Page 23 - OE Guide
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Schedule of Dislocations Bi-Weekly Accident Premium *
Hip joint $2,000 Employee $5.46
Knee joint $1,000
Bones of foot $1,000 Employee + spouse $9.14
Ankle $1,000 Employee + child(ren) $11.30
Wrist $800 Family $11.98
Elbow $600 * Employees residing in the state of
Shoulder $400 Washington are not eligible for this
coverage
Hand $400
Collarbone $400
Lower jaw $400
Finger or toe $100
Open reduction (requires surgery) 2x non-surgical beneit (above)
Follow-Up Care
Follow-up physician ofice visit $100 (10x per accident)
Follow-up physical therapy $50 (10x per accident)
Appliance beneit $150
Additional Beneits
Burns (small/large) $300/$900
Skin grafts 50% of burn beneit
Lacerations (small/large) $100/$200
General anesthesia $200
Abdominal or thoracic surgery $1,500
Tendon, ligament, rotator cuff, or $400/$200
knee surgery (repair/exploratory)
Ruptured disc surgery $750
Eye injury (surgery/removal of $400/$200
foreign object)
Emergency dental (extraction/ $150/$75
broken tooth)
Concussion $150
Coma $10,000
Diagnostic advanced $75
Appliance $150
Prosthesis $500
Paralysis (paraplegia/quadriplegia) $3,000/$6,000
Blood, plasma, platelets $200
Transportation $200
Family lodging $75 per day
Wellness (payable once per year per covered person)
Each Covered Member $75
2016 Open Enrollment
Schedule of Dislocations Bi-Weekly Accident Premium *
Hip joint $2,000 Employee $5.46
Knee joint $1,000
Bones of foot $1,000 Employee + spouse $9.14
Ankle $1,000 Employee + child(ren) $11.30
Wrist $800 Family $11.98
Elbow $600 * Employees residing in the state of
Shoulder $400 Washington are not eligible for this
coverage
Hand $400
Collarbone $400
Lower jaw $400
Finger or toe $100
Open reduction (requires surgery) 2x non-surgical beneit (above)
Follow-Up Care
Follow-up physician ofice visit $100 (10x per accident)
Follow-up physical therapy $50 (10x per accident)
Appliance beneit $150
Additional Beneits
Burns (small/large) $300/$900
Skin grafts 50% of burn beneit
Lacerations (small/large) $100/$200
General anesthesia $200
Abdominal or thoracic surgery $1,500
Tendon, ligament, rotator cuff, or $400/$200
knee surgery (repair/exploratory)
Ruptured disc surgery $750
Eye injury (surgery/removal of $400/$200
foreign object)
Emergency dental (extraction/ $150/$75
broken tooth)
Concussion $150
Coma $10,000
Diagnostic advanced $75
Appliance $150
Prosthesis $500
Paralysis (paraplegia/quadriplegia) $3,000/$6,000
Blood, plasma, platelets $200
Transportation $200
Family lodging $75 per day
Wellness (payable once per year per covered person)
Each Covered Member $75
2016 Open Enrollment
