5k Plan

10k Plan

Annual Maximum Benefits

$5,000

$10,000

Annual Deductible - Individual

$200

$200

Annual Deductible - Family

$500

$500

Outpatient Medical Expense Benefits

Annual Outpatient Maximum Benefits

$1,500

$2,000

Coinsurance

80%

80%

Doctor’s Office Visits

Per Visit Co-pay

$15

$15

Coinsurance

100%

100%

Inpatient Medical Expense Benefits (subject to annual maximum)

Coinsurance

80%

80%

Room & Board per day amount

$200

$400

ICU per day amount

$400

$800

Other Hospital Services Maximum

$1,000

$2,000

Prescription Drug Coverage Benefit

Generic Co-pay

$10

$10

Brand Co-pay

$30

$30

Monthly maximum (no carryover)

$50

$50

Accidental Death Benefit

Employee

$10,000

$10,000

Spouse

$5,000

$5,000

Dependent (6 months to 24 years)

$5,000

$5,000

Dependent (15 days to 6 months)

$1,000

$1,000

Weekly Rates

Employee

$18.95

$26.95

Employee +1

$41.69

$59.29

Employee +Family

$66.33

$94.33