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HIGH DEDUCTIBLE HEALTH PLAN (HDHP/HSA)

This plan is administered by Blue Cross/Blue of Georgia, and provides major medical coverage including diagnosis and/or treatment of illness, injury or medical conditions. Benefits include physician, hospital, surgical, disease state management, mental health/substance abuse and transplant services.

The High Deductible Health Plan is Health Savings Account (HSA) qualified. The University System offers payroll deduction for the HSA account with U.S. Bank. IRS guidelines do not allow both a Health Savings Account (HSA) and a Flexible Health Spending Account. If you are considering opening an HSA, you are advised to consult with a qualified tax advisor.

FEATURE	HIGH DEDUCTIBLE PLAN /HSA
Pre-Existing Conditions	None
Max. Lifetime Benefit	$2 million
Max. Annual Deductible	$1500 Individual (In-Network) $3000Family (In-Network) (entire family deductible must be met for those enrolled in options other than employee only, before plan starts to pay its percentage)
Max. Annual Out-of-Pocket	$3000 Individual (In-Network) $6000 Family (In-Network) $6000 (Out-of-Network) $12,000 (Out-of-Network)
Physician Office Visit	90% of UCR, in-network 70% of UCR, out-of-network
Wellness Care/Preventive Care	Unlimited per person per plan year; paid at 100% of network rate; not subject to deductible. Based on national guidelines for age and gender appropriate services.
Laboratory Services (exclusive of wellness/preventative care)	90% of UCR charges, In-Network 70% of UCR charges, Out-of-Network
Maternity Care (Prenatal, Delivery and Postnatal)	90% of UCR charges, In-Network 70% of UCR charges, Out-of-Network
Outpatient Surgery	90% of UCR charges, In-Network 70% of UCR charges, Out-of-Network
Second Surgical Opinions	90% of UCR charges, In-Network 70% of UCR charges, Out-of-Network
Allergy Testing	90% of UCR charges, In-Network 70% of UCR charges, Out-of-Network
Allergy Shots & Serum	90% of UCR charges, In-Network 70% of UCR charges, Out-of-Network
Treatment of TMJ	90% of UCR charges, In-Network 70% of UCR charges, Out-of-Network
Inpatient Hospital Services for Physician Care/Surgery	90% of UCR charges, In-Network 70% of UCR charges, Out-of-Network
Hospital Services Other than those for Emergency Room Care	90% of UCR charges, In-Network 70% of UCR charges, Out-of-Network
Maternity Care-Inpatient Hospital (Delivery)	90% of UCR charges, In-Network 70% of UCR charges, Out-of-Network
Inpatient-Hospital Lab Services	90% of UCR charges, In-Network 70% of UCR charges, Out-of-Network
Inpatient Hospice Care	90% of UCR charges, In-Network 70% of UCR charges, Out-of-Network
Inpatient Treatment of TMJ	90% of UCR charges, In-Network 70% of UCR charges, Out-of-Network
Outpatient Hospital Svcs for Physician Care/Surgery	90% of UCR charges, In-Network 70% of UCR charges, Out-of-Network
Outpatient Facility Selected by Treating Physician	90% of UCR charges, In-Network 70% of UCR charges, Out-of-Network
Care in a Hospital Emergency Room (treatment of an emergency medical condition or injury)	90% of UCR charges, In-Network 70% of UCR charges, Out-of-Network
Outpatient Hospital/ Facility Laboratory Services	90% of UCR charges, In-Network 70% of UCR charges, Out-of-Network
Urgent Care Services	90% of UCR charges, In-Network 70% of UCR charges, Out-of-Network
Home Nursing Care	90% of UCR charges, In-Network 70% of UCR charges, Out-of-Network
Extended Care Facility	90% of UCR charges, In-Network 70% of UCR charges, Out-of-Network
Home Hyperalimentation	90% of UCR charges, In-Network 70% of UCR charges, Out-of-Network
Outpatient Hospice Care	90% of UCR charges, In-Network 70% of UCR charges, Out-of-Network
Cochlear Implants	90% of UCR charges, In-Network 70% of UCR charges, Out-of-Network
Ambulance Services	90% of UCR charges, In-Network 70% of UCR charges, Out-of-Network
Durable Medical Equipment	90% of UCR charges, In-Network 70% of UCR charges, Out-of-Network
Outpatient Short Term Rehabilitation Svcs	90% of UCR charges, In-Network 70% of UCR charges, Out-of-Network Limited to 20 visits
Chiropractic Care	90% of UCR charges, In-Network 70% of UCR charges, Out-of-Network; limited to 20 visits per plan year.
Surgical Extraction of Impacted Teeth (medical benefits are not available for partially erupted teeth)	90% of UCR charges, In-Network 70% of UCR charges, Out-of-Network
Mental Health/Substance Abuse	Inpatient: 90% of UCR charges, maximum benefit coverage of 30 days per plan year; 90 days per person per lifetime. Outpatient: 90% of UCR charges, maximum of 20 visits per person per plan year.
360 degree Health Programs	Condition Care Programs 1-800-638-4754.
Organ & Transplant Program	For additional information regarding the Centers of Expertise Program for organ and tissue transplants, contact BCBSGa at 1-800-828-6518.
Pharmacy Benefits	90%; subject to deductible

FEATURE

HIGH DEDUCTIBLE PLAN /HSA