Page 7 - Enrollment Guide
P. 7
American Food & Vending
Reliance Standard MEC Plans
Outpatient Beneits Plan 1 Plan 2 Plan 3
Doctor Visit Beneits
Daily Beneit for a New Patient Ofice Visit $75 per day $100 per day $100 per day
Number of Daily Beneits Per Coverage Year 1 1 1
Daily Beneit for an Established Patient Ofice Visit $60 per day $70 per day $70 per day
Number of Daily Beneits Per Coverage Year 3 5 7
Daily Beneit for a Consultation Ofice Visit $75 per day $150 per day $150 per day
Number of Daily Beneits Per Coverage Year 1 1 1
Daily Beneit for an Emergency Room Doctor Visit $75 per day $100 per day $100 per day
Number of Daily Beneits Per Coverage Year 1 1 1
Radiology Beneits
Daily Beneit for a Magnetic Resonance Imaging (MRI) $100 per day $175 per day $300 per day
Number of Daily Beneits Per Coverage Year 1 1 1
Daily Beneit for a Computerized Tomography (CT) Scan $50 per day $75 per day $125 per day
Number of Daily Beneits Per Coverage Year 1 1 1
Daily Beneit for all other Radiology Services $40 per day $40 per day $60 per day
Number of Daily Beneits Per Coverage Year 4 5 5
Pathology Beneits
Daily Beneit for all Pathology Services $40 per day $40 per day $50 per day
Number of Daily Beneits Per Coverage Year 4 5 5
Wellness Care Beneits
Daily Beneit for Annual Physical $75 per day $75 per day $125 per day
Number of Daily Beneits Per Coverage Year 1 1 1
Daily Beneit for a Mammogram Screening $50 per day $50 per day $50 per day
Number of Daily Beneits Per Coverage Year 1 1 1
Daily Beneit for a Prostate or Cervical Cancer Screening $35 per day $35 per day $35 per day
Number of Daily Beneits Per Coverage Year 1 1 1
Emergency Room Visit Beneits
Daily Beneit for the Treatment of an Accidental Injury $500 per day $500 per day $500 per day
Number of Daily Beneits Per Coverage Year 2 2 2
Daily Beneit for the Treatment of a Sickness $50 per day $50 per day $50 per day
Number of Daily Beneits Per Coverage Year 3 3 3
Surgery
Maximum Surgery Beneit Per Procedure 4 $750 per day $1,000 per day $1,500 per day
Maximum Anesthesia Beneit 5 $150 per day $200 per day $300 per day
Prescription Drug Beneits
Daily Beneit per Generic Drug Prescription (Filled or Reilled) $25 per day $25 per day $25 per day
Number of Daily Beneits Per Coverage Year 10 18 32
Daily Beneit per Brand Name Drug (Filled or Reilled) Not Covered $50 per day $50 per day
Number of Daily Beneits Per Coverage Year Not Covered 2 7
Weekly Contribution Rates
Employee Only $12.21 $15.73 $19.07
Employee + Spouse $23.30 $30.71 $37.76
Employee + 1 Child $20.63 $25.90 $30.91
Employee + Children $33.53 $42.42 $50.86
Family $42.14 $53.95 $65.17
4 Beneits for covered outpatient surgery are scheduled and vary based on the speciic surgical procedure performed.
5 Beneits for covered outpatient anesthesia vary and are equal to 20% of the applicable outpatient surgery beneit.
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Reliance Standard MEC Plans
Outpatient Beneits Plan 1 Plan 2 Plan 3
Doctor Visit Beneits
Daily Beneit for a New Patient Ofice Visit $75 per day $100 per day $100 per day
Number of Daily Beneits Per Coverage Year 1 1 1
Daily Beneit for an Established Patient Ofice Visit $60 per day $70 per day $70 per day
Number of Daily Beneits Per Coverage Year 3 5 7
Daily Beneit for a Consultation Ofice Visit $75 per day $150 per day $150 per day
Number of Daily Beneits Per Coverage Year 1 1 1
Daily Beneit for an Emergency Room Doctor Visit $75 per day $100 per day $100 per day
Number of Daily Beneits Per Coverage Year 1 1 1
Radiology Beneits
Daily Beneit for a Magnetic Resonance Imaging (MRI) $100 per day $175 per day $300 per day
Number of Daily Beneits Per Coverage Year 1 1 1
Daily Beneit for a Computerized Tomography (CT) Scan $50 per day $75 per day $125 per day
Number of Daily Beneits Per Coverage Year 1 1 1
Daily Beneit for all other Radiology Services $40 per day $40 per day $60 per day
Number of Daily Beneits Per Coverage Year 4 5 5
Pathology Beneits
Daily Beneit for all Pathology Services $40 per day $40 per day $50 per day
Number of Daily Beneits Per Coverage Year 4 5 5
Wellness Care Beneits
Daily Beneit for Annual Physical $75 per day $75 per day $125 per day
Number of Daily Beneits Per Coverage Year 1 1 1
Daily Beneit for a Mammogram Screening $50 per day $50 per day $50 per day
Number of Daily Beneits Per Coverage Year 1 1 1
Daily Beneit for a Prostate or Cervical Cancer Screening $35 per day $35 per day $35 per day
Number of Daily Beneits Per Coverage Year 1 1 1
Emergency Room Visit Beneits
Daily Beneit for the Treatment of an Accidental Injury $500 per day $500 per day $500 per day
Number of Daily Beneits Per Coverage Year 2 2 2
Daily Beneit for the Treatment of a Sickness $50 per day $50 per day $50 per day
Number of Daily Beneits Per Coverage Year 3 3 3
Surgery
Maximum Surgery Beneit Per Procedure 4 $750 per day $1,000 per day $1,500 per day
Maximum Anesthesia Beneit 5 $150 per day $200 per day $300 per day
Prescription Drug Beneits
Daily Beneit per Generic Drug Prescription (Filled or Reilled) $25 per day $25 per day $25 per day
Number of Daily Beneits Per Coverage Year 10 18 32
Daily Beneit per Brand Name Drug (Filled or Reilled) Not Covered $50 per day $50 per day
Number of Daily Beneits Per Coverage Year Not Covered 2 7
Weekly Contribution Rates
Employee Only $12.21 $15.73 $19.07
Employee + Spouse $23.30 $30.71 $37.76
Employee + 1 Child $20.63 $25.90 $30.91
Employee + Children $33.53 $42.42 $50.86
Family $42.14 $53.95 $65.17
4 Beneits for covered outpatient surgery are scheduled and vary based on the speciic surgical procedure performed.
5 Beneits for covered outpatient anesthesia vary and are equal to 20% of the applicable outpatient surgery beneit.
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