Summary of Benefits Protect HSA 1500 Non-Grandfathered Plans Effective January 1, 2012
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| In-Network | HSA-$1,500 | |
Annual Deductible (combined in/out-of-network)
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$1,500 per individual* $3,000 per family** |
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Out-of-Pocket Maximum (annual)
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$4,500 per individual* $9,000 per family** |
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Lifetime Maximum Benefit
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No lifetime maximum ($2,000,000 calendar year maximum) |
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Office Visits
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30% of negotiated fee after deductible | |
Other Professional Services
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30% of negotiated fee after deductible | |
Emergency Care
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30% of negotiated fee after deductible | |
Inpatient Hospital Services and Surgical Facilities
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30% of negotiated fee after deductible | |
Inpatient Professional Services for Surgery, Anesthesia, Lab and Physician Visits
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30% of negotiated fee after deductible | |
Other Professional Services
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30% of negotiated fee after deductible | |
Preventive Care Ages 7 and Up 1 visit per year |
Not subject to the deductible 100% plan paid |
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Well Woman Care - 1 visit per year
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Not subject to the deductible 100% plan paid |
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Well Baby Care
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Not subject to the deductible 100% plan paid |
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Preventive Care (Ages 7 & Up) - 1 Physical Per Year
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Not subject to the deductible 100% plan paid |
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Nervous and Mental/Substance Abuse Inpatient
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30% of negotiated fee after deductible | |
Nervous and Mental/Substance Abuse Outpatient
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30% of negotiated fee after deductible | |
Physical Therapy, Occupational Therapy, Chiropractic Care
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30% of negotiated fee after deductible, max. 25 visits/year | |
Acupuncture
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30% of negotiated fee after deductible. Plan pays up to $60/visit after deductible, max. 12 visits/year |
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Durable Medical Equipment
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30% of negotiated fee after deductible | |
Skilled Nursing Facility
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30% of negotiated fee after deductible, 100 days/year | |
Hospice Care
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30% of negotiated fee after deductible | |
Home Healthcare
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30% of negotiated fee after deductible, 90 visits/year | |
| Prescription Drugs | HSA-$1,500 | |
Prescription Deductible |
No separate deductible
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Participating Pharmacies (30-day supply)
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30% of negotiated drug fee after deductible |
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Self-Administered Injectable Some specialty drugs are available only through |
30% of negotiated drug fee after deductible
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Mail Order (60-day supply) |
30% of negotiated drug fee after deductible
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Out-of-Network Benefits
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| Annual Deductible |
No separate deductible, Out-of-Network benefits are included in the annual deductible
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Annual Out-of-Pocket Maximum |
No separate Out-of-Pocket Max., Out-of-Network benefits are included in the annual Out-of-Pocket Max imum.
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| Office Visits |
Plan pays 50% of negotiated fee, after deductible
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| Inpatient Hospital Services |
Plan pays 50% of negotiated fee, up to a max. of $540 per day, after deductible
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Mental and Nervous/ Substance Abuse Inpatient |
Plan pays 50% of allowable fee, up to a maximum of $540 per day, after deductible
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| Mental and Nervous/Substance Abuse - Outpatient |
Plan pays 50% of allowable fee
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Prescription Drugs - Out-of-Network | HSA-$1,500 |
Prescription Deductible |
No separate deductible
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Mail Order
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Not covered |
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Retail Pharmacies (30-day supply)
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Plan pays 50% of the allowable drug fee after deductible. Member pays any excess charges.
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Self-Administered Injectable Drugs
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Not covered |
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*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. Lilkewise, 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. |
