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Wellness Treatment, Health Screening Test, or Preventive Care Benefit* Benefit Amount
Examples includes (but are not limited to) routine gynecological exams, $100 per day, limited to 1 per year
general health exams, mammography, and certain blood tests . A 30-day
benefit waiting period applies, during which benefits will not be paid .
* For Childhood Conditions, the Initial Benefit 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 .
Benefits
Initial Critical Illness Benefit for a diagnosis made after the effective date of coverage for each covered condition
Benefit shown above . The amount payable per covered condition is the initial benefit 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 Benefit Benefit for the diagnosis of a subsequent and same covered condition for which an Initial
critical illness benefit 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 Benefit Pays benefit stated above .
and Second Opinion
Maximum Lifetime The maximum benefit payable per covered person is the lesser of 5 times the elected benefit
Limit amount or $100,000 . The following benefits are not subject to this limit: skin cancer, second
opinion, and additional benefits .
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 Employee + Children Employee + Family
(EE+SP) (EE+CH) (EE+F)
Age Non- Tobacco Non- Tobacco Non- Tobacco Non- Tobacco
Tobacco Tobacco 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
16 2019 Benefits Enrollment
Examples includes (but are not limited to) routine gynecological exams, $100 per day, limited to 1 per year
general health exams, mammography, and certain blood tests . A 30-day
benefit waiting period applies, during which benefits will not be paid .
* For Childhood Conditions, the Initial Benefit 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 .
Benefits
Initial Critical Illness Benefit for a diagnosis made after the effective date of coverage for each covered condition
Benefit shown above . The amount payable per covered condition is the initial benefit 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 Benefit Benefit for the diagnosis of a subsequent and same covered condition for which an Initial
critical illness benefit 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 Benefit Pays benefit stated above .
and Second Opinion
Maximum Lifetime The maximum benefit payable per covered person is the lesser of 5 times the elected benefit
Limit amount or $100,000 . The following benefits are not subject to this limit: skin cancer, second
opinion, and additional benefits .
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 Employee + Children Employee + Family
(EE+SP) (EE+CH) (EE+F)
Age Non- Tobacco Non- Tobacco Non- Tobacco Non- Tobacco
Tobacco Tobacco 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
16 2019 Benefits Enrollment
