GBA Insurance Trust, Inc.
2010 Summary of Medical Benefits--Plan # 251
	Lifetime Maximum					UNLIMITED
	Calendar Year Deductibles
	Individual (In-Network and Out-of-Network)					$300
	Family (In-Network and Out-of-Network)					$900
	Out of Pocket Expense Per Calendar Year
	Individual (Deductible Included)					$1,500
	Family (Deductible Included)					$3,500
						In-Network	Out-of-Network
	Co-Insurance % Payable Unless Specified (After Deductible)					90%	70%
	Emergency Services (Life Threatening Medical Conditions)					90%	90%
	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%
	Urgent Care Center Copay					$60	$60*
	Prescription Drug Program Co-Payment
	Generic/Brand Name Formulary/ Non-Formulary**					$15/$35/$60	70%
	Voluntary Mail Order--Maintenance RX (Formulary Only)					$30/$70	NA
	(2 copays for 3 month supply)
	Preventive Care					Included	Limited
	Skeletal Adjustments ($500 Maximum Benefit)					90%	70%
	Additional Information:
	Physician Network on the Internet				www.bcbsga.com
	Paragon Customer Service				877-380-0193
	Claims on the Internet				www.paragonbenefits.com
	Plan Certificates				http://www.gabankers.com/GBAIT/gbaithome.asp
	Nurse Line "Blue Choice On Call"				888-724-2583
	Mail Order				www.wellpointnextrx.com
	This is a summary and not a contract.  Please refer to certificate booklet for complete benefit details.
*Urgent care center out-of-network--Plan pays 60% after copay and deductible
**If generic alternative available to a brand name RX, must choose generic; otherwise, $60 copay will apply