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MetLife's Accident plan supplements existing medical coverage and helps provide financial support to pay for out-of-pocket expenses such as deductibles, co-payments, and non-covered medical services. Benefits are paid regardless of what is covered by medical insurance. Payments are made directly to covered employees to spend as they choose.

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Accidental Death Benefits
Basic Accidental Death
    Low Plan   High Plan
Employee   $25,000   $50,000
Spouse   $12,500   $25,000
Child   $5,000   $10,000
Accidental Death Common Carrier
    Low Plan   High Plan
Employee   $75,000   $150,000
Spouse   $37,500   $75,000
Child   $15,000   $30,000
Accidental Dismemberment/Functional Loss/Paralysis Benefits
Basic Dismemberment/Functional Loss
Loss of One Finger or One Toe
    Low Plan   High Plan
Employee   $750   $1,000
Spouse   $750   $1,000
Child   $750   $1,000
Loss of One Arm or One Leg
    Low Plan   High Plan
Employee   $10,000   $15,000
Spouse   $10,000   $15,000
Child   $10,000   $15,000
Loss of One Hand or One Foot
    Low Plan   High Plan
Employee   $10,000   $15,000
Spouse   $10,000   $15,000
Child   $10,000   $15,000
Loss of Two or More Fingers or Toes
    Low Plan   High Plan
Employee   $1,500   $2,000
Spouse   $1,500   $2,000
Child   $1,500   $2,000
Loss of Sight in One Eye
    Low Plan   High Plan
Employee   $10,000   $15,000
Spouse   $10,000   $15,000
Child   $10,000   $15,000
Loss of Hearing in One Ear
    Low Plan   High Plan
Employee   $10,000   $15,000
Spouse   $10,000   $15,000
Child   $10,000   $15,000
 
Catastrophic Dismemberment/Functional Loss
Loss of Both Arms or Both Legs, or One Arm and One Leg
    Low Plan   High Plan
Employee   $20,000   $40,000
Spouse   $20,000   $40,000
Child   $20,000   $40,000
Loss of Both Hands or Both Feet, or One Hand and One Foot
    Low Plan   High Plan
Employee   $20,000   $40,000
Spouse   $20,000   $40,000
Child   $20,000   $40,000
Loss of Sight in Both Eyes
    Low Plan   High Plan
Employee   $20,000   $40,000
Spouse   $20,000   $40,000
Child   $20,000   $40,000
Loss of Hearing in Both Ears
    Low Plan   High Plan
Employee   $20,000   $40,000
Spouse   $20,000   $40,000
Child   $20,000   $40,000
Loss of Ability to Speak
    Low Plan   High Plan
Employee   $20,000   $40,000
Spouse   $20,000   $40,000
Child   $20,000   $40,000
 
Paralysis
Two Limbs (Paraplegia or Hemiplegia)
    Low Plan   High Plan
Employee   $10,000   $20,000
Spouse   $10,000   $20,000
Child   $10,000   $20,000
Four Limbs (Quadriplegia)
    Low Plan   High Plan
Employee   $20,000   $40,000
Spouse   $20,000   $40,000
Child   $20,000   $40,000
Accidental Injury Benefits
Fracture (Closed)
Face or Nose (Except Mandible or Maxilla)
If more than one bone is fractured, the amount paid for all fractures combined will be no more than 2 times the highest Fracture Benefit.
    Low Plan        High Plan
All Covered Persons   $1,000   $2,000
Skull Fracture - Depressed (Except Bones of Face or Nose)
If more than one bone is fractured, the amount paid for all fractures combined will be no more than 2 times the highest Fracture Benefit.
    Low Plan        High Plan
All Covered Persons   $4,000   $5,000
Skull Fracture - Non-Depressed (Except Bones of Face or Nose)
If more than one bone is fractured, the amount paid for all fractures combined will be no more than 2 times the highest Fracture Benefit.
    Low Plan        High Plan
All Covered Persons   $2,000   $2,500
Lower Jaw Mandible (Except Alveolar Process)
If more than one bone is fractured, the amount paid for all fractures combined will be no more than 2 times the highest Fracture Benefit.
    Low Plan        High Plan
All Covered Persons   $750   $1,000
Upper Jaw Maxilla (Except Alveolar Process)
If more than one bone is fractured, the amount paid for all fractures combined will be no more than 2 times the highest Fracture Benefit.
    Low Plan        High Plan
All Covered Persons   $1,000   $2,000
Upper Arm between Elbow & Shoulder (Humerus)
If more than one bone is fractured, the amount paid for all fractures combined will be no more than 2 times the highest Fracture Benefit.
    Low Plan        High Plan
All Covered Persons   $1,000   $2,000
Shoulder Blade (Scapula), Collarbone (Clavicle, Sternum)
If more than one bone is fractured, the amount paid for all fractures combined will be no more than 2 times the highest Fracture Benefit.
    Low Plan        High Plan
All Covered Persons   $750   $1,000
Forearm (Radius and/or Ulna), Hand, Wrist (Except Fingers)
If more than one bone is fractured, the amount paid for all fractures combined will be no more than 2 times the highest Fracture Benefit.
    Low Plan        High Plan
All Covered Persons   $750   $1,000
Rib
If more than one bone is fractured, the amount paid for all fractures combined will be no more than 2 times the highest Fracture Benefit.
    Low Plan        High Plan
All Covered Persons   $750   $1,000
Finger or Toe
If more than one bone is fractured, the amount paid for all fractures combined will be no more than 2 times the highest Fracture Benefit.
    Low Plan        High Plan
All Covered Persons   $100   $200
Vertebrae, Body of (Excluding Vertebral Processes)
If more than one bone is fractured, the amount paid for all fractures combined will be no more than 2 times the highest Fracture Benefit.
    Low Plan        High Plan
All Covered Persons   $1,500   $2,000
Vertebral Processes
If more than one bone is fractured, the amount paid for all fractures combined will be no more than 2 times the highest Fracture Benefit.
    Low Plan        High Plan
All Covered Persons   $500   $750
Pelvis (Includes Ilium, Ischium, Pubis, Acetabulum Except Coccyx)
If more than one bone is fractured, the amount paid for all fractures combined will be no more than 2 times the highest Fracture Benefit.
    Low Plan        High Plan
All Covered Persons   $1,500   $2,000
Hip, Thigh (Femur)
If more than one bone is fractured, the amount paid for all fractures combined will be no more than 2 times the highest Fracture Benefit.
    Low Plan        High Plan
All Covered Persons   $4,000   $5,000
Coccyx
If more than one bone is fractured, the amount paid for all fractures combined will be no more than 2 times the highest Fracture Benefit.
    Low Plan        High Plan
All Covered Persons   $500   $750
Leg (Tibia and/or Fibula)
If more than one bone is fractured, the amount paid for all fractures combined will be no more than 2 times the highest Fracture Benefit.
    Low Plan        High Plan
All Covered Persons   $1,500   $2,000
Kneecap (Patella)
If more than one bone is fractured, the amount paid for all fractures combined will be no more than 2 times the highest Fracture Benefit.
    Low Plan        High Plan
All Covered Persons   $500   $750
Ankle
If more than one bone is fractured, the amount paid for all fractures combined will be no more than 2 times the highest Fracture Benefit.
    Low Plan        High Plan
All Covered Persons   $500   $750
Chip Fracture
If more than one bone is fractured, the amount paid for all fractures combined will be no more than 2 times the highest Fracture Benefit.
    Low Plan        High Plan
All Covered Persons   25%   25%
Fracture (Open)
Face or Nose (Except Mandible or Maxilla)
If more than one bone is fractured, the amount paid for all fractures combined will be no more than 2 times the highest Fracture Benefit.
    Low Plan        High Plan
All Covered Persons   $2,000   $4,000
Skull Fracture - Depressed (Except Bones of Face or Nose)
If more than one bone is fractured, the amount paid for all fractures combined will be no more than 2 times the highest Fracture Benefit.
    Low Plan        High Plan
All Covered Persons   $8,000   $10,000
Skull Fracture - Non-Depressed (Except Bones of Face or Nose)
If more than one bone is fractured, the amount paid for all fractures combined will be no more than 2 times the highest Fracture Benefit.
    Low Plan        High Plan
All Covered Persons   $4,000   $5,000
Lower Jaw Mandible (Except Alveolar Process)
If more than one bone is fractured, the amount paid for all fractures combined will be no more than 2 times the highest Fracture Benefit.
    Low Plan        High Plan
All Covered Persons   $1,500   $2,000
Upper Jaw Maxilla (Except Alveolar Process)
If more than one bone is fractured, the amount paid for all fractures combined will be no more than 2 times the highest Fracture Benefit.
    Low Plan        High Plan
All Covered Persons   $2,000   $4,000
Upper Arm between Elbow & Shoulder (Humerus)
If more than one bone is fractured, the amount paid for all fractures combined will be no more than 2 times the highest Fracture Benefit.
    Low Plan        High Plan
All Covered Persons   $2,000   $4,000
Shoulder Blade (Scapula), Collarbone (Clavicle, Sternum)
If more than one bone is fractured, the amount paid for all fractures combined will be no more than 2 times the highest Fracture Benefit.
    Low Plan        High Plan
All Covered Persons   $1,500   $2,000
Forearm (Radius and/or Ulna), Hand, Wrist (Except Fingers)
If more than one bone is fractured, the amount paid for all fractures combined will be no more than 2 times the highest Fracture Benefit.
    Low Plan        High Plan
All Covered Persons   $1,500   $2,000
Rib
If more than one bone is fractured, the amount paid for all fractures combined will be no more than 2 times the highest Fracture Benefit.
    Low Plan        High Plan
All Covered Persons   $1,500   $2,000
Finger or Toe
If more than one bone is fractured, the amount paid for all fractures combined will be no more than 2 times the highest Fracture Benefit.
    Low Plan        High Plan
All Covered Persons   $200   $400
Vertebrae, Body of (Excluding Vertebral Processes)
If more than one bone is fractured, the amount paid for all fractures combined will be no more than 2 times the highest Fracture Benefit.
    Low Plan        High Plan
All Covered Persons   $3,000   $4,000
Vertebral Processes
If more than one bone is fractured, the amount paid for all fractures combined will be no more than 2 times the highest Fracture Benefit.
    Low Plan        High Plan
All Covered Persons   $1,000   $1,500
Pelvis (Includes Ilium, Ischium, Pubis, Acetabulum Except Coccyx)
If more than one bone is fractured, the amount paid for all fractures combined will be no more than 2 times the highest Fracture Benefit.
    Low Plan        High Plan
All Covered Persons   $3,000   $4,000
Hip, Thigh (Femur)
If more than one bone is fractured, the amount paid for all fractures combined will be no more than 2 times the highest Fracture Benefit.
    Low Plan        High Plan
All Covered Persons   $8,000   $10,000
Coccyx
If more than one bone is fractured, the amount paid for all fractures combined will be no more than 2 times the highest Fracture Benefit.
    Low Plan        High Plan
All Covered Persons   $1,000   $1,500
Leg (Tibia and/or Fibula)
If more than one bone is fractured, the amount paid for all fractures combined will be no more than 2 times the highest Fracture Benefit.
    Low Plan        High Plan
All Covered Persons   $3,000   $4,000
Kneecap (Patella)
If more than one bone is fractured, the amount paid for all fractures combined will be no more than 2 times the highest Fracture Benefit.
    Low Plan        High Plan
All Covered Persons   $1,000   $1,500
Ankle
If more than one bone is fractured, the amount paid for all fractures combined will be no more than 2 times the highest Fracture Benefit.
    Low Plan        High Plan
All Covered Persons   $1,000   $1,500
Chip Fracture
If more than one bone is fractured, the amount paid for all fractures combined will be no more than 2 times the highest Fracture Benefit.
    Low Plan        High Plan
All Covered Persons   25%   25%
Dislocation (Closed)
Lower Jaw
If more than one joint is dislocated, the amount we will pay for all dislocations combined will be no more than 2 times the highest Dislocation Benefit.
    Low Plan        High Plan
All Covered Persons   $750   $1,000
Collarbone (Sternoclavicular)
If more than one joint is dislocated, the amount we will pay for all dislocations combined will be no more than 2 times the highest Dislocation Benefit.
    Low Plan        High Plan
All Covered Persons   $1,000   $1,500
Collarbone (acromioclavicular and separation)
If more than one joint is dislocated, the amount we will pay for all dislocations combined will be no more than 2 times the highest Dislocation Benefit.
    Low Plan        High Plan
All Covered Persons   $750   $1,000
Shoulder (Glenohumeral)
If more than one joint is dislocated, the amount we will pay for all dislocations combined will be no more than 2 times the highest Dislocation Benefit.
    Low Plan        High Plan
All Covered Persons   $750   $1,000
Rib
If more than one joint is dislocated, the amount we will pay for all dislocations combined will be no more than 2 times the highest Dislocation Benefit.
    Low Plan        High Plan
All Covered Persons   $750   $1,000
Elbow
If more than one joint is dislocated, the amount we will pay for all dislocations combined will be no more than 2 times the highest Dislocation Benefit.
    Low Plan        High Plan
All Covered Persons   $750   $1,000
Wrist
If more than one joint is dislocated, the amount we will pay for all dislocations combined will be no more than 2 times the highest Dislocation Benefit.
    Low Plan        High Plan
All Covered Persons   $750   $1,000
Bone or Bones of the Hand (Other Than Fingers)
If more than one joint is dislocated, the amount we will pay for all dislocations combined will be no more than 2 times the highest Dislocation Benefit.
    Low Plan        High Plan
All Covered Persons   $750   $1,000
Hip
If more than one joint is dislocated, the amount we will pay for all dislocations combined will be no more than 2 times the highest Dislocation Benefit.
    Low Plan        High Plan
All Covered Persons   $4,000   $5,000
Knee (Except Patella)
If more than one joint is dislocated, the amount we will pay for all dislocations combined will be no more than 2 times the highest Dislocation Benefit.
    Low Plan        High Plan
All Covered Persons   $2,000   $2,500
Ankle - Bone or Bones of the Foot (Other Than Toes)
If more than one joint is dislocated, the amount we will pay for all dislocations combined will be no more than 2 times the highest Dislocation Benefit.
    Low Plan        High Plan
All Covered Persons   $750   $1,000
One Toe or Finger
If more than one joint is dislocated, the amount we will pay for all dislocations combined will be no more than 2 times the highest Dislocation Benefit.
    Low Plan        High Plan
All Covered Persons   $100   $200
Partial Dislocation
If more than one joint is dislocated, the amount we will pay for all dislocations combined will be no more than 2 times the highest Dislocation Benefit.
    Low Plan        High Plan
All Covered Persons   25%   25%
Dislocation (Open)
Lower Jaw
If more than one joint is dislocated, the amount we will pay for all dislocations combined will be no more than 2 times the highest Dislocation Benefit.
    Low Plan        High Plan
All Covered Persons   $1,500   $2,000
Collarbone (Sternoclavicular)
If more than one joint is dislocated, the amount we will pay for all dislocations combined will be no more than 2 times the highest Dislocation Benefit.
    Low Plan        High Plan
All Covered Persons   $2,000   $3,000
Collarbone (acromioclavicular and separation)
If more than one joint is dislocated, the amount we will pay for all dislocations combined will be no more than 2 times the highest Dislocation Benefit.
    Low Plan        High Plan
All Covered Persons   $1,500   $2,000
Shoulder (Glenohumeral)
If more than one joint is dislocated, the amount we will pay for all dislocations combined will be no more than 2 times the highest Dislocation Benefit.
    Low Plan        High Plan
All Covered Persons   $1,500   $2,000
Rib
If more than one joint is dislocated, the amount we will pay for all dislocations combined will be no more than 2 times the highest Dislocation Benefit.
    Low Plan        High Plan
All Covered Persons   $1,500   $2,000
Elbow
If more than one joint is dislocated, the amount we will pay for all dislocations combined will be no more than 2 times the highest Dislocation Benefit.
    Low Plan        High Plan
All Covered Persons   $1,500   $2,000
Wrist
If more than one joint is dislocated, the amount we will pay for all dislocations combined will be no more than 2 times the highest Dislocation Benefit.
    Low Plan        High Plan
All Covered Persons   $1,500   $2,000
Bone or Bones of the Hand (Other Than Fingers)
If more than one joint is dislocated, the amount we will pay for all dislocations combined will be no more than 2 times the highest Dislocation Benefit.
    Low Plan        High Plan
All Covered Persons   $1,500   $2,000
Hip
If more than one joint is dislocated, the amount we will pay for all dislocations combined will be no more than 2 times the highest Dislocation Benefit.
    Low Plan        High Plan
All Covered Persons   $8,000   $10,000
Knee (Except Patella)
If more than one joint is dislocated, the amount we will pay for all dislocations combined will be no more than 2 times the highest Dislocation Benefit.
    Low Plan        High Plan
All Covered Persons   $4,000   $5,000
Ankle - Bone or Bones of the Foot (Other Than Toes)
If more than one joint is dislocated, the amount we will pay for all dislocations combined will be no more than 2 times the highest Dislocation Benefit.
    Low Plan        High Plan
All Covered Persons   $1,500   $2,000
One Toe or Finger
If more than one joint is dislocated, the amount we will pay for all dislocations combined will be no more than 2 times the highest Dislocation Benefit.
    Low Plan        High Plan
All Covered Persons   $200   $400
Partial Dislocation
If more than one joint is dislocated, the amount we will pay for all dislocations combined will be no more than 2 times the highest Dislocation Benefit.
    Low Plan        High Plan
All Covered Persons   25%   25%
Burns
2nd Degree w/ Less Than 10% of Surface Skin Burnt
1 time per accident; Unlimited times per calendar year
    Low Plan        High Plan
All Covered Persons   $75   $100
2nd Degree 10-25% of Surface Skin Burnt
1 time per accident; Unlimited times per calendar year
    Low Plan        High Plan
All Covered Persons   $150   $200
2nd Degree 25-35% of Surface Skin Burnt
1 time per accident; Unlimited times per calendar year
    Low Plan        High Plan
All Covered Persons   $500   $750
2nd Degree 35% or More of Surface Skin Burnt
1 time per accident; Unlimited times per calendar year
    Low Plan        High Plan
All Covered Persons   $1,000   $1,500
3rd Degree Less Than 10% of Surface Skin Burnt
1 time per accident; Unlimited times per calendar year
    Low Plan        High Plan
All Covered Persons   $1,000   $1,500
3rd Degree 10-25% of Surface Skin Burnt
1 time per accident; Unlimited times per calendar year
    Low Plan        High Plan
All Covered Persons   $1,500   $2,000
3rd Degree 25-35% of Surface Skin Burnt
1 time per accident; Unlimited times per calendar year
    Low Plan        High Plan
All Covered Persons   $5,000   $7,500
3rd Degree 35% or More of Surface Skin Burnt
1 time per accident; Unlimited times per calendar year
    Low Plan        High Plan
All Covered Persons   $10,000   $15,000
Concussion
1 time per calendar year
    Low Plan        High Plan
All Covered Persons   $250   $500
Coma
1 time per accident; Unlimited times per calendar year
    Low Plan        High Plan
All Covered Persons   $7,500   $10,000
Lacerations
Without Repair by Stitches
1 time per accident; 3 time(s) per calendar year
    Low Plan        High Plan
All Covered Persons   $50   $75
Repair by Stitches But Less Than 2 Inches Long
1 time per accident; 3 time(s) per calendar year
    Low Plan        High Plan
All Covered Persons   $75   $125
Repair by Stitches & 2-6 Inches Long
1 time per accident; 3 time(s) per calendar year
    Low Plan        High Plan
All Covered Persons   $400   $700
Broken Teeth
Crown
1 time per accident; Unlimited times per calendar year (applies to all procedures)
    Low Plan        High Plan
All Covered Persons   $200   $300
Extraction
1 time per accident; Unlimited times per calendar year (applies to all procedures)
    Low Plan        High Plan
All Covered Persons   $100   $150
Filling
1 time per accident; Unlimited times per calendar year (applies to all procedures)
    Low Plan        High Plan
All Covered Persons   $25   $50
Eye Injury
Crown
1 time per accident; Unlimited times per calendar year
    Low Plan        High Plan
All Covered Persons   $300   $400
Medical Treatment & Services Benefits
Ground Ambulance
1 time per accident; Unlimited times per calendar year
    Low Plan        High Plan
All Covered Persons   $300   $400
 
Air Ambulance
1 time per accident; Unlimited times per calendar year
    Low Plan        High Plan
All Covered Persons   $1,000   $1,250
 
Emergency Room
1 time per accident (combined with Non-Emergency Initial Care Benefit). Payable within 96 hours after the accident.
    Low Plan        High Plan
All Covered Persons   $150   $200
 
Physician's Office
1 time per accident (combined with Non-Emergency Initial Care Benefit). Payable within 96 hours after the accident.
    Low Plan        High Plan
All Covered Persons   $75   $100
 
Urgent Care
1 time per accident (combined with Non-Emergency Initial Care Benefit). Payable within 96 hours after the accident.
    Low Plan        High Plan
All Covered Persons   $75   $100
 
Non-Emergency Initial Care
1 time per accident (combined with Emergency Care Benefit)
    Low Plan        High Plan
All Covered Persons   $75   $100
 
Medical Testing (X-rays, MRI/MR, Ultrasound, NCV, CT/CAT, EEG)
2 times per accident; Unlimited times per calendar year
    Low Plan        High Plan
All Covered Persons   $150   $200
 
Physician Follow-Up Visit
2 times per accident; 6 time(s) per calendar year
    Low Plan        High Plan
All Covered Persons   $75   $100
 
Transportation
1 time per accident; 2 times per calendar year
    Low Plan        High Plan
All Covered Persons   $300   $400
 
Acupuncture
10 time(s) per accident; Unlimited times per calendar year
    Low Plan        High Plan
All Covered Persons   $35   $50
 
Chiropractic Therapy
10 time(s) per accident; Unlimited times per calendar year
    Low Plan        High Plan
All Covered Persons   $35   $50
 
Cognitive Behavioral Therapy
10 time(s) per accident; Unlimited times per calendar year
    Low Plan        High Plan
All Covered Persons   $35   $50
 
Occupational Therapy
10 time(s) per accident; Unlimited times per calendar year
    Low Plan        High Plan
All Covered Persons   $35   $50
 
Physical Therapy
10 time(s) per accident; Unlimited times per calendar year
    Low Plan        High Plan
All Covered Persons   $35   $50
 
Respiratory Therapy
10 time(s) per accident; Unlimited times per calendar year
    Low Plan        High Plan
All Covered Persons   $35   $50
 
Speech Therapy
10 time(s) per accident; Unlimited times per calendar year
    Low Plan        High Plan
All Covered Persons   $35   $50
 
Vocational Therapy
10 time(s) per accident; Unlimited times per calendar year
    Low Plan        High Plan
All Covered Persons   $35   $50
 
Pain Management (for Epidural Anesthesia)
1 time per accident; Unlimited times per calendar year
    Low Plan        High Plan
All Covered Persons   $75   $100
 
Prosthetic - One Device Only
10 time(s) per accident; Unlimited times per calendar year
    Low Plan        High Plan
All Covered Persons   $750   $1,000
 
Prosthetic - More Than One Device
10 time(s) per accident; Unlimited times per calendar year
    Low Plan        High Plan
All Covered Persons   $1,500   $2,000
 
Brace
    Low Plan        High Plan
All Covered Persons   $75   $150
 
Cane
    Low Plan        High Plan
All Covered Persons   $75   $150
 
Crutches
    Low Plan        High Plan
All Covered Persons   $75   $150
 
Walker (Expected Use Less Than 1 Year)
    Low Plan        High Plan
All Covered Persons   $150   $200
 
Walker (Expected Use Greater Than 1 Year)
    Low Plan        High Plan
All Covered Persons   $300   $400
 
Walking Boot
    Low Plan        High Plan
All Covered Persons   $75   $150
 
Wheelchair or Motorized Scooter (Expected Use Less Than 1 Year)
    Low Plan        High Plan
All Covered Persons   $200   $300
 
Wheelchair or Motorized Scooter (Expected Use Greater Than 1 Year)
    Low Plan        High Plan
All Covered Persons   $750   $1,000
 
Other Medical Device Used for Mobility
    Low Plan        High Plan
All Covered Persons   $75   $100
 
Medical Appliance Benefit Limit (for All Appliances Combined per Accident)
    Low Plan        High Plan
All Covered Persons   $750   $1,000
 
Modification
1 time per accident; Unlimited times per calendar year
    Low Plan        High Plan
All Covered Persons   $1,000   $1,500
 
Blood/Plasma/Platelets
1 time per accident; Unlimited times per calendar year
    Low Plan        High Plan
All Covered Persons   $400   $500
 
Surgical Repair - Cranial
1 time per accident; Unlimited times per calendar year
    Low Plan        High Plan
All Covered Persons   $1,500   $2,000
 
Surgical Repair - Hernia
1 time per accident; Unlimited times per calendar year
    Low Plan        High Plan
All Covered Persons   $150   $200
 
Surgical Repair - Ruptured Disc
1 time per accident; Unlimited times per calendar year
    Low Plan        High Plan
All Covered Persons   $750   $1,500
 
Surgical Repair - Skin Graft (% of Burn Benefit)
1 time per accident; Unlimited times per calendar year
    Low Plan        High Plan
All Covered Persons   50%   50%
 
Surgical Repair - Torn Cartilage in Knee
1 time per accident; Unlimited times per calendar year
    Low Plan        High Plan
All Covered Persons   $750   $1,000
 
Surgical Repair - Torn Tendon/Ligament/Rotator Cuff - One
1 time per accident; Unlimited times per calendar year
    Low Plan        High Plan
All Covered Persons   $750   $1,000
 
Surgical Repair - Torn Tendon/Ligament/Rotator Cuff - Two or More
1 time per accident; Unlimited times per calendar year
    Low Plan        High Plan
All Covered Persons   $1,500   $2,000
 
Surgical Repair - Thoracic Cavity or Abdominal Pelvic Cavity
1 time per accident; Unlimited times per calendar year
    Low Plan        High Plan
All Covered Persons   $1,500   $2,000
 
Exploratory Surgery (for any Surgery Benefit Procedure)
1 time per accident; Unlimited times per calendar year
    Low Plan        High Plan
All Covered Persons   $150   $200
 
Other Outpatient Surgery Benefit
1 time per accident; Unlimited times per calendar year
    Low Plan        High Plan
All Covered Persons   $300   $400
Hospital Benefits
Hospital Admission
1 Time Per Accident; Unlimited Times Per Calendar Year
    Low Plan        High Plan
All Covered Persons   $1,000   $1,500
 
Hospital ICU Supplemental Confinement
(Paid in Addition to Admission)
1 Time Per Accident; Unlimited Times Per Calendar Year
    Low Plan        High Plan
All Covered Persons   $1,000   $1,500
 
Hospital Confinement
15 days per accident. Payable after the first day of admission. ICU Supplemental Confinement will pay an additional benefit for 15 of those days.
    Low Plan        High Plan
All Covered Persons   $200   $300
 
ICU Supplemental Confinement
(Paid in Addition to Confinement)
15 days per accident. Payable after the first day of admission. ICU Supplemental Confinement will pay an additional benefit for 15 of those days.
    Low Plan        High Plan
All Covered Persons   $200   $300
 
Inpatient Rehabilitation
15 days per accident; 30 days per calendar year.
    Low Plan        High Plan
All Covered Persons   $150   $200
Lodging Benefit
15 Day(s) per Calendar Year
    Low Plan        High Plan
All Covered Persons   $100   $200
Organized Sports Activity Injury Benefit
If a covered person has an accident that is due to organized sports activity, we will pay an extra 25% of eligible benefits, subject to limitations described in the certificate, under the following benefit categories: Accidental Injury, Accident - Medical Treatment and Services, Hospital benefits.
Health Screening Benefit
Benefit Amount: $50
Payable if an eligible covered person takes one of the screening/prevention measures listed below. Times Payable per Calendar Year: 1 time per Employee, 1 time per Spouse/Domestic Partner, 1 time per Dependent Child. Eligible Screening / Prevention Measures:
 
  Routine Health Check-Up Exam
  Biopsies For Cancer
  Blood Chemistry Panel
  Blood Test To Determine Total Cholesterol
  Blood Test To Determine Triglycerides
  Bone Marrow Testing
  Breast MRI
  Breast Ultrasound
  Breast Sonogram
  Cancer Antigen 15-3 Blood Test For Breast Cancer (CA 15-3)
  Cancer Antigen 125 Blood Test For Ovarian Cancer (CA 125)
  Carcinoembryonic Antigen Blood Test For Colon Cancer (CEA)
  Carotid Doppler
  Chest X-Rays
  Clinical Testicular Exam
  Colonoscopy
  Complete Blood Count (CBC)
  Coronavirus Testing Skin Exam
  Dental Exam
  Digital Rectal Exam (DRE)
  Doppler Screening For Cancer
  Doppler Screening For Peripheral Vascular Disease
  Echocardiogram
  Electrocardiogram (EKG)
  Electroencephalogram (EEG)
  Endoscopy
  Fasting Plasma Glucose Test
  Fasting Blood Glucose Test
  Flexible Sigmoidoscopy
  Hearing Test
  Hemoccult Stool Specimen
  Hemoglobin A1c
  Human Papillomavirus (HPV) Vaccination
  Immunizations
  Lipid Panel
  Mammogram
  Oral Cancer Screening
  PAP Smears Or Thin Prep PAP Test
  Prostate-Specific Antigen (PSA) Test
  Serum Cholesterol Test To Determine Ldl And Hdl Levels
  Serum Protein Electrophoresis
  Skin Cancer Biopsy
  Skin Cancer Screening
  Stress Test On Bicycle Or Treadmill
  Successful Completion Of Smoking Cessation Program
  Tests For Sexually Transmitted Infections (STI's)
  Thermography
  Two-Hour Post-Load Plasma Glucose Test
  Ultrasounds For Cancer Detection
  Ultrasound Screening Of The Abdominal Aorta For Abdominal Aortic Aneurysms
  Virtual Colonoscopy
Monthly Rates
Coverage & Rates shown are for the 2025/26 Plan Year, effective 7/1/2025 through 6/30/2026.
Type   Low Plan        High Plan
Employee Only   10.23   16.11
Employee & Spouse   20.29   31.88
Employee & Child(ren)   24.36   38.12
Employee, Spouse & Child(ren)   28.80   45.16
Enrollment

  Eligibility:
      For eligible active employee members only.
      Only available if Employer group allows this coverage to be offered.
  Opportunities:
      OPEH&W Initial Enrollment.
      OPEH&W Annual Open Enrollment.
      First Offering from OPEH&W.





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