5
HSA Plans -- Benefit Highlights
This chart only summarizes standard covered expenses, exclusions, and limitations of each plan. To be considered for
reimbursement, expenses must qualify as covered expenses. Expenses are also subject to reasonable and customary
limits unless you use a network. We recommend review of the more detailed plan information on pages 9-13.
HSA 100
SM
HSA Saver
®
Design Basics
Network Type
Preferred or Savings-Based Network
Calendar-Year Deductible Choices
(one per family)
See HSA Insert
See HSA Insert
Coinsurance After Deductible
100%
100%
Lifetime Maximum Benefit
(per covered person)
$3 million
$3 million
Initial Rate Guarantee
12 months
12 months
(subject to benefit and address changes)
Coverage percentages below are effective AFTER deductibles have been met unless otherwise indicated.
Inpatient Expense Benefits
Room and Board, Intensive Care Unit,
100%
100%
Operating Room, Recovery Room, and Professional
Fees of Doctors, Surgeons, Nurses
Other Covered Inpatient Services
100%
100%
Outpatient Expense Benefits
Surgeon, Assistant Surgeon, and Facility Fees
100%
100%
Hemodialysis, Radiation, Chemotherapy,
100%
100%
and Organ Transplant Drugs
CAT Scans, MRIs
100%
100%
Outpatient X-ray and Lab
100%
100% if performed within 14 days
of surgery or confinement
Emergency Room Fees
100%
100% if admitted; if not admitted --
limited to $250/person/year
Other Covered Outpatient Expenses
100%
See page 10 for details
Routine Health Benefits
Doctor Office Visit Fees
100%
Not Covered
Outpatient Prescription Drugs
100%
Not Covered --
(Preferred Price Card included with all plans)
Preferred Price Card Included
Mammography, Pap Smear, and PSA Testing
100%
100%
Adult Preventive Care
(Up to $500 annually for each adult
100%
Not Covered
age 19 or older; subject to 3-month waiting period)
Childhood Immunizations
(Up to $500 annually for ages
100%
Not covered
0-18
;
subject to 3-month waiting period)
Optional Benefits
For a complete list, see page 8.
