GBA Insurance Trust, Inc.  
2008 Summary of Medical Benefits--Plan # 270  

(For use with outside of Georgia only where no PPO option is available)
Click here for a printable version of this summary

  
               
                 
  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)   $1,300    
    Family (Deductible Included)   $3,600    
                 
  Co-Insurance % Payable Unless Specified (After Deductible) 80%    
                 
  Emergency Services (Life Threatening Medical Conditions) 80%    
                 
  Inpatient Psychiatric Care *     80%    
                 
  Prescription Drug Program Co-Payment        
    Generic/Brand Name Formulary/ Non-Formulary $15/$35/$60    
                 
  Surgery Office Visits     80%    
                 
  Skeletal Adjustments ($500 Maximum Benefit)   80%    
                 
  Important Numbers:          
                 
    Paragon Customer Service   877-380-0193    
    Claims on the Internet     www.paragonbenefits.com    
    Plan Certificates     www.gabankers.com/gbaitplancertificatebooklets.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.