| |
 | 
|
| GS200 Plan Pays: | GS350 Plan Pays: | GS500 Plan Pays: | GS1000 Plan Pays: |
| | | |
|
Physician Office Visits
5 visits per covered person per Plan Year* for medically necessary treatment of injury or sickness. |
| $40
Per Visit | $50
Per Visit | $65
Per Visit | $100
Per Visit |
|
Outpatient Lab & X-ray
3 visits per Plan Year for diagnostic tests and x-rays which are ordered by a doctor and performed in an outpatient setting. |
| $40
Per Visit | $50
Per Visit | $65
Per Visit | $100
Per Visit |
|
Wellness Visits
1 visit per Plan Year for a routine examination or well-child care. |
| $40
Per Visit | $50
Per Visit | $65
Per Visit | $100
Per Visit |
|
| | | | |
Regular Inpatient Accident & Sickness Stay
A maximum of 30 days per Plan Year. |
| $200
Per Day | $350
Per Day | $500
Per Day | $1000
Per Day |
|
Intensive Care Unit/Critical Care Unit
Up to 10 days per Plan Year. |
| $400
Per Day | $700
Per Day | $1000
Per Day | $2000
Per Day |
|
Mental/Nervous
A maximum of 10 days per Plan Year. |
| $100
Per Day | $175
Per Day | $250
Per Day | $500
Per Day |
Substance Abuse
A maximum of 10 days per Plan Year. |
| $100
Per Day | $175
Per Day | $250
Per Day | $500
Per Day |
|
Skilled Nursing Facility
A maximum of 20 days per Plan Year. Confinement must begin within 3 days of a hospital stay. |
| $100
Per Day | $175
Per Day | $250
Per Day | $500
Per Day |
|
| $500 | $1000 | $2000 | $2500 |
| Inpatient surgery. Plan pays the indicated amount for 1 surgery per Plan Year. |
|
| Outpatient surgery. Plan pays the indicated amount for 1 surgery per Plan Year. |
| $200 | $400 | $800 | $1000 |
|
Anesthesia
– Inpatient (1 surgery/Plan Year)
– Outpatient (1 surgery/Plan Year) |
| | | | |
| $125 | $250 | $500 | $625 |
| $50 | $100 | $200 | $250 |
|
| Emergency Room Emergency Room (Injury or Sickness) – Applicable for emergency room visits for a medical emergency caused by an injury or sickness. 2 visits for injury and 1 visit for sickness per Plan Year. |
| $100
Per Visit | $100
Per Visit | $250
Per Visit | $250
Per Visit |
|
| $5,000 | $5,000 | $10,000 | $10,000 |
|
| $2,500 | $2,500 | $5,000 | $5,000 |
|
| $1,000 | $1,000 | $1,000 | $1,000 |
|
Vision Benefit
Benefits are $25 for 1 eye exam per Plan Year and $50 toward eyeglasses or contact lenses every 2 Plan Years. |
| $25 | $25 | $25 | $25 |
| $50 | $50 | $50 | $50 |
|
| Non-Insured Features Included In The Plan |
|
| Included | Included | Included | Included |
|
24-hour Nurse Line
24-hour access to a toll-free number for health consultations and basic health information. |
| Included | Included | Included | Included |
|
| Included | Included | Included | Included |
|
| Optional Insured Benefits |
|
Insured Dental Plan Available
Optional at the group or employee level. Scheduled amounts are payable up to $1,500 per covered person per Plan Year. Some services require a 12 month waiting period before benefits are available. Requires additional premium. |
| Option | Option | Option | Option |
| |
|
Blanket Monthly Costs
Employer contributes 100% of Employee Only cost | | | GS200 Plan | GS350 Plan | GS500 Plan | GS1000 Plan | | | | Employee Only | $52.00 | $66.00 | $85.00 | $124.00 | | Employee & Spouse | $97.00 | $128.00 | $166.00 | $247.00 | | Employee & Child(ren) | $76.00 | $99.00 | $127.00 | $189.00 | | Employee & Family | $127.00 | $168.00 | $219.00 | $329.00 |
|
| |
|
Contributory Monthly Costs
Employer contributes at least 50% of Employee Only cost | | | GS200 Plan | GS350 Plan | GS500 Plan | GS1000 Plan | | | | Employee Only | $59.00 | $76.00 | $98.00 | $143.00 | | Employee & Spouse | $112.00 | $148.00 | $193.00 | $289.00 | | Employee & Child(ren) | $87.00 | $114.00 | $148.00 | $220.00 | | Employee & Family | $148.00 | $196.00 | $256.00 | $385.00 |
|
| |
|
Dental Plan Monthly Costs
If the Dental Plan is added at the group level (i.e., automatically added to a GS Plan), add the Contributory Costs shown below to the appropriate amount(s) above. If the Dental Plan is available as an employee option, the Voluntary Costs shown below would be added to the appropriate amount(s) above. | | | Contributory Costs | Voluntary Costs | | | | Employee Only | $21.00 | $24.00 | | Employee & Spouse | $41.00 | $48.00 | | Employee & Child(ren) | $55.00 | $64.00 | | Employee & Family | $75.00 | $88.00 |
|
|
| A modal billing fee of up to $9 depending on group size will be reflected on each bill. |
 |
* Plan Year, wherever referenced, means the 12 consecutive month period beginning on each group’s effective date and each anniversary date thereafter.
|
