| Subcategory | Benefit Limits | Benefit | Low Plan | High Plan |
|---|---|---|---|---|
| Hospital Benefits | ||||
| Admission Benefit | 4 times per calendar year | Admission | $500 | $1,000 |
| ICU Supplemental Admission (paid concurrently when admitted to ICU) | $500 | $1,000 | ||
| Confinement Benefit | 15 days per calendar year | Confinement | $100 | $100 |
| ICU Supplemental Confinement (paid concurrently when admitted to ICU) | $65 | $65 | ||
Plan Highlights
✓ No Limitation on Pre-Existing Conditions
✓ Benefit Paid Directly – No COB
✓ Pregnancy Covered, NO Waiting Period
✗ Drugs/Alcohol Treatment NOT Covered
! Benefit Reduction: 25% at age 65-69, 50% at age 70+
Monthly Rates
Low Plan
Employee Only $5.06
Employee + Spouse $11.06
Employee + Children $8.44
Employee + Spouse & Children $14.42
High Plan
Employee Only $8.35
Employee + Spouse $18.27
Employee + Children $13.61
Employee + Spouse & Children $23.53
