Life Insurance/AD&D
Employee life insurance, incl. Accidental Death & Dismemberment. |
$5,000 |
Dependent Life Insurance
Spouse
Child |
$2,500
$1,250 |
| Hospital Indemnity: Per day dollar benefit for hospital confinement
up to a calendar year maximum of 60 days. |
$500 |
| Intensive Care: Per day dollar benefit up to a calendar year
maximum of 30 days |
$1,000 |
| Substance Abuse: Per day dollar benefit up to a calendar year
maximum of 30 days |
$250 |
| Mental Health: Per day dollar benefit up to a calendar year
maximum of 60 days |
$250 |
| Skilled Nursing Facility: Per day dollar benefit up to a calendar
year maximum of 60 days (Benefit available only if following
a covered hospital stay of at least 3 days). |
$250 |
| Doctors Office Visit: Pays the indemnity amount specified per visit with the maximum amount of $330 per person per calendar year. |
$55 / $330 |
| Outpatient DXL: Pays $35 per lab test, 3 times per year. Pays $100 per X-Ray, 2 times per year. Pays up to $1,000 per year for advanced testing per Schedule B. |
$35 / $100 / B-Max $1,305 |
| Surgical Schedule: 100% of eligible expenses up to the maximum per person per calendar year - Per Surgical Schedule. |
$800 |
| Wellness Care: Pays an indemnity amount as specified per annual physical exam, well child care, and mammogram's with a maximum of $150 per person per calendar year. |
$100/ $150 |
| Accident Coverage: 100% of actual charges incurred within 90 days of accident up to a maximum of $500 per accident. |
$500 |
| ER-Sickness Benefit: Pays $75 per emergency room visit for illness only up to a maximum of $300 per calendar year. |
$75 / $300 |
| Prescription Drug Benefit: $10 Co-Pay / $1,500 Annual Benefit per person for formulary Generic Drugs; Brand Name Drug Discount Program Included. |
$1,500 |
