2007 Symetra Benefits Plan Matrix |
Plan #4 |
Plan #7
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Plan #10
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| Life Insurance / AD&D Benefit | |||
Life Insurance Benefit |
$5,000.00 |
$10,000.00 |
$20,000.00 |
AD&D |
$5,000.00 |
$10,000.00 |
$20,000.00 |
| Dependent Life Insurance Benefit | |||
Spouse |
$2,500.00 |
$5,000.00 |
$7,500.00 |
Child (6 months - 19 years / 26 if full-time student) |
$1,250.00 |
$2,500.00 |
$3,750.00 |
Infant (14 days - 6 months) |
$200.00 |
$400.00 |
$600.00 |
| Hospital Indemnity Benefit | |||
| Per Day, Per Person; 30 days maximum per calendar year | $200.00 |
$500.00 |
$500.00 |
| Per Day, Per Person for treatment of alcoholism or drug abuse; 30 days maximum per calendar year | $200.00 |
$500.00 |
$500.00 |
| Per Day, Per Person for ICU; 30 days maximum per calendar year | $400.00 |
$1000.00 |
$1000.00 |
| Per Day, Per Person for mental illness; 300 days maximum per calendar year, 180 days per lifetime | $100.00 |
$250.00 |
$250.00 |
| Per Day, Per Person for stays in a skilled nursing facility (only if following a covered hospital stay of at least three consecutive days and the person is less than age 65); maximum 60 consecutive days per stay | $100.00 |
$250.00 |
$250.00 |
| Maximum days lifetime per person (except for mental illness) | 500 |
500 |
500 |
| Benefits become payable on the first day of coverage confinement |  |
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| Maternity Care covered as any other illness | |
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| No Deductible and no Co-payment | |
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| No additional premium charge for additional eligible dependents | |
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| Surgical Benefit | |||
| Surgical Benefit per person, per calendar year maximum. Benefits paid directly to the physician/surgeon, not to the facility. No deductible and no additional premium charge for eligible dependents. | None |
$1,000.00 |
$1,000.00 |
| Doctor's Office Visit Indemnity Benefit | |||
| Selected dollar benefit per person, per visit up to a calendar year maximum. No deductible. Excludes routine exams and injections. No additional premium charge for eligible dependents | $40/$300 |
$55/$300 |
$55/$300 |
| Outpatient Diagnostic X-ray and Lab (DXL) Indemnity Benefit | |||
| Tests ordered or performed by a doctor, payable at selected dollar benefit per person, per visit up to a calendar year maximum when hospital confinement is not required. Must be medically necessary. No deductible. No additional premium charge for eligible dependents. | $45/$300 |
$55/$300 |
$55/$300 |
| Additional Accident Benefit | |||
| Covered charges payable for services furnished by a doctor or hospital within 90 days after an accident. No deductible or co-payment. No additional premium for eligible dependents. Per Person, Per Calendar Year Maximum. | $300.00 |
$500.00 |
$500.00 |
| Prescription Drug Benefit | |||
| Per person calendar year maximum, per family calendar year maximum; Co-Payment: Generic- $10 Name Brand-$20 | None |
None |
$150/$300 |
| Preventive Care Indemnity Benefit | |||
| Routine exams, medical treatment and injections payable at selected dollar benefit per visit, up to a calendar year maximum. | None |
$50/$150 |
$75/$150 |
| Other Additional Benefits | |||
Survivor Benefit |
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Pharmacy Discount Program |
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Vision Benefit |
No |
No |
|
Dental Care Benefit |
No |
No |
|
Employee Disability Weekly Benefit |
No |
No |
|
COBRA Eligible (Plan is portable) |
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