GBA Insurance Trust, Inc.
2008 Summary of Medical Benefits--Plan # 201 Click here for a printable version of this summary
	Calendar Year Deductibles
		Individual (In-Network and Out-of-Network)				$500
		Family (In-Network and Out-of-Network)				$1,500
	Out of Pocket Expense Per Calendar Year
		Individual (Deductible Included)				$1,700
		Family (Deductible Included)				$3,500
						Preferred	Other
	Co-Insurance % Payable Unless Specified (After Deductible)					90%	70%
	Emergency Services (Life Threatening Medical Conditions)					90%	90%
	Inpatient Psychiatric Care *					90%	70%
	Co-Payment (Preferred Providers Only)
		Office Visit Co-Pay - Primary Care Physician				$25	NA
		Office Visit Co-Pay - Specialist Physician				$35	NA
		Surgery office visits				90%	70%
		Psychiatric office visits*				90%	70%
	Prescription Drug Program Co-Payment
		Generic/Brand Name Formulary/ Non-Formulary				$15/$35/$60	70%
	Preventive Care					$500 max	limited
	Skeletal Adjustments ($500 Maximum Benefit)					90%	70%
	Important Numbers:
		Physician Network on the Internet				www.bcbsga.com
		Paragon Customer Service				877-380-0193
		Claims on the Internet				www.paragonbenefits.com
		Plan Certificates				www.gabankers.com/gbait/plancertificatebooklets.htm
	Coinsurance amount paid after deductible satisfied unless 100%.
	*  Complies with Mental Health Parity Act and has limited benefits.
	This is a summary and not a contract.  Please refer to certificate booklet for complete benefit details.