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Plans
& Benefit Payment
|
|
Benefit
Type
|
Value
Plan
Pays
|
Standard
Plan
Pays
|
Enhanced
Plan
Pays
|
| Doctor's
Office Visit |
$40.00
|
$50.00
|
$65.00
|
| Dianostic
Testing |
$40.00
|
$50.00
|
$65.00
|
| Child
Wellness Visits |
$40.00
|
$50.00
|
$65.00
|
| Hospitalization |
$200.00
|
$350.00
|
$500.00
|
| Surgery
- Inpatient |
$500.00
|
$1,500.00
|
$2,0000
|
| Surgery
-Outpatient |
$200.00
|
$600.00
|
$800.00
|
| Emergency
Room |
$150.00
|
$250.00
|
$300.00
|
| Drug
Card |
Included
|
Included
|
Included
|
|
| |
|
Plan
Monthly Premium Rates
|
|
|
Value
Plan
|
|
Employee's
Age
|
Employee
|
Employee
& Spouse
|
Employee&
Children
|
Family
|
|
Under
30
|
$35.83
|
$65.71
|
$95.75
|
$121.62
|
|
30-34
|
$44.97
|
$82.09
|
$104.88
|
$138.00
|
|
35-39
|
$50.31
|
$91.42
|
$110.22
|
$147.34
|
|
40-44
|
$55.65
|
$100.63
|
$115.57
|
$156.55
|
|
45-49
|
$61.17
|
$110.05
|
$121.08
|
$165.96
|
|
50-54
|
$67.36
|
$120.72
|
$127.28
|
$176.63
|
|
55-59
|
$79.85
|
$141.93
|
$139.77
|
$197.85
|
|
60-64
|
$105.01
|
$186.23
|
$164.92
|
$242.15
|
|
65+
|
$135.90
|
$240.90
|
$195.82
|
$296.82
|
|
| |
|
Standard
Plan
|
|
Employee's
Age
|
Employee
|
Employee
& Spouse
|
Employee&
Children
|
Family
|
|
Under
30
|
$59.03
|
$108.04
|
$155.14
|
$200.16
|
|
30-34
|
$74.49
|
$135.99
|
$170.60
|
$228.11
|
|
35-39
|
$84.77
|
$154.24
|
$180.88
|
$246.36
|
|
40-44
|
$95.34
|
$172.50
|
$191.45
|
$264.61
|
|
45-49
|
$106.41
|
$191.36
|
$202.52
|
$283.47
|
|
50-54
|
$118.98
|
$213.00
|
$215.10
|
$305.11
|
|
55-59
|
$144.70
|
$256.47
|
$240.81
|
$348.58
|
|
60-64
|
$196.02
|
$346.64
|
$292.13
|
$438.76
|
|
65+
|
$263.06
|
$465.21
|
$359.17
|
$557.33
|
|
| |
|
Enhanced
Plan
|
|
Employee's
Age
|
Employee
|
Employee
& Spouse
|
Employee&
Children
|
Family
|
|
Under
30
|
$77.10
|
$140.93
|
$201.91
|
$261.74
|
|
30-34
|
$97.43
|
$177.72
|
$222.24
|
$298.54
|
|
35-39
|
$111.06
|
$201.88
|
$235.88
|
$322.69
|
|
40-44
|
$125.12
|
$226.15
|
$249.94
|
$346.96
|
|
45-49
|
$139.83
|
$251.22
|
$264.64
|
$372.03
|
|
50-54
|
$156.59
|
$280.05
|
$281.40
|
$400.86
|
|
55-59
|
$190.83
|
$337.91
|
$315.64
|
$458.72
|
|
60-64
|
$259.40
|
$458.44
|
$384.22
|
$579.25
|
|
65+
|
$348.93
|
$616.79
|
$473.75
|
$737.61
|
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Powered
By:
WORLDWIDE
INSURANCE SERVICES, INC.
237 Melvin Drive
Northbrook, IL 60062
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