Page 13 - Guide
P. 13
Outpatient Beneits Plan 1 Plan 2 Plan 3
Doctor Visit Beneits
Daily beneit for a new patient ofice visit $75 per day $100 per day $100 per day
Number of daily beneits per coverage year 1 1 1
Daily beneit for an established patient ofice visit $60 per day $70 per day $70 per day
Number of daily beneits per coverage year 3 5 7
Daily beneit for a consultation ofice visit $75 per day $150 per day $150 per day
Number of daily beneits per coverage year 1 1 1
Daily beneit for an emergency room doctor visit $75 per day $100 per day $100 per day
Number of daily beneits per coverage year 1 1 1
Chiropractic care daily beneit $60 per day $70 per day $70 per day
Number of daily beneits per coverage year 26 26 26
Cancer specialist second opinion daily beneit $60 per day $70 per day $70 per day
Number of daily beneits per coverage year 1 1 1
Radiology Beneits
Daily beneit for a magnetic resonance imaging (MRI) $100 per day $175 per day $300 per day
Number of daily beneits per coverage year 1 1 1
Daily beneit for a computerized tomography (CT) $50 per day $75 per day $125 per day
scan
Number of daily beneits per coverage year 1 1 1
Daily beneit for all other radiology services $40 per day $40 per day $60 per day
Number of daily beneits per coverage year 4 5 5
Pathology Beneits
Daily beneit for all pathology services $40 per day $40 per day $50 per day
Number of daily beneits per coverage year 4 5 5
Emergency Room Visit Beneits
Daily beneit for the treatment of an accidental injury $500 per day $500 per day $500 per day
Number of daily beneits per coverage year 2 2 2
Daily beneit for the treatment of a sickness $50 per day $50 per day $50 per day
Number of daily beneits per coverage year 3 3 3
Maximum surgery beneit per procedure 4 $750 per day $1,000 per day $1,500 per day
Maximum anesthesia beneit 5 $150 per day $200 per day $300 per day
Prescription Drug Beneits
Daily beneit per generic drug prescription (illed or $25 per day $25 per day $25 per day
reilled)
Number of daily beneits per coverage year 10 18 32
Daily beneit per brand name drug Not covered $50 per day $50 per day
(illed or reilled)
Number of daily beneits per coverage year Not covered 2 7
Weekly Contribution Rates
Employee only $9.58 $13.09 $16.43
Employee + spouse $18.99 $26.41 $33.45
Employee + 1 child $15.33 $20.60 $25.61
Employee + children $25.31 $34.20 $42.64
Family $32.59 $44.40 $55.62
4 Beneits for covered outpatient surgery are scheduled and range from $14 to $750 under Plan 1, from $14 to $1,000 under Plan 2, and $14 to
$1,500 under Plan 3 based on the speciic surgical procedure performed.
5 Beneits for covered outpatient anesthesia vary and are equal to 20% of the applicable outpatient surgery beneit.
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Doctor Visit Beneits
Daily beneit for a new patient ofice visit $75 per day $100 per day $100 per day
Number of daily beneits per coverage year 1 1 1
Daily beneit for an established patient ofice visit $60 per day $70 per day $70 per day
Number of daily beneits per coverage year 3 5 7
Daily beneit for a consultation ofice visit $75 per day $150 per day $150 per day
Number of daily beneits per coverage year 1 1 1
Daily beneit for an emergency room doctor visit $75 per day $100 per day $100 per day
Number of daily beneits per coverage year 1 1 1
Chiropractic care daily beneit $60 per day $70 per day $70 per day
Number of daily beneits per coverage year 26 26 26
Cancer specialist second opinion daily beneit $60 per day $70 per day $70 per day
Number of daily beneits per coverage year 1 1 1
Radiology Beneits
Daily beneit for a magnetic resonance imaging (MRI) $100 per day $175 per day $300 per day
Number of daily beneits per coverage year 1 1 1
Daily beneit for a computerized tomography (CT) $50 per day $75 per day $125 per day
scan
Number of daily beneits per coverage year 1 1 1
Daily beneit for all other radiology services $40 per day $40 per day $60 per day
Number of daily beneits per coverage year 4 5 5
Pathology Beneits
Daily beneit for all pathology services $40 per day $40 per day $50 per day
Number of daily beneits per coverage year 4 5 5
Emergency Room Visit Beneits
Daily beneit for the treatment of an accidental injury $500 per day $500 per day $500 per day
Number of daily beneits per coverage year 2 2 2
Daily beneit for the treatment of a sickness $50 per day $50 per day $50 per day
Number of daily beneits per coverage year 3 3 3
Maximum surgery beneit per procedure 4 $750 per day $1,000 per day $1,500 per day
Maximum anesthesia beneit 5 $150 per day $200 per day $300 per day
Prescription Drug Beneits
Daily beneit per generic drug prescription (illed or $25 per day $25 per day $25 per day
reilled)
Number of daily beneits per coverage year 10 18 32
Daily beneit per brand name drug Not covered $50 per day $50 per day
(illed or reilled)
Number of daily beneits per coverage year Not covered 2 7
Weekly Contribution Rates
Employee only $9.58 $13.09 $16.43
Employee + spouse $18.99 $26.41 $33.45
Employee + 1 child $15.33 $20.60 $25.61
Employee + children $25.31 $34.20 $42.64
Family $32.59 $44.40 $55.62
4 Beneits for covered outpatient surgery are scheduled and range from $14 to $750 under Plan 1, from $14 to $1,000 under Plan 2, and $14 to
$1,500 under Plan 3 based on the speciic surgical procedure performed.
5 Beneits for covered outpatient anesthesia vary and are equal to 20% of the applicable outpatient surgery beneit.
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