Summary of Benefits

HDHP Plans

Summary of Benefits - HSA Qualified High Deductible Health Plans Effective: January 1, 2008
This outline does not constitute the group policy and is not a contract of insurance. It explains in simple language the essential features
of the group benefits provided. All rights with respect to the benefits of an insured person will be governed solely by the group policy.

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
Calendar Year Deductible
PPO Individual	$1,100	$2,900	$5,600
Family	$2,200	$5,800	$11,200
Non PPO Individual	Double PPO	Double PPO	Double PPO
Family	Double PPO	Double PPO	Double PPO
Calendar Year Coinsurance Plan Pay 50% in network/40% out of network
PPO Individual	$4,500	$2,700	$-0-
Family	$9,000	$5,400	$-0-
Non PPO Individual	Double PPO	Double PPO	Double PPO
Family	Double PPO	Double PPO	Double PPO
	Maximum Out-of-Pocket	Individual $5,600, Family $11,200	Out-of-Network Doubled

Pre-existing Limitation	None
Physician/Practitioner Office Visit	Subject to Deductible and Coinsurance.
Routine Physical Exam	PPO payable 100%. Non-PPO subject to Deductible and Coinsurance.
Preventive Child Care/Year	PPO payable 100%. Non-PPO subject to Deductible and Coinsurance.
Immunizations Per CDC	PPO payable 100%. Non-PPO subject to Deductible and Coinsurance. Foreign travel immunizations are excluded.
In-patient Hospitalization	Subject to Deductible and Coinsurance.
Out-patient Hospitalization	Subject to Deductible and Coinsurance.
Surgery	Subject to Deductible and Coinsurance.
Anesthesiologist	Subject to Deductible and Coinsurance. If surgeon is PPO, then anesthesiologist treated as PPO.
Skilled Nursing	Subject to Deductible and Coinsurance. 100 days per calendar year.
Home Health Care	Subject to Deductible and Coinsurance. 100 days per calendar year.
Hospice Care	Subject to Deductible and Coinsurance. $10,000 Lifetime Maximum.
Bereavement Counseling	Four sessions/$25 Maximum
Hospital Emergency Room	Subject to Deductible and Coinsurance.
Maternity	Subject to Deductible and Coinsurance. Family coverage.
Bariatric Surgery	Not covered
Ambulance	Subject to Deductible and Coinsurance.
Chiropractic Office Visit	Subject to Deductible and Coinsurance. 26 visits per Calendar Year
Durable Medical Equipment	Subject to Deductible and Coinsurance.
TMJ	Subject to Deductible and Coinsurance. $1,000 Lifetime Maximum.
Prescription Drugs
	Patient Pays 100% at the Point of Sale - Reimbursed After Applying Deductible and Coinsurance.
Retail:	Receive up to a 31 day supply at a retail store:
Generic	Subject to Deductible and Coinsurance, then 100% coverage in-network.
Preferred Brand	Subject to Deductible and Coinsurance, then 100% coverage in-network.
Non-Preferred Brand	Subject to Deductible and Coinsurance, then 100% coverage in-network.
Mail Order:	Receive up to a 90 day supply through TCSIG's mail order:
Generic	Subject to Deductible and Coinsurance, then 100% coverage in-network.
Preferred Brand	Subject to Deductible and Coinsurance, then 100% coverage in-network.
Non-Preferred Brand	Subject to Deductible and Coinsurance, then 100% coverage in-network.
Mental Health	Pre-certification required for both Inpatient and Outpatient services.
In-patient Hospitalization	PPO Only. Subject to Deductible and Coinsurance, then 100% coverage in-network.
Days Limitation	30 per yr/90 lifetime
PPO Out-patient	Maximum Allowed $100. Subject to Deductible and Coinsurance.
Non PPO Out-patient	Maximum Allowed $50. Subject to Deductible and Coinsurance.
Calendar Year Maximum	Subject to Deductible and Coinsurance. 52 visits, 1 per day
Chemical Dependency	Subject to Deductible and Coinsurance. Calendar Year Max $10,000; Lifetime Max $20,000

Phone: (530) 822-5299 or Toll-Free (866) 822-5299

Last modified: 04-22-08

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