year period |
| Intentionally destructive
injury |
Plan pays 50% up to
$5,000 per event |
| Pre-existing condition |
Plan pays 50% up to
$5,000 per condition |
| Hospital charges for
dental surgery |
Plan pays 50% up to
$5,000 per event |
| Treatment of varicose veins |
$2,500 per leg, lifetime maximum |
| Voice communication
machine |
$7,500 per person,
lifetime maximum |
|
Prescription Drug Benefit For You and Your Dependents |
| Annual benefit maximum |
$14,000 per person |
| Percentage paid |
Plan pays 100% after
you pay any co-payment |
| Dispensing limitation |
30-day supply; 90-day
supply for maintenance drugs |
|
Co-payment for 30-day supply |
| generic drug |
$7 |
| brand-name drug |
$15 |
| preferred drug |
$0 |
| non-preferred drug |
$25 |
|
Co-payment for 90-day supply of a maintenance drug is 2 times the
30-day supply co-payment |
|
Vision Benefit For You and Your Dependents |
| Maximum benefit |
$135 per person per
calendar year |
| Annual deductible |
none |
| Percentage paid |
Plan pays 100% |
Dental Benefit For You and Your Dependents |
|
Annual deductible |
| diagnostic and
preventive treatment |
None |
| all other covered Dental
charges, including Orthodontia |
$50 per person |
| Percentage paid |
Plan pays 100% up to
scheduled amount |
| Orthodontia
(including TMJ) |
| percentage paid |
Plan pays 50%, you
pay 50% |
| maximum orthodontia
benefit |
$1,000 per person per
lifetime |
