| Health Plans for Medical
Savings Account Benefit Summary
All benefits listed below are for
In-Network Providers Only* |
| LOW DEDUCTIBLE OPTION | HIGH DEDUCTIBLE OPTION | |
| Deductible
In-Network (A family is two or more Members) |
$1,550
(Single) $3,050 (Family) |
$2,300(Single) $4,600 (Family) |
| Deductible Out-of-Network | Does Not Apply* | Does Not Apply* |
| Out-of-Network Benefit | None* | None* |
| Lifetime Maximum Benefit | $5,000,000 | $5,000,000 |
| Annual Out-of-Pocket Maximum** (including deductibles, co-payments, co-insurance & costs for covered services in excess of any limited benefit payments) per member in-network. Once your co-insurance reaches your annual out-of-pocket maximum, you pay nothing for covered expenses for the rest of the calendar year, except for specific services listed in your Evidence of Coverage booklet. | $3,050
(Single) $5,500 (Family) |
$3,050
(Single) $5,500 (Family) |
| Professional Service - Office Visit Co-Insurance | 20% of negotiated fee after annual deductible | 20% of negotiated fee after annual deductible |
| Professional Service - Maternity Benefits including prenatal and postnatal care and hospital and inpatient physician services for deliveries and complications of pregnancy. | 20% of negotiated fee after annual deductible | 20% of negotiated fee after annual deductible |
| Professional Service - Well-Baby and Well-Child Care by Primary Care Physicians for members through age six including childhood immunizations, associated routine physical exams, associated procedures, and routine hearing and vision tests. | 50% of negotiated fee. No deductible required. | 50% of negotiated fee. No deductible required. |
| Professional Service - Outpatient Surgical | 20% of negotiated fee after annual deductible | 20% of negotiated fee after annual deductible |
| Professional Service - Outpatient Preventive Care includes mammograms, PSA, cancer screenings when ordered by your physician | 20% of negotiated fee after annual deductible | 20% of negotiated fee after annual deductible |
| Professional Service - Outpatient Infusion Therapy (requires pre-service review) | 20% of negotiated fee after annual deductible | 20% of negotiated fee after annual deductible |
| Preventive
Care at Prudent Buyer Check Up Centers Age 19 and above: physical assessment, blood pressure, cholesterol and
glucose measurement, tetanus and flu immunizations and other medically appropriate tests
as indicated. |
$25 co-payment | $25 co-payment |
| Inpatient
Hospital Professional Services - Surgery, Anesthesia, Lab, Physician visits |
20% of negotiated fee after annual deductible | 20% of negotiated fee after annual deductible |
| Inpatient Hospital Services, Supplies, and Medications including facility fees. Requires pre-service review. | 20% of negotiated fee after annual deductible | 20% of negotiated fee after annual deductible |
| Inpatient Nervous and Mental | You pay all covered expenses except a $175 per day after annual deductible ($5,250 maximum benefit per year) | You pay all covered expenses except a $175 per day after annual deductible ($5,250 maximum benefit per year) |
| Outpatient Surgical Services, Supplies and Medications including facility fees | 20% of negotiated fee after annual deductible | 20% of negotiated fee after annual deductible |
| Outpatient Nervous and Mental | Limited to one visit per day; 20 visits per year for physician's services. You pay any amount over $25 per visit after annual deductible. | Limited to one visit per day; 20 visits per year for physician's services. You pay any amount over $25 per visit after annual deductible. |
| Emergency Room Outpatient for medical emergencies only as defined in your Evidence of Coverage | 20% of negotiated fee after annual deductible | 20% of negotiated fee after annual deductible |
| Ambulance for medical emergencies only as defined in your Evidence of Coverage | 20% of negotiated fee after annual deductible | 20% of negotiated fee after annual deductible |
| Home Health Care must be ordered by physician and renewed every 30 days | 20% of negotiated fee after annual deductible up to 60 visits (4 hours or less of treatment) per year | 20% of negotiated fee after annual deductible up to 60 visits (4 hours or less of treatment) per year |
| Durable Medical Equipment | 20% of negotiated fee after annual deductible | 20% of negotiated fee after annual deductible |
| Skilled Nursing Facility includes facility, lab tests, physical, occupational, speech, and respiratory therapy, and medications. Requires pre-service review. | 20% of negotiated fee after annual deductible limited to 100 days per year | 20% of negotiated fee after annual deductible limited to 100 days per year |
| Acupuncture | You pay any amount over $25 per visit after annual deductible limited to 12 visits per year | You pay any amount over $25 per visit after annual deductible limited to 12 visits per year |
| MedCall | 24 hours/day, 7 days/week, toll-free, no fee | 24 hours/day, 7 days/week, toll-free, no fee |
| * Only exceptions are for
service received by a non-participating provider, foreign country provider,
non-contracting hospital, and out-of-state provider only as a result of a medical
emergency or an authorized referral as described in the Evidence of Coverage and
Disclosure form. ** Your annual out-of-pocket expenses may exceed this maximum because of exclusions, limitations or conditions of coverage. |