VEBA Plans Summary of Benefits

National PPO Network Lifetime

Max: None $1500 Deductible $2000 Deductible
Annual Deductibles
Individual $1,500 Family $3,000 Individual $2,000 Family $4,000
(Does not include Co-payments)

Non-Network Providers Individual $3,000 Family $6,000 Individual $5,000 Family $10,000
Annual Co-Insurance Out of Pocket Maximums Individual $3,000 Family $6,000 Individual $6,000 Family $12,000
Non-Network Providers Individual $6,000 Family $12,000 Individual $12,000 Family $24,000
Office Visits - Primary Care (exams $25 Co-payment, then Plan pays
$40 Co-payment, then Plan pays
or consultations) 100% 100%
Deductible, then Plan pays 60%
Deductible, then Plan pays 60%
Non-Network Providers
of allowed amount of allowed amount
Office Visits - Specialist (exams or $45 Co-payment, then Plan pays
$60 Co-payment, then Plan pays
consultations) 100% 100%
Deductible, then Plan pays 60%
Deductible, then Plan pays 60%
Non-Network Providers
of allowed amount of allowed amount
Office Services - basic services Plan pays 100% Plan pays 100%
Deductible, then Plan pays 60% of
Deductible, then Plan pays 60% of
Non-Network Providers
allowed amount allowed amount
Wellness Care - Adult Plan pays 100% Plan pays 100%
Non-Network Providers No Benefit No Benefit
Wellness Care - Children Plan pays 100% Plan pays 100%
Non-Network Providers No Benefit No Benefit
Allergy Treatment - Injections & No Benefit No Benefit
Allergy Treatment - Testing Plan pays 80% Plan pays 80%
Deductible, then Plan pays 60%
Deductible, then Plan pays 60%
Non-Network Providers
of allowed amount of allowed amount
Ambulance: up to $5000 Plan pays 80% Plan pays 80%
Deductible, then Plan pays 60%
Deductible, then Plan pays 60%
Non-Network Providers
of allowed amount of allowed amount
Birth Control / IUD Plan pays 100% Plan pays 100%
Deductible, then Plan pays 60% of
Deductible, then Plan pays 60% of
Non-Network Providers
allowed amount allowed amount
Chiropractic Services: Limit of 20 Plan pays 80% Plan pays 80%
Deductible, then Plan pays 60% of
Deductible, then Plan pays 60% of
Non-Network Providers
allowed amount allowed amount
Emergency Room - Facility (Co- $200 Co-payment, then Plan pays
$300 Co-payment, then Plan pays
payment waived if admitted) 100% 100%
Generic - $10 Co-payment Brand
Covered Prescription Drugs - RxEDO Generic - $10 Co-payment Brand
Formulary - $40 Copay Br/Non-form -
Customer Service: 888-879-7336 Rx Formulary - $30 Copay Br/Non-form
$70
Bin:610220 RxPCN:0398000 - $60 Co-pay Spec Drugs $100 Co-
Spec Drugs 25% Co-pay up to
www.rxedo.com pay
$300 maximum
Non-Network Providers No Benefit No Benefit

$20 monthly policy fee and $100 annual trust maintenance fee.

This comparison is for illustration purposes only. Complete benefit information and actual premium cost are
subject to change according to the underwriting guidelines and will be in the group contract.
Mail Order Drugs Mail prescriptions
to: Walgreens Generic - $25 Co-pay Brand Form - Generic - $25 Co-pay Brand Form -
P.O. Box 29061 Phoenix, AZ 85038- $75 Co-pay $100 Co-pay Br / Non-form - $175
9061 Br / Non-form - $150 Co-pay Co-pay
Customer Service: 800-345-1985

Non-Network Providers No Benefit No Benefit

Coverage Tier $1500 Deductible $2000 Deductible
INDIVIDUAL ONLY $619 $573
INDIVIDUAL & CHILD(REN) $962 $863
NDIVIDUAL & SPOUSE $1,204 $1,105
INDIVIDUAL & Family $1,276 $1,178

$20 monthly policy fee and $100 annual trust maintenance fee.

This comparison is for illustration purposes only. Complete benefit information and actual premium cost are
subject to change according to the underwriting guidelines and will be in the group contract.