Benefits	Standard Plan	Select Plan	Premier Plan
Doctor’s Office Visit	$50 per visit $300 calendar year max	$50 per visit $300 calendar year max	$60 per visit $360 calendar year max
Outpatient Diagnostic, X-ray and Lab	Not Included	$50 per day $300 calendar year max	$60 per day $360 calendar year max
Advanced Studies	Not Included	$200 per day $600 calendar year max	$250 per day $750 calendar year max
Preventive Care	$50 per visit $150 calendar year max	$50 per visit $150 calendar year max	$75 per visit $225 calendar year max
Surgical Benefit Inpatient Outpatient Outpatient Minor Outpatient Venipuncture	Not Included	$850 overall max $500 lump sum $250 lump sum $75 lump sum $25 lump sum	$1,600 overall max $1,000 lump sum $500 lump sum $75 lump sum $25 lump sum
Anesthesiology	Not Included	$125 lump sum	$250 lump sum
Emergency Room Indemnity Benefit for Illness Only	$75 per visit $300 calendar year max	$100 per visit $400 calendar year max	$100 per visit $400 calendar year max
Daily In-Patient Hospital Benefit Intensive Care Unit Mental Illness Disorder Substance Abuse In-Patient Skilled Nursing Facility	$100 per day $200 per day $50 per day $50 per day $50 per day	$300 per day $600 per day $150 per day $150 per day $150 per day	$500 per day $1,000 per day $250 per day $250 per day $250 per day
Hospital Admission	Not Included	$300 per confinement	$500 per confinement
Accident Coverage	$300 max per occurrence	$500 max per occurrence	$1,000 max per occurrence
AD&D Only (Employee)	$10,000	$10,000	$10,000
Network	First Health Network Doctor	First Health Network Doctor	First Health Network Doctor & Hospital
*Health Savings Program	Included	Included	Included
*Tier’d RX Program	Included	Included	Included
Employer Paid Rates (Minimum 50% employer contribution) Employee Employee Plus Child(ren) Employee Plus Spouse Family	Monthly $35.33 $52.35 $75.36 $80.22	Monthly $65.99 $99.05 $156.01 $164.26	Monthly $94.70 $143.65 $227.42 $240.86
Voluntary Rates Employee Employee Plus Child(ren) Employee Plus Spouse Family	Monthly $41.35 $62.13 $90.88 $96.96	Monthly $76.68 $120.51 $191.69 $202.02	Monthly $114.93 $175.62 $280.34 $297.14

*These benefits are not underwritten by Standard Security Life Insurance Company of New York.