KPS Health Plans - HSA with RX Plan

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SUMMARY OF BENEFITS

	The Healthy Investor ^TMIndividual/Family HSA with Rx
*Annual Deductible - Individuals Only**	$1,750 or $2,600
*Annual Deductible - Families Only**	$3,500 or $5,150+
Annual Coinsurance Maximum - Individual (includes deductible)	$5,000
Annual Coinsurance Maximum - Family (includes deductible)	$10,000
Lifetime maximum	$1,000,000/person
Preventive Care: (Not subject to deductible, unless otherwise stated) Annual Routine Physical Exam Well-Baby Exam (to 24 months of age) Annual Routine Eye Exam Smoking Cessation- Professional Services	Not a benefit if you choose a non–participating provider 80% 80% (exams only not subject to deductible) 80% (subject to deductible) 80% (subject to deductible) $300 maximum per year total for all preventive care, except well baby care
Professional Services Office, home, naturopath or urgent care visits Other outpatient professional services	80% 80%
Outpatient Lab & X-Ray Mammography Services and Prostate Cancer Screening-Routine Mammography Services and Prostate Cancer Screening-Diagnostic	80% 80% (not subject to deductible) 80% (subject to deductible)
Facility/Hospital Inpatient	80%
Facility/Hospital Outpatient	80%
Emergency Room & Supplies	80%
Acupuncture (12 treatments per year maximum)	80%
Ambulance Services Air and Ground Combined - $5,000 max per year	80%
Home Health and Hospice Home Health – 60 visits maximum Hospice – 6 months maximum per year	80% 80%
Maternity	Not a benefit
Medical Equipment & Supplies $2,500 per calendar year maximum	80%
Mental Health Inpatient (prior authorization required)-10 days per year maximum Outpatient-12 visits per year maximum	80% 80%
Nutritional Guidance $400 maximum per year	80%
Outpatient Rehabilitation (Physical, Speech, Massage & Occupational Therapy)	80% ($500 maximum per year)
Prescriptions	80% (subject to deductible)
Skilled Nursing Facility (in lieu of hospitalization)	80%
Spinal & Extremity Manipulations (12 manipulations per year maximum)	80%
Sterilization	Not a benefit
Vision Hardware	Not a benefit

All benefits are subject to annual deductible unless otherwise stated. This benefit comparison contains only a brief explanation of the more important coverage features offered. It does not constitute a contract. Complete coverage details, including waiting periods and other limits and exclusions, are in the Benefits Booklet. In the event of discrepancies, the Benefits Booklet shall govern. *After member satisfies the annual deductible and coinsurance maximum, KPS pays 100% of covered benefits for the remainder of the calendar year. If you choose a Non-Participating Provider, your coinsurance costs are higher. In addition, it is your responsibility to pay the difference between any amounts billed by the Non-Participating Provider or Facility and the amount paid by KPS. +The Healthy Investor TM family plans are designed for two or more family members. The entire family deductible must be satisfied before benefits are paid, annual routine physical exams, well-baby exams and routine mammography are not subject to the annual deductible.

Note: This summary contains a brief explanation of the coverage features offered through KPS Health Plans. It does not constitute a contract. Complete coverage details are in the Benefit Booklet. In the event of discrepancies, the Benefit Booklet shall govern. There are exceptions, limitations, and reductions which may affect your coverage.