Summary of Benefits Protect HSA 2500
|
||
| In-Network | HSA-$2,500 | |
Annual Deductible (Combined in/out-of-network deductibles)
|
$2,500 per individual* $5,000 per family** |
|
Out-of-Pocket Maximum (annual) (Separate in/out-of-network annual out-of-pocket maximums)
|
$2,500 per individual* $5,000 per family** |
|
Lifetime Maximum Benefit
|
No lifetime maximum ($2,000,000 calendar year maximum) |
|
Office Visits
|
100% paid after deductible | |
Other Professional Services
|
100% paid after deductible | |
Emergency Care
|
100% paid after deductible | |
Inpatient Hospital Services and Surgical Facilities
|
100% paid after deductible | |
Inpatient Professional Services for Surgery, Anesthesia, Lab and Physician Visits
|
100% paid after deductible | |
Other Professional Services
|
100% paid after deductible | |
Outpatient Surgical Facility
|
100% paid after deductible | |
Well Woman Care - 1 visit per year
|
Not subject to the deductible, 100% plan paid. | |
Well Baby Care
|
Not subject to the deductible, 100% plan paid. |
|
Preventive Care (Ages 7 & Up)
|
Not subject to the deductible, 100% plan paid. |
|
Mental & Nervous/Substance Abuse - Inpatient
|
100% paid after deductible | |
Mental & Nervous/Substance Abuse - Outpatient
|
100% paid after deductible | |
Physical Therapy, Occupational Therapy, Chiropractic Care
|
100% paid after deductible, max. 25 visits/year (combined with out-of-network visits) |
|
Acupuncture
|
100% paid after deductible. Plan pays up to $60/visit, max. 12 visits/year (combined with out-of-network visits)
|
|
Durable Medical Equipment
|
100% paid after deductible | |
Skilled Nursing Facility
|
100% paid after deductible, up to 100 days per year (combined in/out-of-network) |
|
Hospice Care
|
100% paid after deductible | |
Home Healthcare
|
100% paid after deductible max. 90 visits/year (combined in/out of network) | |
| Prescription Drugs | HSA-$2,500 | |
Prescription Deductible |
No separate deductible
|
|
Participating Pharmacies (30-day supply)
|
Plan pays 100% of negotiated drug rate after deductible |
|
Self-Administered Injectable Some specialty drugs are available only through
|
Plan pays 100% of negotiated drug rate after deductible
|
|
Mail Order (60-day supply)
|
Plan pays 100% of negotiated drug rate after deductible
|
Out-of-Network Benefits
|
| Annual Deductible |
$2,500 per individual*
|
|
Annual Out-of-Pocket Maximum |
$5,000 per individual*
|
|
| Office Visits |
Plan pays 70% of allowable fee after deductible
|
|
| Inpatient Hospital Services |
Plan pays 70% of allowable fee after deductible, up to a maximum of $650 per day
|
|
| Mental & Nervous/Substance Abuse - Inpatient |
Plan pays 70% of allowable fee after deductible, up to a maximum of $650 per day
|
|
| Mental and Nervous/Substance Abuse - Outpatient |
Plan pays 70% of allowable fee after deductible, up to a maximum of $380 per day
|
Prescription Drugs | HSA-$2,500 |
Prescription Deductible |
No separate deductible
|
|
Mail Order
|
Not covered |
|
Retail Pharmacies (30-day supply)
|
After the deductible is satisfied, member pays 30% of the allowable drug fee, plus any excess charges
|
|
Self-Administered Injectable Drugs
|
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. 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. |
