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	$500 lump sum $250 lump sum $75 lump sum $25 lump sum	$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
First Health Network	Doctor	Doctor	Doctor & Hospital
*Health Savings Program	Included	Included	Included
*Prescription Program	Tiered-pricing pharmacy	Tiered-pricing pharmacy	Tiered-pricing pharmacy
Employer Paid Rates (Minimum 50% employer contribution) Employee Employee Plus Child(ren) Employee Plus Spouse Family	Monthly $35.33 $52.35 $75.35 $80.21	Monthly $65.99 $99.06 $156.01 $164.25	Monthly $94.70 $143.64 $227.43 $240.87
Voluntary Rates Employee Employee Plus Child(ren) Employee Plus Spouse Family	Monthly $44.16 $65.44 $94.19 $100.26	Monthly $82.49 $123.83 $195.01 $205.31	Monthly $118.38 $179.55 $284.29 $301.09

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