Hsa plans.xls

Benefits after the Calendar Year Deductible Non-Network
Lifetime Benefits
Deductible - Calendar Year
Out-of-Pocket Maximum - Calendar Year †
Chiropractic
Durable Medical Equipment (DME) & Prosthetic Devices
Emergency Care
Injections - Includes allergy shots.
Maternity Physican Services
Includes routine prenatal, delivery, and postnatal care.
Outpatient Health / Substance Abuse
Physician Office Visit
Preventive Care Services
Routine Annual Physical Exam (maximum $350) Prescription Drugs ††
Generic Drug
Stop Smoking
Includes Zyban and Nicoderm CQ. If a member presents a prescription and enrolls in a covered support program.
Generic Drug Limited to three units of covered therapies per year.
Transplant Services
Includes evaluation, reasonable transportation and lodging.
Ugrent Care
Vision Care - Routine - One refraction exam per year.
Others Eligible Charges
Hospital, surgical expenses, anesthesia, outpatient and inpatient services, and diagnostic x-rays and lab.
Home healthcare, skilled nursing, rehabilitation services limited to 100 visits per Calednar Year.
† Should out-of-pocket expenses exceed the per pserson or per family limit during a Calendar Year, benefits will be paid at 100% of eligible expenses for the remainder of that year.
†† 31-day supply from a retail network pharmacy or 90-day supply from mail order pharmacy The member's cost for care from non-network providers includes all charges greater than the eligible expenses.
Benefits after the Calendar Year Deductible Non-Network
Lifetime Benefits
Deductible - Calendar Year
Out-of-Pocket Maximum - Calendar Year †
Chiropractic
Durable Medical Equipment (DME) & Prosthetic Devices
Emergency Care
Injections - Includes allergy shots.
Maternity Physican Services
Includes routine prenatal, delivery, and postnatal care.
Outpatient Health / Substance Abuse
Physician Office Visit
Preventive Care Services
Routine Annual Physical Exam (maximum $350) Prescription Drugs ††
Generic Drug
Stop Smoking
Includes Zyban and Nicoderm CQ. If a member presents a prescription and enrolls in a covered support program.
Generic Drug Limited to three units of covered therapies per year.
Transplant Services
Includes evaluation, reasonable transportation and lodging.
Ugrent Care
Vision Care - Routine - One refraction exam per year.
Others Eligible Charges
Hospital, surgical expenses, anesthesia, outpatient and inpatient services, and diagnostic x-rays and lab.
Home healthcare, skilled nursing, rehabilitation services limited to 100 visits per Calednar Year.
† Should out-of-pocket expenses exceed the per pserson or per family limit during a Calendar Year, benefits will be paid at 100% of eligible expenses for the remainder of that year.
†† 31-day supply from a retail network pharmacy or 90-day supply from mail order pharmacy The member's cost for care from non-network providers includes all charges greater than the eligible expenses.
Benefits after the Calendar Year Deductible Non-Network
Lifetime Benefits
Deductible - Calendar Year
Out-of-Pocket Maximum - Calendar Year †
Chiropractic
Durable Medical Equipment (DME) & Prosthetic Devices
Emergency Care
Injections - Includes allergy shots.
Maternity Physican Services
Includes routine prenatal, delivery, and postnatal care.
Outpatient Health / Substance Abuse
Physician Office Visit
Preventive Care Services
Routine Annual Physical Exam (maximum $350) Prescription Drugs ††
Generic Drug
Stop Smoking
Includes Zyban and Nicoderm CQ. If a member presents a prescription and enrolls in a covered support program.
Generic Drug Limited to three units of covered therapies per year.
Transplant Services
Includes evaluation, reasonable transportation and lodging.
Ugrent Care
Vision Care - Routine - One refraction exam per year.
Others Eligible Charges
Hospital, surgical expenses, anesthesia, outpatient and inpatient services, and diagnostic x-rays and lab.
Home healthcare, skilled nursing, rehabilitation services limited to 100 visits per Calednar Year.
† Should out-of-pocket expenses exceed the per pserson or per family limit during a Calendar Year, benefits will be paid at 100% of eligible expenses for the remainder of that year.
†† 31-day supply from a retail network pharmacy or 90-day supply from mail order pharmacy The member's cost for care from non-network providers includes all charges greater than the eligible expenses.
Benefits after the Calendar Year Deductible Non-Network
Lifetime Benefits
Deductible - Calendar Year
Out-of-Pocket Maximum - Calendar Year †
Chiropractic
Durable Medical Equipment (DME) & Prosthetic Devices
Emergency Care
Injections - Includes allergy shots.
Maternity Physican Services
Includes routine prenatal, delivery, and postnatal care.
Outpatient Health / Substance Abuse
Physician Office Visit
Preventive Care Services
Routine Annual Physical Exam (maximum $350) Prescription Drugs ††
Generic Drug
Stop Smoking
Includes Zyban and Nicoderm CQ. If a member presents a prescription and enrolls in a covered support program.
Generic Drug Limited to three units of covered therapies per year.
Transplant Services
Includes evaluation, reasonable transportation and lodging.
Ugrent Care
Vision Care - Routine - One refraction exam per year.
Others Eligible Charges
Hospital, surgical expenses, anesthesia, outpatient and inpatient services, and diagnostic x-rays and lab.
Home healthcare, skilled nursing, rehabilitation services limited to 100 visits per Calednar Year.
† Should out-of-pocket expenses exceed the per pserson or per family limit during a Calendar Year, benefits will be paid at 100% of eligible expenses for the remainder of that year.
†† 31-day supply from a retail network pharmacy or 90-day supply from mail order pharmacy The member's cost for care from non-network providers includes all charges greater than the eligible expenses.
Benefits after the Calendar Year Deductible Non-Network
Lifetime Benefits
Deductible - Calendar Year
Out-of-Pocket Maximum - Calendar Year †
Chiropractic
Durable Medical Equipment (DME) & Prosthetic Devices
Emergency Care
Injections - Includes allergy shots.
Maternity Physican Services
Includes routine prenatal, delivery, and postnatal care.
Outpatient Health / Substance Abuse
Physician Office Visit
Preventive Care Services
Routine Annual Physical Exam (maximum $350) Prescription Drugs ††
Generic Drug
Stop Smoking
Includes Zyban and Nicoderm CQ. If a member presents a prescription and enrolls in a covered support program.
Generic Drug Limited to three units of covered therapies per year.
Transplant Services
Includes evaluation, reasonable transportation and lodging.
Ugrent Care
Vision Care - Routine - One refraction exam per year.
Others Eligible Charges
Hospital, surgical expenses, anesthesia, outpatient and inpatient services, and diagnostic x-rays and lab.
Home healthcare, skilled nursing, rehabilitation services limited to 100 visits per Calednar Year.
† Should out-of-pocket expenses exceed the per pserson or per family limit during a Calendar Year, benefits will be paid at 100% of eligible expenses for the remainder of that year.
†† 31-day supply from a retail network pharmacy or 90-day supply from mail order pharmacy The member's cost for care from non-network providers includes all charges greater than the eligible expenses.

Source: http://www.benefitsaba.com/products/hsa_plans.pdf?PHPSESSID=613898d2f743425e7f7183350ab38d14

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