28 Voluntary Accident Plan Group # 068729 Value Plan Advantage Plan Premier Plan Wellness Screening $50 $75 $100 Ambulance $150 $200 $300 Emergency Room Treatment $150 $200 $250 Diagnostic Examination $100 per CT/MRI Scan $200 per CT/MRI Scan $400 per CT/MRI Scan Hospital Admission $500 $1,000 $1,500 ICU Hospital Admission $1,000 $2,000 $3,000 Hospital Confinement $200/day 365-day max $250/day 365-day max $350/day 365-day max ICU Confinement $400/day 15-day max $500/day 15-day max $700/day 15-day max Fractures Up to $5,000 Up to $8,000 Up to $10,000 Dislocations Up to 4,000 Up to $5,000 Up to $7,000 Transfusion $300 $300 $300 Burns 9-18 square inches = $0 - $2,000 18-35 square inches = $1,000 - $4,000 Over 35 square inches = $3,000 - $12,000 Concussion $100 $200 $300 Exploratory Surgery $300 $400 $500 Knee Cartilage Surgery $250 $500 $750 Abdominal/Thoracic Surgery Up to $1,000 Up to $1,500 Up to $2,000 Ruptured Disc Surgery $250 $500 $750 Physical Therapy $25/day up to 10 days $35/day up to 10 days $50/day up to 10 days Accidental Death - Employee $25,000 $50,000 $100,000 Accidental Death - Spouse $12,500 $25,000 $50,000 Accidental Death - Children $5,000 $10,000 $20,000 Dismemberment - One member 50% of Death Benefit 50% of Death Benefit 50% of Death Benefit Dismemberment - Two or more members 100% of Death Benefit 100% of Death Benefit 100% of Death Benefit Accident Insurance can help lessen your financial burden by providing a lump-sum cash payment upon accidental injury. Staff Member select District Resource Center click on Human Resources select D203 Staff Resource Library Select Address or Name Change Process Annual Benefits Enrollment Starts mid-October with a January 1 effective date Outcomes Based Wellness Program Screenings start mid-September; participation required to receive with-Wellness premium Benefits Plan Carriers Medical BlueCross BlueShield of Illinois Prescription Drugs Prime Therapeutics Dental Guardian - NEW Vendor Vision Guardian - NEW Vendor Health Care Flexible Spending Account Inspira Financial Dependent Care Flexible Spending Account Inspira Financial Health Savings Account Lively Employee Assistance Program ComPsych - NEW Vendor Telehealth Medical Teladoc Telehealth Behavioral Health Teladoc Basic Life Insurance Guardian - NEW Vendor Voluntary Life, Critical Illness, Accident Insurance Guardian - NEW Vendor Contact information for carriers is available on the last page of this Employee Benefits Guide, on your benefit account on the district website and on your insurance cards.