|
|
HSA Choice
HSA Qualified
|
| Lifetime Maximum |
$4,000,000
|
| Calendar Year Deductible |
$2,500 Individual; $5,000 Family
|
| Coinsurance Maximum Per Individual |
$1,000 Individual; $2,000 Family
|
| Out-of-Pocket Maximum |
Deductible + Coinsurance Maximum
|
| PREVENTATIVE CARE |
Member Responsibility
|
| |
Any Provider
|
Routine Physical Exams
Well-Baby Care |
Not Covered
|
| Routine Immunizations/Vaccinations |
| Women’s Routine Mammograms |
20% †
|
| Women’s & Men's Annual Health
Exams |
20% †
|
| PHYSICIAN PROVIDER SERVICES |
| Office visits |
20%
|
| Alternative Care (12 visit PCY Limit) |
20%
(Preferred Providers only)
|
| HOSPITAL SERVICES |
Inpatient & Outpatient Surgery
Room & Ancillary Charges
Physician Services |
20%
|
| MATERNITY |
All Pre/Post Office Visits & Doctor
Delivery
Hospital Charges |
20%
|
| EMERGENCY SERVICES |
| Urgent Care |
20%
|
Hospital Emergency Room
Ambulance
($5,000 PCY Limit for Air & Ground) |
20%
|
| OTHER FACILITIES & SERVICES |
Lab & X-ray Services
Medical Supplies & Devices - ($2,500 PCY limit)
Home Health Care - (130 visit PCY limit) |
20%
|
Prescription Services
(No Mail Order Program) |
Deductible, then 20% except generic cardiac preventive
drugs covered in full/deductible waived
|
| Accident Benefit |
Paid as any other illness subject to deductible/coinsurance
|
| SUPPLEMENTAL BENEFIT OPTIONS |
Prescription Drug
Buy-Up Option |
Not Available
|
| Alcohol Dependency Treatment Option |
This optional benefit is available at an additional
cost.
It is limited to $4,500 in any 24 consecutive months.
|
|
† - Deductible waived.
* Family deductible applies when an individual and a spouse or one (1)
or more dependents are enrolled. Therefore, prior to benefits being paid,
the entire family deductible must be met.
|
Plan Updates 
