Page 37 - MOCO

Offered to the employees of:

Includes coverage for 23 Specified Diseases
from Allstate Benefits

BENEFIT AMOUNTS
HOSPITAL CONFINEMENT/RELATED BENEFITS PLAN 1 PLAN 2 PLAN 1 WEEKLY PREMIUMS
Continuous Hospital Confinement (daily) $200 $300 AGES INDIVIDUAL FAMILY
Government or Charity Hospital (daily) $200 $300 18­64 $8.37 $16.56
Private Duty Nursing Services (daily) $200 $300 65­69 N/A° N/A°
Extended Care Facility (daily)† $200 $300 70­74 N/A° N/A°
At Home Nursing (daily)† $200 $300 75­80 N/A° N/A°
Hospice Care Center or Team First Day $2,000 $3,000
Days 2+ $200 $300 PLAN 1 BI­WEEKLY PREMIUMS
RADIATION/CHEMOTHERAPY/RELATED BENEFITS PLAN 1 PLAN 2 AGES INDIVIDUAL FAMILY
Radiation/Chemotherapy Up to $10,000 $15,000 18­64 $16.74 $33.12
for Cancer¹ (every 12 months) Lifetime Max $50,000 $75,000 65­69 N/A° N/A°
Blood, Plasma, and Platelets¹ (every 12 months) $10,000 $15,000 70­74 N/A° N/A°
Medical Imaging (every 12 months) $500 $750 75­80 N/A° N/A°
Hematological Drugs (every 12 months) $200 $300
SURGERY/RELATED BENEFITS PLAN 1 PLAN 2 PLAN 1 SEMI­MONTHLY PREMIUMS
Surgery² $3,000 $4,500 AGES INDIVIDUAL FAMILY
Anesthesia (% of Surgery benefit) 25% 25% 18­64 $18.14 $35.88
Ambulatory Surgical Center (daily) $500 $750 65­69 N/A° N/A°
Second Opinion (every 12 months) $200 $300 70­74 N/A° N/A°
Bone Marrow Transplant (every 12 months) $7,000 $10,500 75­80 N/A° N/A°
Stem Cell Transplant (every 12 months) $7,000 $10,500
MISCELLANEOUS BENEFITS PLAN 1 PLAN 2 PLAN 1 MONTHLY PREMIUMS
Inpatient Drugs and Medicine (daily) $25 $25 AGES INDIVIDUAL FAMILY
Physician’s Attendance (daily) $50 $50 18­64 $36.27 $71.76
Ambulance (per confinement) Ground $250 $250 65­69 N/A° N/A°
Air $10,000 $10,000 70­74 N/A° N/A°
Non­Local Transportation $0.50/mi $0.50/mi 75­80 N/A° N/A°
Outpatient Lodging Daily $100 $100
Yearly Max $2,000 $2,000 PLAN 2 WEEKLY PREMIUMS
Family Member Lodging (daily per trip; max. 60 days) $100 $100 AGES INDIVIDUAL FAMILY
and Transportation $0.50/mi $0.50/mi 18­64 $11.58 $22.93
Physical or Speech Therapy (daily) $50 $50 65­69 N/A° N/A°
New or Experimental Treatment¹ (every 12 months) $5,000 $5,000 70­74 N/A° N/A°
Prosthesis (per year) $100 $100 75­80 N/A° N/A°
Hair Prosthesis (once per covered person) $350 $350
Nonsurgical External Breast Prosthesis (per year) $100 $100 PLAN 2 BI­WEEKLY PREMIUMS
Anti­Nausea Drugs (every 12 months) $200 $200 AGES INDIVIDUAL FAMILY
National Cancer Institute Evaluation/Consultation (every 12 mos.) $500 $500 18­64 $23.16 $45.86
Egg Harvesting and Storage (one­time benefit) Extraction $500 $500 65­69 N/A° N/A°
Storage $175 $175 70­74 N/A° N/A°
Waiver of Premium (primary insured only) Yes Yes 75­80 N/A° N/A°
ADDITIONAL RIDER BENEFITS PLAN 1 PLAN 2
Cancer Initial Diagnosis Level Benefit (one­time benefit) $6,000 $10,000 PLAN 2 SEMI­MONTHLY PREMIUMS
Cancer Initial Diagnosis Progressive Benefit (one­time benefit) $800 $800 AGES INDIVIDUAL FAMILY
Fixed Wellness Benefit $100 $100 18­64 $25.09 $49.68
Intensive Care (ICU) ICU (daily max. 45 days) $400 $600 65­69 N/A° N/A°
Step­down (daily max. 45 days) $200 $300 70­74 N/A° N/A°
Ground Ambulance $500 $750 75­80 N/A° N/A°
Air Ambulance $20,000 $30,000
Second Opinion $200 $300 PLAN 2 MONTHLY PREMIUMS
FOR HOME OFFICE USE ONLY ­ CP12 AGES INDIVIDUAL FAMILY
Opt 1 ­ 2HOSP; 2CHEM; 2SURG; 1MISC; 2ICR5; 6CLR3; 2CPR3; 0CABR3; 4WBR6; 0WBR7 18­64 $50.18 $99.36
Opt 2 ­ 3HOSP; 3CHEM; 3SURG; 1MISC; 3ICR5; 10CLR3; 2CPR3; 0CABR3; 4WBR6; 0WBR7 65­69 N/A° N/A°
70­74 N/A° N/A°
75­80 N/A° N/A°
Issue Ages: 18­80
†Up to number of days of previous hospital confinement.
¹Pays actual cost up to amount listed.
For use in: Maryland ²Pays up to amount listed in policy Schedule of Surgical
This rate insert is part of the CP12 Brochure for and is not to be used on its own. Procedures. Amount paid depends on surgery.
This material is valid as long as information remains current, but in no event later than May, 21, 2022. Allstate Benefits is the marketing name used by °Cancer Initial Diagnosis Progressive Benefit Rider is only
American Heritage Life Insurance Company (Home Office, Jacksonville, FL), a subsidiary of The Allstate Corporation. ©2019 Allstate Insurance Company. available for ages 18­64
www.allstate.com or allstatebenefits.com.

ABJ31044­Insert­78704

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