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Life Insurance Benefits
Employee
Spouse (if enrolled)
Dependent Child(ren) if enrolled |
$5,000
$2,500
$1,250 |
$5,000
$2,500
$1,250 |
$5,000
$2,500
$1,250 |
$10,000
$2,500
$1,250 |
Hospitalization
Daily Indemnity Benefit
Daily Intensive Care Benefit |
$300
$600 |
$500
$1,000 |
$700
$1,400 |
$1,000
$2,000 |
Doctors Office Visit
Per Visit Indemnity Benefit
Calendar Year Maximum |
$50
$300 |
$55
$330 |
$60
$300 |
$60
$360 |
Outpatient Diag. X-Ray, Lab
Lab / X-Ray / Advanced Studies
Calendar Year Maximum |
$20/70/2,000
$2,400 |
$35/100/1,000
$1,305 |
$35/100/2000
$2,610 |
$50/150/1,000
$1,450 |
Surgical Benefit
Calendar Year Maximum
Surgical Schedule Applies |
$500 |
$800 |
$1,000 |
$1,500 |
Wellness Care Benefit
Per Visit Indemnity Benefit
Calendar Year Maximum |
$75
$150 |
$100
$150 |
$100
$300 |
$150
$450 |
Accident Coverage
Per Accident Limit |
$500 |
$500 |
$1,000 |
$2,500 |
ER-Sickness Benefit
Per Visit Indemnity Benefit
Calendar Year Maximum |
$75
$300 |
$75
$300 |
$75
$300 |
$75
$300 |
Prescription Drug Benefit
Co-Payment - Generic Drugs
Discount - Brand Drugs
Calendar Year Maximum |
Discount Only |
$10
Included
$1,500 |
$10
Included
$1,500 |
$10
Included
$1,500 |
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