GBA Insurance Trust, Inc.
2008 Summary of Medical Benefits--Plan # 780
High Deductible Health Plan  /  Health Savings Account Eligible Click here for a printable version of this summary.
	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-	Out-of-
						Network	Network
	Out of Pocket Expense Per Calendar Year
	Individual Plan (Deductible Included)					$2,750	$5,250
	Family Plan (Deductible Included)					$5,000	$10,500
	Co-Insurance Amount Payable After Deductible Satisfied **
	Office Visits					100%	60%
	Inpatient  Hospital & Physician					100%	60%
	Prescription Drugs					100%	60%
	Emergency Services (Life Threatening Med. Conditions)					100%	60%
	Inpatient Psychiatric Care ***					100%	60%
	Skeletal Adjustments ($500 Maximum Benefit)					100%	60%
	Preventive Care					$500 max	Limited
		Ages 1-5				100%*	60%*
		Ages 6-17				100%*	60%
		Adult PAP Smear, PSA & corresponding facility charge				100%*	60%
		Adult routine physical by schedule				100%*	0%
		Routine Mammogram				100%*	100%*
	For more information:
		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.booklets.htm
	*Deductible waived
	** Complies with state mandated benefits & reimbursements where applicable
	***Complies with Mental Health Parity Act and has limited benefits.							&n