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HSA Eligible Plans
Non-Grandfathered Plans Effective January 1, 2012 In-Network Benefits
Benefit Description	Protect HSA $1,500	Protect HSA $2,500	Protect HSA $2,850	Protect HSA $3,500
Annual Deductible	$1,500 per member* $3,000 per family**	$2,500 per individual* $5,000 per family**	$2,850 per member* $5,650 per family**	$3,500 per member* $7,000 per family**
Annual Out-of-Pocket Maximum	$4,500 per member* $9,000 per family**	$2,500 per individual* $5,000 per family**	$5,500 per member* $11,000 per family**	$5,500 per member* $11,000 per family**
Lifetime Maximum Benefit	None ($2,000,000 cal. year max.)	None ($2,000,000 cal. year max.)	None ($2,000,000 cal. year max.)	None ($2,000,000 cal. year max.)
Office Visits	30% of negotiated fee after deductible	100% paid after deductible	30% of negotiated fee after deductible	20% of negotiated fee after deductible
Other Professional Services	30% of negotiated fee after deductible	100% paid after deductible	30% of negotiated fee after deductible	20% of negotiated fee after deductible
Emergency Care	30% of negotiated fee after deductible	100% paid after deductible	30% of negotiated fee after deductible	20% of negotiated fee after deductible
Inpatient Hospital Services and Surgical Facilities	30% of negotiated fee after deductible	100% paid after deductible	30% of negotiated fee after deductible	20% of negotiated fee after deductible
Inpatient Professional Services for Surgery, Anesthesia, Lab and Physician Visits	30% of negotiated fee after deductible	100% paid after deductible	30% of negotiated fee after deductible	20% of negotiated fee after deductible
Other Professional Services	30% of negotiated fee after deductible	100% paid after deductible	30% of negotiated fee after deductible	20% of negotiated fee after deductible
Well Woman Care	Not subject to the deductible, 100% plan paid. 1 visit/year	Not subject to the deductible, 100% plan paid. 1 visit/year	Not subject to the deductible, 100% plan paid. 1 visit/year	Not subject to the deductible, 100% plan paid. 1 visit/year
Well Baby Care	Not subject to the deductible, 100% plan paid.	Not subject to the deductible, 100% plan paid.	Not subject to the deductible, 100% plan paid.	Not subject to the deductible, 100% plan paid.
Preventive Care (Ages 7 & Up)	Not subject to the deductible, 100% plan paid. 1 visit/year	Not subject to the deductible, 100% plan paid. 1 visit/year	Not subject to the deductible, 100% plan paid. 1 visit/year	Not subject to the deductible, 100% plan paid. 1 visit/year
Mental and Nervous/Substance Abuse - Inpatient	30% of negotiated fee after deductible	100% paid after deductible	30% of negotiated fee after deductible	30% of negotiated fee after deductible
Mental and Nervous/Substance Abuse - Outpatient	30% of negotiated fee after deductible	100% paid after deductible	30% of negotiated fee after deductible	20% of negotiated fee after deductible
Physical Therapy, Occupational Therapy, Chiropractic Care	30% of negotiated fee after deductible, 25 visits/year	100% paid after deductible, max. 25 visits/year (combined with out-of-network visits)	30% of negotiated fee after deductible, 25 visits/year	20% of negotiated fee after deductible, 25 visits/year
Acupuncture	30% of negotiated fee after deductible. Plan pays up to $60/visit after deductible, max. 12 visits/year	100% paid after deductible. Plan pays up to $60/visit, max. 12 visits/year (combined with out-of-network visits)	30% of negotiated fee after deductible. Plan pays up to $60/visit, max. 12 visits/year	20% of negotiated fee after deductible. Plan pays up to $60/visit after deductible, max. 12 visits/year
Durable Medical Equipment	30% of negotiated fee after deductible	100% paid after deductible	30% of negotiated fee after deductible	20% of negotiated fee after deductible
Skilled Nursing Facility	30% of negotiated fee after deductible, 100 days/year	100% paid after deductible, up to 100 days per year (combined in/out-of-network)	30% of negotiated fee after deductible, 100 days/year	20% of negotiated fee after deductible, 100 days/year
Hospice Care	30% of negotiated fee after deductible, up to the $5,000 lifetime max.	100% paid after deductible, up to $5,000 lifetime maximum	30% of negotiated fee after deductible, up to the $5,000 lifetime max.	20% of negotiated fee after deductible, up to the $5,000 lifetime max.
Home Healthcare	30% of negotiated fee after deductible, 90 visits/year	100% paid after deductible max. 90 visits/year (combined in/out of network)	30% of negotiated fee after deductible, 90 visits/year	20% of negotiated fee after deductible, 90 visits/year
Prescription Drugs
Prescription Deductible	No separate deductible	No separate deductible	No separate deductible	No separate deductible
Participating Pharmacies (30-day supply)	30% of negotiated drug rate after deductible	Plan pays 100% of negotiated drug rate after deductible	30% of negotiated drug rate after deductible	20% of negotiated drug rate after deductible
Self-Administered Injectable Drugs (excluding Insulin) Retail (30-day supply) Mail Order (60-day supply) Anthem Blue Cross Express Scripts Only	30% of negotiated drug rate after deductible	Plan pays 100% of negotiated drug rate after deductible	30% of negotiated drug rate after deductible	30% of negotiated drug rate after deductible
Mail Order (60-day supply) Anthem Blue Cross Express Scripts Only Note: Some specialty drugs are available only through Anthem Blue Cross’s CuraScript mail order program	30% of negotiated drug rate after deductible	Plan pays 100% of negotiated drug rate after deductible	30% of negotiated drug rate after deductible	20% of negotiated drug rate after deductible
Out-of-Network Benefits
Annual Deductible	No separate deductible, Out-of-Network benefits are included in the annual deductible	No separate deductible, Out-of-Network benefits are included in the annual deductible	No separate deductible, Out-of-Network benefits are included in the annual deductible	No separate deductible, Out-of-Network benefits are included in the annual deductible
Annual Out-of-Pocket Maximum	No separate Out-of-Pocket Max., Out-of-Network benefits are included in the annual Out-of-Pocket Max.	$5,000 per individual* $10,000 per family (Separate in-/out-of-network Out-of-Pocket Maximums)**	No separate Out-of-Pocket Max., Out-of-Network benefits are included in the annual Out-of-Pocket Max.	No separate Out-of-Pocket Max., Out-of-Network benefits are included in the annual Out-of-Pocket Max.
Office Visits	Plan pays 50% of allowable fee after deductible	Plan pays 70% of allowable fee after deductible	Plan pays 50% of allowable fee after deductible	Plan pays 50% of allowable fee after deductible
Inpatient Hospital Services - Contracting Hospital	Plan pays 50% of allowable fee, up to a max. of $540 per day after deductible	Plan pays 70% of allowable fee after deductible, up to a maximum of $650 per day	Plan pays 50% of allowable fee, up to a max. of $540 per day after deductible	Plan pays 50% of allowable fee, up to a max. of $540 per day after deductible
Mental and Nervous/Substance Abuse - Inpatient	Plan pays 50% of allowable fee, up to a max. of $540 per day, after deductible	Plan pays 70% of allowable fee after deductible, up to a maximum of $650 per day	Plan pays 50% of allowable fee, up to a max. of $540 per day, after deductible	Plan pays 50% of allowable fee, up to a max. of $540 per day, after deductible
Mental and Nervous/Substance Abuse - Outpatient	Plan pays 50% of allowable fee after deductible	Plan pays 70% of allowable fee after deductible, up to a maximum of $380 per day	Plan pays 50% of allowable fee after deductible	Plan pays 50% of allowable fee after deductible
Out-of-Network Prescription Drugs
Prescription Deductible	No separate deductible	No separate deductible	No separate deductible	No separate deductible
Mail Order	Not covered	Not covered	Not covered	Not covered
Retail Pharmacies (30-day supply)	Plan pays 50% of the allowable drug fee after deductible. Member pays any excess charges.	Plan pays 70% of the allowable drug fee after deductible. Member pays any excess charges.	Plan pays 50% of the allowable drug fee after deductible. Member pays any excess charges.	Plan pays 50% of the allowable drug fee after deductible. Member pays any excess charges.
Self-Administered Injectable Drugs (excluding Insulin)	Not covered	Not covered	Not covered	Not covered
Individual Coverage refers to a subscriber without covered dependents. Individual subscribers are subject to the Individual Deductible and Individual Out-of-Pocket Maximum. *Family Coverage refers to a subscriber and covered dependents. Benefits will not be paid for any family member until the full Family Deductible is met. Likewise, the Family Out-of-Pocket Maximum will not be considered met for any family member until the full Family Out-of-Pocket Maximum is met. Prescription drug benefits are provided through Medco. Specialty drugs are provided through Accredo.