GBA Insurance Trust, Inc.
2010 Summary of Medical Benefits--Plan # 719
High Deductible Health Plan  /  Health Savings Account Eligible
(Early Retiree Plan)
	Lifetime Maximum					UNLIMITED
	Calendar Year Deductibles
		Individual (In-Network and Out-of-Network)				$2,750
		Family (In-Network and Out-of-Network)				$5,000
						In-Network	Out-of-Network
	Out of Pocket Expense Per Calendar Year
		Individual Plan (Deductible Included)				$5,250	$5,950
		Family Plan (Deductible Included)				$10,000	$11,900
	Co-Insurance Amount Payable After Deductible Satisfied **
	Office Visits					80%	70%
	Inpatient  Hospital & Physician					80%	70%
	Prescription Drugs					80%	70%
	Emergency Services (Life Threatening Med. Conditions)					80%	80%
	Skeletal Adjustments ($500 Maximum Benefit)					80%	70%
	Preventive Care					Included	Limited
		Ages 1-5				80%*	70%*
		Ages 6-17				80%*	70%
		Adult PAP Smear, PSA & corresponding facility charge				80%*	70%
		Adult routine physical by schedule				80%*	70%
		Routine Mammogram				80%*	80%*
	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
	*Deductible waived
	** Complies with State and Federal mandated benefits & reimbursements where applicable
	This is a summary and not a contract.  Please refer to certificate booklet for complete benefit details.