ODS Individual HSA Value Plan

	HSA Value
Services	In Network	Out of Network
Lifetime benefit maximum	$2,000,000	$250,000
Plan year deductible	$2,800 (individual) $5,600 (family)†
Out-of-pocket maximum, per person (after deductible)	$2,200 (individual) $4,400 (family)	No maximum
PREVENTIVE CARE	Member Responsibility
	In-Network	Out-of-Network
Annual women's exam - pap, pelvic, breast	50%*	50%
Women's routine mammogram	50%*	50%
Well-baby care	50%*	50%
Routine physical exams	50%*	50%
Immunizations	50%*	50%
Professional Services
Office Visits	50%	50%
Alternative care ($1,000 per plan year limit) Chiropractic, naturopathic and acupuncture	50%	50%
Maternity
All pre/post office visits and doctor delivery; hospital charges	50%	50%
Hospital Services
Inpatient and outpatient surgery; room, ancillary and physician charges; skilled nursing facility care	50%	50%
Emergency Services (deductible applies)
Urgent Care	50%	50%
Hospital emergency room	50%	50%
Ambulance	50%
Other Facilites and Services
X-ray & lab services; rehabilitation servoces; medical supplies and devices; in-hospital care; home healthcare	50%	50%
Prescription services	50%
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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