Your Out-of-Network High Deductible Health Plan (HDHP) Benefits At A Glance (These plans are all compatible with Health Savings Accounts)

High Deductible PPO Out-of-Network Benefit Summary* (click here for out-of-network benefit summary)
Description of Benefits		1,150 / 2,300 Ded 100% Plan	1,800 / 3,500 Ded 100% Plan	2,600 / 5,150 Ded 100% Plan	1,150 / 2,300 Ded 80% Plan	1,800 / 3,500 Ded 80% Plan	2,600 / 5,150 Ded 80% Plan
Lifetime Maximum Per Member		$5,000,000	$5,000,000	$5,000,000	$5,000,000	$5,000,000	$5,000,000
Annual Deductible: Individual Family		$1,000 $2,000	$1,800 $3,500	$2,600 $5,150	$1,000 $2,000	$1,800 $3,500	$2,600 $5,150
Annual Out-of-Pocket Maximum: Individual Family		$1,000 $2,000	$1,800 $3,500	$2,600 $5,150	$3,000 $6,000	$4,000 $8,000	$5,000 $10,000
Office Visits - (PPO Physicians and Specialists- includes X-ray and lab work when performed and billed by the physician's office)		70% after deductible	70% after deductible	70% after deductible	60% after deductible	60% after deductible	60% after deductible
Preventive Care for Babies and Children (through age 5)		70% with deductible waived	70% with deductible waived	70% with deductible waived	60% with deductible waived	60% with deductible waived	60% with deductible waived
Preventive Care for Adults ($250 benefit max. per year)		70% with deductible waived	70% with deductible waived	70% with deductible waived	60% with deductible waived	60% with deductible waived	60% with deductible waived
Professional Services Including surgery, anesthesia in-hospital physician care, diagnostic X-ray and lab.		70% after deductible	70% after deductible	70% after deductible	60% after deductible	60% after deductible	60% after deductible
Inpatient Hospital Services Surgery, x-ray, in-hospital physician visits, organ/tissue transplants		70% after deductible	70% after deductible	70% after deductible	60% after deductible	60% after deductible	60% after deductible
Maternity (Available on Family Contracts Only) Note: No maternity benefits are payable for the first 12 months of coverage.		70% after deductible	70% after deductible	70% after deductible	60% after deductible	60% after deductible	60% after deductible
Outpatient Medical Care		70% after deductible	70% after deductible	70% after deductible	60% after deductible	60% after deductible	60% after deductible
Physical/Occupational Therapy, Chiropractic (Limited to 30 visits per year combined)		70% after deductible	70% after deductible	70% after deductible	60% after deductible	60% after deductible	60% after deductible
Mental, Emotional or Functional Nervous Disorders - Hospital Inpatient Only - Outpatient is not a covered benefit		$100/day - $3,000 maximum per year - $10,000 lifetime maximum	$100/day - $3,000 maximum per year - $10,000 lifetime maximum	$100/day - $3,000 maximum per year - $10,000 lifetime maximum	$100/day - $3,000 maximum per year - $10,000 lifetime maximum	$100/day - $3,000 maximum per year - $10,000 lifetime maximum	$100/day - $3,000 maximum per year - $10,000 lifetime maximum
Infusion Therapy/Chemotherapy		70% after deductible	70% after deductible	70% after deductible	60% after deductible	60% after deductible	60% after deductible
Emergency Room Care		70% after deductible	70% after deductible	70% after deductible	60% after deductible	60% after deductible	60% after deductible
Ambulatory Surgical Center		70% after deductible	70% after deductible	70% after deductible	60% after deductible	60% after deductible	60% after deductible
Ambulance Service		70% after deductible	70% after deductible	70% after deductible	60% after deductible	60% after deductible	60% after deductible
Home Health Care Maximum of 100 visits per year for preferred and non-preferred providers combined		70% after deductible	70% after deductible	70% after deductible	60% after deductible	60% after deductible	60% after deductible
Speech/Respiratory Therapy/Skilled Nursing Maximum of 30 visits per year per specialty		70% after deductible	70% after deductible	70% after deductible	60% after deductible	60% after deductible	60% after deductible
Hospice Maximum lifetime covered expense of $10,000		70% after deductible	70% after deductible	70% after deductible	60% after deductible	60% after deductible	60% after deductible
Home Health Care - Maximum of 100 visits per year		70% after deductible	70% after deductible	70% after deductible	60% after deductible	60% after deductible	60% after deductible
Durable Medical Equipment and Prosthetics		70% after deductible	70% after deductible	70% after deductible	60% after deductible	60% after deductible	60% after deductible
Private Duty Nursing $2,500 per year maximum		70% after deductible	70% after deductible	70% after deductible	60% after deductible	60% after deductible	60% after deductible
Prescription Drugs - Includes Generic, Brand Formulary and Non-Brand Formulary		70% after deductible	70% after deductible	70% after deductible	60% after deductible	60% after deductible	60% after deductible
Waiting period for all pre-existing conditions is at least one year from contract effective date. *Refer to your individual certificate of coverage for complete benefit details
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