| Benefits | Base Plan | Standard Plan | Select Plan | Premier Plan |
| |
|
|
|
|
| Network |
First Health Network Doctor |
First Health Network Doctor |
First Health Network Doctor & Hospital |
First Health Network Doctor & Hospital |
| Life/AD&D Insurance |
$5,000 |
$5,000 |
$5,000 |
$5,000 |
| Dependent Life Insurance |
$2,500 |
$2,500 |
$2,500 |
$2,500 |
| Critical Illness |
N/A |
N/A |
N/A |
$10,000
(Employee) |
Daily In-Hospital Indemnity
500 day lifetime max
|
$100 per day
$200 per day
$50 per day
$50 per day
$50 per day |
$300 per day
$600 per day
$150 per day
$150 per day
$150 per day |
$500 per day
$1,000 per day
$250 per day
$250 per day
$250 per day |
$800 per day
$1,600 per day
$400 per day
$400 per day
$400 per day |
Inpatient Miscellaneous
60 day calendar year max |
N/A |
$200 per day |
$300 per day |
$500 per day |
| Hospital Admission |
N/A |
$300 Single Sum |
$500 Single Sum |
$800 Single Sum |
| Doctor’s Office Visit |
$50 per visit
$300 calendar year max |
$50 per visit
$300 calendar year max |
$60 per visit
$360 calendar year max |
$75 per visit
$450 calendar year max |
Outpatient Diagnostic
X-Ray and Lab |
N/A |
$50 per test
$300 calendar year max |
$60 per test
$360 calendar year max |
$75 per test
$450 calendar year max |
Outpatient Diagnostic
Advanced Studies |
N/A |
$200 per test
$600 calendar year max |
$300 per test
$900 calendar year max |
$500 per test
$1,500 calendar year max |
IP/OP/OP Minor Surgical
Indemnity |
N/A |
$500/$250/$50 |
$1,000/$500/$100 |
$2,000/$1,000/$200 |
| Anesthesia |
N/A |
$150
$500 calendar year max |
$300
$1,000 calendar year max |
$600
$2,000 calendar year max |
| Outpatient Surgical Facility |
N/A |
N/A |
$500 |
$500 |
| Preventive Care |
$50 per visit
$150 calendar year max |
$50 per visit
$150 calendar year max |
$75 per visit
$150 calendar year max |
$75 per visit
$150 calendar year max |
| Accident Expense |
$300 max per occurrence |
$500 max per occurrence |
$1,000 max per occurrence |
$1,000 max per occurrence |
Emergency Room Indemnity
Benefit for Illness Only |
$75 per visit
$300 calendar year max |
$75 per visit
$300 calendar year max |
$75 per visit
$300 calendar year max |
$75 per visit
$300 calendar year max |
| *Health Savings Program |
Included |
Included |
Included |
Included |
| *Tier’d RX Program |
Included |
Included |
Included |
Included |
Employer Paid Rates
Employee
Employee Plus Child(ren)
Employee Plus Spouse
Family |
Monthly
$35.90
$57.04
$72.93
$78.69 |
Monthly
$73.84
$125.33
$167.78
$183.18 |
Monthly
$109.79
$188.04
$253.91
$277.38 |
Monthly
$166.21
$285.80
$386.46
$424.51 |
Voluntary Rates
Employee
Employee Plus Child(ren)
Employee Plus Spouse
Family |
Monthly
$42.07
$68.00
$87.87
$95.06 |
Monthly
$89.51
$153.40
$206.47
$225.67 |
Monthly
$135.33
$233.87
$317.27
$346.88 |
Monthly
$202.22
$350.47
$476.00
$522.79 |
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