ODS Individual HSA Choice Plan

	HSA Choice
Services	In Network	Out of Network
Lifetime benefit maximum	$2,000,000	$250,000
Plan year deductible	$1,500 (individual) $3,000 (family)†
Out-of-pocket maximum, per person (after deductible)	$3,500 (individual) $7,000 (family)	No maximum
PREVENTIVE CARE	Member Responsibility
	In-Network	Out-of-Network
Annual women's exam - pap, pelvic, breast	20%*	40%
Women's routine mammogram	20%*	40%
Well-baby care	20%*	40%
Routine physical exams	20%*	40%
Immunizations	40%*	40%
Professional Services
Office Visits	20%	40%
Alternative care ($1,000 per plan year limit) Chiropractic, naturopathic and acupuncture	20%	40%
Maternity
All pre/post office visits and doctor delivery; hospital charges	20%	40%
Hospital Services
Inpatient and outpatient surgery; room, ancillary and physician charges; skilled nursing facility care	20%	40%
Emergency Services (deductible applies)
Urgent Care	20%	40%
Hospital emergency room	20%	40%
Ambulance	20%
Other Facilites and Services
X-ray & lab services; rehabilitation servoces; medical supplies and devices; in-hospital care; home healthcare	20%	40%
Prescription services	30%
Accident benefit	Paid as any other illness subject to deductible/co-insurance
*The plan deductible is waived for these services. † Family deductible applies when and individual and a spouse or one (1) or more dependents are enrolled. Therefore, prior to benefits being paid, the entire deductible must be met.

Note: This is a benefit summary only. For a complete description of benefits, refer to your Policy.

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