Page 21 - MOMS NEW ALLSTATE GROUP VOLUNTARY BENEFITS

Group Supplemental Health (GVSP1)

from Allstate Benefits

BENEFIT AMOUNTS
HOSPITALIZATION BENEFITS* PLAN 1 PLAN 2 PLAN 1 BI-WEEKLY PREMIUMS
Initial Hospital Confinement (daily, once per year) $500 $1,000 AGES EE EE+ SP EE+ CH F
Daily Hospital Confinement (daily) $200 $400 18-35 $19.70 $37.72 $33.12 $50.12
Hospital Intensive Care (daily) $200 $400 36-49 $22.94 $44.04 $38.00 $58.02
SURGERY BENEFITS* PLAN 1 PLAN 2 50-59 $28.08 $55.26 $43.60 $69.58
Surgery (according to schedule) $40-$1,000 $80-$2000 60-64 $36.72 $73.44 $52.68 $88.00
Anesthesia(% of Surgery) 25% 25% 65+ $48.36 $96.70 $65.80 $112.52
Inpatient Physician's Treatment (daily) $50 $100
OUTPATIENT BENEFITS* PLAN 1 PLAN 2 PLAN 2 BI-WEKLY PREMIUMS
Outpatient Emergency Accident (daily) $250 $500 AGES EE EE+ SP EE+ CH F
Outpatient Physician's Treatment (daily) $25 $50 18-35 $32.50 $61.66 $52.44 $80.58
At Home Nursing (daily) $50 $100 36-49 $38.64 $73.62 $61.54 $95.44
Ambulance (daily) Ground $150 $300 50-59 $48.28 $94.72 $71.42 $116.68
Air $300 $600 60-64 $64.14 $128.28 $86.74 $95.33
Non-Local Transportation (daily) $150 $300 65+ $85.74 $171.48 $71.42 $121.88
*Policy benefit dollar amounts increase by 5% after the first coverage year and each coverage
year thereafter, for the next 5 years. The benefit dollar amounts in coverage years 6 and later are EE= Employee; EE+ SP= Employee+ Spouse;
125% of the initial benefit amounts stated here. EE+ CH= Employee+ Child(ren); F = Family
Issue Ages: 18 and over if Actively at Work

•Allstate. I For use in enrollments sitused in: AL, AK, DE, GA, HI, IL, KY, LA, ME, MS, NE, NV, OR, PA, RI, SC, SD, TX, UT, VA, VI, WI, WV
BENEFITS Allstate Benefits is the marketing name used by American Heritage Life Insurance Company (Home Office, Jacksonville, F L ), a
subsidiary of The Allstate Corporation. ©2019 Allstate Insurance Company. www.allstate.com or allstatebenefits.com.