29 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. It can be accessed from anywhere at anytime Can provide significant cost savings versus going in-person If there is a need for multiple appointments, you can receive care from the same Behavioral Health expert throughout the duration of treatment Cost for Blue Choice Options PPO and Blue Choice Select PPO Plans $20 Copay for the first Behavioral Health Consultation with a psychiatrist $20 Copay for all subsequent Behavioral Health Consultations with a psychiatrist $20 Copay for each Behavioral Health Consultation with a therapist other than a psychiatrist Cost for Blue Choice Options HDHP and Blue Choice Select HDHP Plans $235 for the first Behavioral Health Consultation with a psychiatrist $105 for all subsequent Behavioral Health Consultations with a psychiatrist $95 for each Behavioral Health Consultation with a therapist other than a psychiatrist 18 Teladoc - Nutrition & Dermatology Naperville Community Unit School District 203 offers Nutrition and Dermatology options in conjunction with current Teladoc services.