PLAN I
	Network Provider	Non-Network Provider
HOSPITAL Calendar Year Deductible	TIHN – $150/person; $300/family Blue Cross/PHCS – $250/person; $500/family	$500/person; $1,000/family
Inpatient (Room & Board & Ancillary Services)	100%	90%
Outpatient Surgery	100%	90%
Emergency Room	100% after $100 co-pay; co-pay is waived if admitted	90%
Out-Of-Pocket Maximum (after Deductible)	N/A	$1,000/person; $2,000/family
MAJOR MEDICAL Calendar Year Deductible	TIHN – $150/person; $300/family Blue Cross/PHCS – $250/person; $500/family	$500/person; $1,000/family
Office Visit (including X-ray & Lab)	100% after $15 co-pay	80%
Surgeon - Inpatient - Outpatient Hospital, Surgical Center, Surgical Suite - Doctor’s Office	100% after $100 co-pay 100% after $100 co-pay 100% after $15 co-pay	80% 80% 80%
Maternity Care	100% after $100 co-pay	80%
Routine Physical Exam	No deductible; 100% after $15 co-pay	No deductible; 80%
Well Child Care	No deductible; 100% after $15 co-pay	No deductible; 80%
Well Woman (Mammogram/Pap)	No deductible; 100% after $15 co-pay	No deductible; 80%
Out-of-Pocket Maximum (after Deductible)	N/A	$1,000/person; $2,000/family
HOSPITAL/MAJOR MEDICAL LIFETIME MAXIMUM	$2,000,000	$2,000,000

	PLAN II
	Network Provider		Non-Network Provider
HOSPITAL Calendar Year Deductible	TIHN- $150/person; $300/family Blue Cross/PHCS - $500/person; $1,000/family	California No coverage	Non- California $750/person; $1,500/family
Inpatient (Room & Board & Ancillary Services)	100%	No coverage	80%
Outpatient Surgery	100%	No coverage	80%
Emergency Room	100% after $200 co-pay; co-pay is waived if admitted	No coverage	80%
Out-Of-Pocket Maximum (after Deductible)	N/A	No coverage	No maximum
MAJOR MEDICAL Calendar Year Deductible	TIHN- $150/person; $300/family Blue Cross/PHCS - $500/person; $1,000/family	$750/person; $1,500/family
Office Visit (including X-ray & Lab)	100% after $25 co-pay	70%
Surgeon - Inpatient - Outpatient Hospital, Surgical Center, Surgical Suite - Doctor’s Office	100% after $100 co-pay 100% after $100 co-pay 100% after $25 co-pay	70% 70% 70%
Maternity Care	100% after $25 co-pay	70%
Routine Physical Exam	Age 40 or over -100%, after $25 co-pay	Not covered
Well Child Care	To age 6 - 100% after $25 co-pay	Not covered
Well Woman (Mammogram/Pap)	100%, after $25 co-pay	70%
Out-of-Pocket Maximum (after Deductible)	N/A	$1,500/person; $3,000/family
HOSPITAL/MAJOR MEDICAL LIFETIME MAXIMUM	$2,000,000	$2,000,000

	LOWER COST SELF-PAY (Individual coverage only)
	Network Provider	Non-Network Provider
HOSPITAL Calendar Year Deductible	TIHN- $150/person Blue Cross/PHCS - $500/person	California No coverage	Non- California $750/person
Inpatient (Room & Board & Ancillary Services)	100%	No coverage	80%
Outpatient Surgery	100%	No coverage	80%
Emergency Room	100% after $200 co-pay; co-pay is waived if admitted	No coverage	80%
Out-Of-Pocket Maximum (after Deductible)	N/A	No coverage	No maximum
MAJOR MEDICAL Calendar Year Deductible	TIHN- $150/person Blue Cross/PHCS - $500/person $750/person	$750/person
Office Visit (including X-ray & Lab)	100% after $25 co-pay	70%
Surgeon - Inpatient - Outpatient Hospital, Surgical Center, Surgical Suite - Doctor’s Office	100% after $100 co-pay 100% after $100 co-pay 100% after $25 co-pay	70% 70% 70%
Maternity Care	100% after $25 co-pay	70%
Routine Physical Exam	Age 40 or over - 100%, after $25 co-pay	Not covered
Well Child Care	To age 6 - 100% after $25 co-pay	Not covered
Well Woman (Mammogram/Pap)	100%, after $25 co-pay	70%
Out-of-Pocket Maximum (after Deductible)	N/A	$1,500/person
HOSPITAL/MAJOR MEDICAL LIFETIME MAXIMUM	$2,000,000	$2,000,000

PLAN I BENEFITS SUMMARY
PRESCRIPTION DRUGS
Calendar Year Deductible	$100/person; $200/family
Retail at Participating Pharmacy
- Supply	Up to a 30 day supply/prescription or refill
- Co-pay	The greater of: Generic - $10 or 20%; Brand name when no generic exists - $20 or 25%; Brand name when generic exists - $20 or 25% plus difference in price between generic and brand name
Medco by Mail
- Supply	Up to a 90 day supply/prescription or refill
- Co-pay	The greater of: Generic - $10 or 15%; Brand name when no generic exists - $20 or 20%; Brand name when generic exists - $20 or 20% plus difference in price between generic and brand name; Maximum co-pay of $75/prescription (after the deductible)
	Network Provider	Non-Network Provider
MENTAL HEALTH
Inpatient	100% for up to 60 days/calendar year	Not covered
Outpatient	100% after $20 co-pay/visit; maximum 40 visits/calendar year	Not covered
CHEMICAL DEPENDENCY*
Inpatient	100%* after $250 co-pay/treatment course; co-pay is waived for detoxification	Not covered
Outpatient	100%*	Not covered
Maximums	Detoxification - $1,200/calendar year; Annual - 1 treatment course; Lifetime - 2 treatment courses or $37,500, whichever is reached first	Not covered

* Chemical dependency benefits are reduced to 50% without certification from ValueOptions that indicates completion of the recommended treatment program.

PLAN II BENEFITS SUMMARY
PRESCRIPTION DRUGS – Applies to Lower Cost Self-Pay as well.
Calendar Year Deductible	$100/person; $200/family
Retail at Participating Pharmacy
- Supply	Up to a 30 day supply/prescription or refill
- Co-pay	The greater of: Generic - $10 or 20%; Brand name when no generic exists - $20 or 25%; Brand name when generic exists - $20 or 25% plus difference in price between generic and brand name
Medco by Mail
- Supply	Up to a 90 day supply/prescription or refill
- Co-pay	The greater of: Generic - $10 or 15%; Brand name when no generic exists - $20 or 20%; Brand name when generic exists - $20 or 20% plus difference in price between generic and brand name; Maximum co-pay of $75/prescription (after the deductible)
	Network Provider	Non-Network Provider
MENTAL HEALTH – Must have three or more years of prior Earned Eligibility.
Inpatient	100% for up to 30 days/calendar year	Not covered
Outpatient	50%; maximum 20 visits/calendar year	Not covered
CHEMICAL DEPENDENCY* – Must have three or more years of prior Earned Eligibility.
Inpatient	100%* after $250 co-pay/treatment course; co-pay is waived for detoxification	Not covered
Outpatient	100%*	Not covered
Maximums	Detoxification - $1,200/calendar year; Annual - 1 treatment course or $7,500, whichever is reached first; Lifetime - 2 treatment courses or $10,000, whichever is reached first	Not covered

* Chemical dependency benefits are reduced to 50% without certification from ValueOptions that indicates completion of the recommended treatment program.