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Wellness Treatment, Health Screening Test, or Preventive Care Beneit* Beneit Amount
Examples includes (but are not limited to) routine gynecological exams, general health exams, $100 per day, limited to 1 per year
mammography, and certain blood tests. A 30 day beneit waiting period applies, during which
beneits will not be paid.
* For childhood conditions, the initial beneit amount % listed above refers to the employee’s percentage amount. Please refer to the beginning of
the available coverage section above for details on how much coverage is available for covered children.
Beneits
Initial Critical Illness Beneit for a diagnosis made after the efective date of coverage for each covered condition shown above. The amount
Beneit payable per covered condition is the initial beneit amount multiplied by the applicable percentage shown. Each
covered condition will be payable one time per covered person, subject to the maximum lifetime limit. A 180 days
separation period between the dates of diagnosis is required.*
Recurrence Beneit Beneit for the diagnosis of a subsequent and same covered condition for which an Initial critical illness beneit has
been paid, payable after a 12 month separation period from diagnosis of a previous covered condition, subject to the
maximum lifetime limit.
Skin Cancer Beneit and Pays beneit stated above.
Second Opinion
Maximum Lifetime Limit The maximum beneit payable per covered person is the lesser of 5 times the elected beneit amount or $100,000. The
following beneits are not subject to this limit: skin cancer, second opinion, and additional beneits.
Portability Feature: You can continue 100% of coverage for all covered persons at the time your coverage ends.
You must be covered under the policy and be under the age of 70 in order to continue your coverage. Rates
may change and all coverage ends at age 100. Applies to United States Citizens and Permanent Resident Aliens
residing in the United States.
Bi-Weekly Cost of Coverage
Benefit Amount: $5,000
Employee (EE) Employee + Spouse (EE+SP) Employee + Children (EE+CH) Employee + Family (EE+F)
Age Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco
<25 $2.93 $3.02 $4.45 $4.60 $2.93 $3.02 $4.45 $4.60
25 to 29 $3.02 $3.18 $4.55 $4.81 $3.02 $3.18 $4.55 $4.81
30 to 34 $3.25 $3.59 $4.85 $5.34 $3.25 $3.59 $4.85 $5.34
35 to 39 $3.58 $4.28 $5.31 $6.34 $3.58 $4.28 $5.31 $6.34
40 to 44 $3.88 $4.92 $5.77 $7.29 $3.88 $4.92 $5.77 $7.29
45 to 49 $4.45 $6.14 $6.65 $9.20 $4.45 $6.14 $6.65 $9.20
50 to 54 $5.07 $7.41 $7.81 $11.40 $5.07 $7.41 $7.81 $11.40
55 to 59 $5.85 $8.79 $9.33 $14.80 $5.85 $8.79 $9.33 $14.80
60 to 64 $6.71 $10.13 $10.85 $16.42 $6.71 $10.13 $10.85 $16.42
65 to 69 $7.77 $11.79 $12.52 $18.60 $7.77 $11.79 $12.52 $18.60
70 to 74 $10.17 $14.99 $16.11 $23.56 $10.17 $14.99 $16.11 $23.56
75 to 79 $13.14 $17.80 $20.43 $27.87 $13.14 $17.80 $20.43 $27.87
80 to 84 $15.59 $21.20 $24.24 $33.22 $15.59 $21.20 $24.24 $33.22
85 to 89 $21.08 $25.01 $32.80 $39.03 $21.08 $25.01 $32.80 $39.03
90 to 94 $21.08 $25.01 $32.80 $39.03 $21.08 $25.01 $32.80 $39.03
95+ $21.08 $25.01 $32.80 $39.03 $21.08 $25.01 $32.80 $39.03
Florida Cancer Specialists and Research Institute 23
Examples includes (but are not limited to) routine gynecological exams, general health exams, $100 per day, limited to 1 per year
mammography, and certain blood tests. A 30 day beneit waiting period applies, during which
beneits will not be paid.
* For childhood conditions, the initial beneit amount % listed above refers to the employee’s percentage amount. Please refer to the beginning of
the available coverage section above for details on how much coverage is available for covered children.
Beneits
Initial Critical Illness Beneit for a diagnosis made after the efective date of coverage for each covered condition shown above. The amount
Beneit payable per covered condition is the initial beneit amount multiplied by the applicable percentage shown. Each
covered condition will be payable one time per covered person, subject to the maximum lifetime limit. A 180 days
separation period between the dates of diagnosis is required.*
Recurrence Beneit Beneit for the diagnosis of a subsequent and same covered condition for which an Initial critical illness beneit has
been paid, payable after a 12 month separation period from diagnosis of a previous covered condition, subject to the
maximum lifetime limit.
Skin Cancer Beneit and Pays beneit stated above.
Second Opinion
Maximum Lifetime Limit The maximum beneit payable per covered person is the lesser of 5 times the elected beneit amount or $100,000. The
following beneits are not subject to this limit: skin cancer, second opinion, and additional beneits.
Portability Feature: You can continue 100% of coverage for all covered persons at the time your coverage ends.
You must be covered under the policy and be under the age of 70 in order to continue your coverage. Rates
may change and all coverage ends at age 100. Applies to United States Citizens and Permanent Resident Aliens
residing in the United States.
Bi-Weekly Cost of Coverage
Benefit Amount: $5,000
Employee (EE) Employee + Spouse (EE+SP) Employee + Children (EE+CH) Employee + Family (EE+F)
Age Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco
<25 $2.93 $3.02 $4.45 $4.60 $2.93 $3.02 $4.45 $4.60
25 to 29 $3.02 $3.18 $4.55 $4.81 $3.02 $3.18 $4.55 $4.81
30 to 34 $3.25 $3.59 $4.85 $5.34 $3.25 $3.59 $4.85 $5.34
35 to 39 $3.58 $4.28 $5.31 $6.34 $3.58 $4.28 $5.31 $6.34
40 to 44 $3.88 $4.92 $5.77 $7.29 $3.88 $4.92 $5.77 $7.29
45 to 49 $4.45 $6.14 $6.65 $9.20 $4.45 $6.14 $6.65 $9.20
50 to 54 $5.07 $7.41 $7.81 $11.40 $5.07 $7.41 $7.81 $11.40
55 to 59 $5.85 $8.79 $9.33 $14.80 $5.85 $8.79 $9.33 $14.80
60 to 64 $6.71 $10.13 $10.85 $16.42 $6.71 $10.13 $10.85 $16.42
65 to 69 $7.77 $11.79 $12.52 $18.60 $7.77 $11.79 $12.52 $18.60
70 to 74 $10.17 $14.99 $16.11 $23.56 $10.17 $14.99 $16.11 $23.56
75 to 79 $13.14 $17.80 $20.43 $27.87 $13.14 $17.80 $20.43 $27.87
80 to 84 $15.59 $21.20 $24.24 $33.22 $15.59 $21.20 $24.24 $33.22
85 to 89 $21.08 $25.01 $32.80 $39.03 $21.08 $25.01 $32.80 $39.03
90 to 94 $21.08 $25.01 $32.80 $39.03 $21.08 $25.01 $32.80 $39.03
95+ $21.08 $25.01 $32.80 $39.03 $21.08 $25.01 $32.80 $39.03
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