Summary of Benefits Protect HSA 2850 Non-Grandfathered Plans Effective January 1, 2012
|
||
| In-Network | HSA-$2,850 | |
Annual Deductible (combined in/out-of-network)
|
$2,850 per member* |
|
Out-of-Pocket Maximum (annual)
|
$5,500 per member* |
|
Lifetime Maximum Benefit
|
No lifetime maximum ($2,000,000 calendar year maximum) |
|
Office Visits
|
30% of negotiated fee after deductible | |
Other Professional Services
|
30% of negotiated fee after deductible | |
Emergency Care
|
30% of negotiated fee after deductible | |
Inpatient Hospital Services and Surgical Facilities
|
30% of negotiated fee after deductible | |
Inpatient Professional Services for Surgery, Anesthesia, Lab and Physician Visits
|
30% of negotiated fee after deductible | |
Other Professional Services
|
30% of negotiated fee after deductible | |
Outpatient Surgical Facility
|
30% of negotiated fee after deductible | |
Well Woman Care - 1 visit per year
|
Not subject to the deductible |
|
Preventive Care Ages 7 and Up - 1 visit per year
|
Not subject to the deductible 100% plan paid |
|
Well Baby Care
|
Not subject to the deductible 100% plan paid |
|
Nervous and Mental/Substance Abuse Inpatient
|
30% of negotiated fee after deductible | |
Nervous and Mental/Substance Abuse Outpatient
|
30% of negotiated fee after deductible | |
Physical Therapy, Occupational Therapy, Chiropractic Care
|
30% of negotiated fee after deductible, max. 25 visits/year | |
Acupuncture
|
30% of negotiated fee after deductible. Plan pays up to $60/visit, max. 12 visits/year |
|
Durable Medical Equipment
|
30% of negotiated fee after deductible | |
Skilled Nursing Facility
|
30% of negotiated fee after deductible, 100 days/year | |
Hospice Care
|
30% of negotiated fee after deductible | |
Home Healthcare
|
30% of negotiated fee after deductible, 90 visits/year | |
| Prescription Drugs | HSA-$2,850 | |
Prescription Deductible |
No separate deductible
|
|
Participating Pharmacies (30-day supply)
|
30% of negotiated drug fee after deductible |
|
Self-Administered Injectable
|
30% of negotiated drug fee after deductible
|
|
Mail Order (60-day supply)
|
30% of negotiated drug fee 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 50% of allowable fee after deductible
|
|
| Inpatient Hospital Services |
Plan pays 50% of allowable fee, up to a maximum of $540 per day, after deductible
|
|
| Mental and Nervous/Substance Abuse - Inpatient |
Plan pays 50% of allowable fee, up to a maximum of $540 per day, after deductible
|
|
| Mental and Nervous/Substance Abuse- Outpatient |
Plan pays 50% of allowable fee
|
Prescription Drugs - Out of Network | HSA-$2,850 |
Prescription Deductible |
No separate deductible
|
|
Mail Order
|
Not covered |
|
Retail Pharmacies (30-day supply)
|
Plan pays 50% of the allowable drug fee after deductible. Member pays 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. |
