GBA Insurance Trust, Inc.

2008 Summary of Medical Benefits--Plan # 229

(Early Retiree Plan)
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)   $3,000
    Family (Deductible Included)   $6,000
               
            Preferred Other
               
  Co-Insurance % Payable Unless Specified (After Deductible) 80% 60%
               
  Emergency Services (Life Threatening Medical Conditions) 80% 80%
               
  Inpatient Psychiatric Care *     80% 60%
               
  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     80% 60%
    Psychiatric office visits*   80% 60%
               
  Prescription Drug Program Co-Payment      
    Generic/Brand Name Formulary/ Non-Formulary $15/$35/$60 60%
               
  Preventive Care       $500 max limited
               
  Skeletal Adjustments ($500 Maximum Benefit) 80% 60%
               
  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.