| Summary of Benefits
- HSA Qualified High Deductible Health Plans
Effective: January 1, 2007
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| This
outline does not constitute the group policy and is not a contract of
insurance. It explains in
simple language the essential features |
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the group benefits provided. All
rights with respect to the benefits of an insured person will
be governed solely by the group policy. |
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| Benefits |
High
Deductible Health Plan -1 |
High
Deductible Health Plan - 2 |
High Deductible Health Plan - 3 |
| Composite |
$750 |
$669 |
$651 |
| Employee
Only |
$375 |
$334 |
$326 |
| Employee +
1 |
$713 |
$636 |
$618 |
| Employee +
Family |
$938 |
$836 |
$814 |
| Single
Medicare |
$248 |
$221 |
$215 |
| Maximum
Lifetime |
$6,000,000 |
$6,000,000 |
$6,000,000 |
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Calendar
Year Deductible
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| PPO
Individual |
$1,100 |
$2,850 |
$5,500 |
| Family |
$2,200 |
$5,650 |
$11,000 |
| Non
PPO Individual |
Double
PPO |
Double
PPO |
Double
PPO |
| Family |
Double
PPO |
Double
PPO |
Double
PPO |
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Calendar
Year Coinsurance Plan Pay 50% in network/40% out of network |
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PPO
Individual
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$4,400 |
$2,650 |
$-0- |
| Family |
$8,800 |
$5,350 |
$-0- |
| Non PPO
Individual |
Double
PPO |
Double
PPO |
Double
PPO |
| Family |
Double
PPO |
Double
PPO |
Double
PPO |
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| Pre-existing
Limitation |
None |
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| Physician/Practitioner
Office Visit |
Subject
to Deductible & Coinsurance |
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| Routine
Physical Exam |
Plan
pays 100% to $300 Maximum per Calendar Year |
| Preventive
Child Care/Year |
Plan
pays 100% to $300 Maximum per Calendar Year |
| Immunizations |
Covered through age
7 as part of $200 Preventive Child Care. |
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Covered through age
18 as part of $300 Routine Physical Exam |
| Skilled
Nursing |
Deductible
and Coinsurance. 100 days Per Calendar Year. |
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| Home
Health Care/Year |
Deductible
and Coinsurance. 100 visits Per Calendar Year. |
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| Hospice
Care/Lifetime |
Deductible
and Coinsurance.$10,000 |
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| Bereavement
Counseling |
Deductible
and Coinsurance. Four sessions/$25 |
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| Hospital
Emergency Room |
Subject
to Deductible and Coinsurance. |
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| Maternity |
Subject
to Deductible and Coinsurance. |
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| Surgery |
Subject
to Deductible and Coinsurance. |
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| Anesthesiologist |
Subject
to Deductible and Coinsurance. |
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| Bariatric Surgery |
Not covered |
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| Ambulance |
Subject
to Deductible and Coinsurance. |
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| Chiropractic
Office Visit |
Subject
to Deductible and Coinsurance. 26 Visits per Calendar Year. |
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| Durable
Medical Equipment |
Subject
to Deductible and Coinsurance. |
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| TMJ/Lifetime
Benefit |
Subject
to Deductible and Coinsurance. $1,000 Lifetime Maximum. |
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Prescription Drugs
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Retail:
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Receive up to a 31
day supply at a retail store: |
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Generic
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Subject
to Deductible and Coinsurance, then 100% coverage in-network. |
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| Preferred Brand |
Subject
to Deductible and Coinsurance, then 100% coverage in-network. |
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| Non-Preferred |
Subject
to Deductible and Coinsurance, then 100% coverage in-network. |
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Mail Order:
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Receive up to a 90
day supply through TCSIG's mail order: |
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| Generic |
Subject
to Deductible and Coinsurance, then 100% coverage in-network. |
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| Preferred Brand |
Subject
to Deductible and Coinsurance, then 100% coverage in-network. |
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| Non-Preferred |
Subject
to Deductible and Coinsurance, then 100% coverage in-network. |
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| Mental Health |
Pre-certification
required for both Inpatient and Outpatient services |
| In-patient
Hospitalization |
PPO Only.Subject
to Deductible and Coinsurance. |
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| Days Limitation |
30 per yr/90 lifetime |
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| PPO Out-patient |
Subject
to Deductible and Coinsurance. |
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| Non PPO Out-patient |
Subject
to Deductible and Coinsurance |
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| Cal Year Maximum |
Subject
to Deductible and Coinsurance. 52 visits, 1 per day |
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| Chemical Dependency |
Subject
to Deductible and Coinsurance. Calendar Year Max
$10,000; Lifetime Max $20,000. |
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