Page 21 - 2017 Benefits Enrollment
P. 21
2017 New Hire Guide
Wellness Benefit Plan Pays You
This beneit pays $50 per Additional Beneits $400/$1,500
Ambulance (ground/air)
calendar year per insured Appliance $100
individual (employee, spouse, Blood/plasma/platelets $400
and children) if a covered Burns Up to $10,000
$10,000
Coma
health screening test is Concussion $150
performed, including blood Emergency dental work—extraction/ $100/$300
crown
tests, chest x-rays, stress Eye Injury $300
tests, mammograms, and Knee cartilage with surgical repair—torn/ $750/$150
colonoscopies. A full list of exploratory up to $600
Lacerations
covered tests will be provided in Lodging $150 per day (up to 30 days per accident)
your certiicate. Medical imaging test (MRI, CT, CAT, MR, $200
EEG)
Open abdominal or thoracic surgery $1,500
Outpatient surgery facility service $300
Pain management (epidural) $100
Physician follow-up (physician, specialist $75 per visit (max 2 per accident)
or urgent care)
Prosthetic device 1: $750 / 2+: $1,500
Ruptured disc (with surgical repair) $800
Skin grafts 50% of burn beneit
Tendon/ligament/rotator cuff repair 1: $800 / 2+: $1,200 / Exploratory: $150
Therapy services (physical, speech, $25 per visit (max 2 per accident)
occupational)
Transportation $0.40 per mi (50+ mi from residence. Max
3x per accident)
Monthly Premium
Employee $12.91
Employee + spouse or child $22.72
Family $32.53
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Wellness Benefit Plan Pays You
This beneit pays $50 per Additional Beneits $400/$1,500
Ambulance (ground/air)
calendar year per insured Appliance $100
individual (employee, spouse, Blood/plasma/platelets $400
and children) if a covered Burns Up to $10,000
$10,000
Coma
health screening test is Concussion $150
performed, including blood Emergency dental work—extraction/ $100/$300
crown
tests, chest x-rays, stress Eye Injury $300
tests, mammograms, and Knee cartilage with surgical repair—torn/ $750/$150
colonoscopies. A full list of exploratory up to $600
Lacerations
covered tests will be provided in Lodging $150 per day (up to 30 days per accident)
your certiicate. Medical imaging test (MRI, CT, CAT, MR, $200
EEG)
Open abdominal or thoracic surgery $1,500
Outpatient surgery facility service $300
Pain management (epidural) $100
Physician follow-up (physician, specialist $75 per visit (max 2 per accident)
or urgent care)
Prosthetic device 1: $750 / 2+: $1,500
Ruptured disc (with surgical repair) $800
Skin grafts 50% of burn beneit
Tendon/ligament/rotator cuff repair 1: $800 / 2+: $1,200 / Exploratory: $150
Therapy services (physical, speech, $25 per visit (max 2 per accident)
occupational)
Transportation $0.40 per mi (50+ mi from residence. Max
3x per accident)
Monthly Premium
Employee $12.91
Employee + spouse or child $22.72
Family $32.53
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