GBA Insurance Trust, Inc.   2008 Summary of Medical Benefits--Plan # 641 Click here for a printable version of this summary.                                                       Calendar Year Deductibles              Individual (In-Network and Out-of-Network) $250       Family (In-Network and Out-of-Network) $750                       Out of Pocket Expense Per Calendar Year             Individual (Deductible Included)   $1,250       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.bcbs.com         Paragon Customer Service   877-380-0193         Claims on the Internet     www.bcbsga.com                                                         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.