HSA Benefits and HSA Health Plans

Benefit Highlights:	HSA 100^®	HSA 70^SM	Copay Select
Calendar-Year Deductible Choices	You pay: Single — $1,250, $2,500, $3,500 or $5,000 Family — $2,500, $5,000, $7,000 or $10,000	You pay: Single — $1,250, $2,500, $3,500 or $5,000 Family — $2,500, $5,000, $7,000 or $10,000	You pay: $500, $1,000, $1,500, $2,500, $5,000, $7,500, or $10,000 (maximum 2 per family, per calendar year)
Coinsurance Choices (% of covered expenses after deductible)	You pay: 0%	You pay: 30%	You pay: 0%, 20%, 30%
Coinsurance Out-of-Pocket Maximum (in-network, per calendar year, after deductible)	$0	Single (deductuble) Family (deductuble) $3,000 ($1,250) $6,000 ($2,500) $3,000 ($2,500) $6,000 ($5,000) $2,100 ($3,500) $4,200 ($7,000) $600 ($5,000) $1,200 ($10,000)	$0, $3,000, $5,000 (per person)
Lifetime Maximum Benefit (per covered person)	$3 Million ($5 Million plan enhancement available)	$3 Million ($5 Million plan enhancement available)	$3 Million ($5 Million plan enhancement available)
Initial Rate Guarantee (does not apply to benefit and address changes)	12 Months (24 Months plan enhancement available)	12 Months (24 Months plan enhancement available)	12 Months (24 Months plan enhancement available)
Physicians (Illness & Injury)
Office Visit–History and Exam (primary Care or Specialist, in-network only)	No charge after deductible	You pay: 30% after deductible	$35 copay - no deductible ($25 Copay plan enhancement available)
Primary Care Physician/Specialist Referrals Required	No	No	No
Prescription Drugs
Preferred price card (You pay for prescriptions at the point of sale, at the lowest price available, and submit a claim to Golden Rule.)	Preferred price card — no charge after deductible	Preferred price card — You pay: 30% after deductible	Tier 1 drugs — $15 copay, no deductible. Tier 2-4 — combined $200 deductible per person, per calendar year, then: Tier 2 — $35 copay. Tier 3 — $65 copay. Tier 4 — you pay 25% coinsurance.
Annual Maximum (covered expense, per person, per calendar year)	$3,000 (No Annual Max. plan enhancement available)	$3,000 (No Annual Max. plan enhancement available)	$3,000 (No Annual Max. plan enhancement available)
Wellness/Preventive Care Benefits (3-month waiting period,not subject to deductible)
Doctor Office Visit (adult or child, in-network only)	$35 copay	$35 copay	$35 copay
X-ray and lab (in conjunction with the preventive office visit, performed in the doctor’s office or a network facility)	You pay: $0	You pay: 30%	You pay: chosen coinsurance
Child Immunizations (0-18)	You pay: $0	You pay: 30%	You pay: chosen coinsurance
Preventive Mammogram, Pap Smear, PSA screening (no waiting period, see page 13-14 for additional covered benefits)	You pay: $0	You pay: 30%	You pay: chosen coinsurance
Outpatient Expense Benefits
X-ray and lab (performed in the doctor’s office or a network facility)	No charge after deductible	You pay: 30% after deductible	You pay: chosen coinsurance after deductible
Facility/Hospital for Outpatient Surgery	No charge after deductible	You pay: 30% after deductible	You pay: chosen coinsurance after deductible
Surgeon, Assistant Surgeon, and Facility Fees	No charge after deductible	You pay: 30% after deductible	You pay: chosen coinsurance after deductible
Hemodialysis, Radiation, Chemotherapy, Organ Transplant Drugs, and CAT Scans, MRIs	No charge after deductible	You pay: 30% after deductible	You pay: chosen coinsurance after deductible
Emergency Room Fees	No charge after deductible	You pay: 30% after deductible	You pay: $100 copay if not admitted, then chosen coinsurance after deductible
Other Covered Outpatient Expenses	No charge after deductible	You pay: 30% after deductible	You pay: chosen coinsurance after deductible
Spine and Back Disorders (CAT scan and MRI tests are not subject to this limitation)	No charge after deductible (Limited benefit)	You pay: 30% after deductible (Limited benefit)	You pay: chosen coinsurance after deductible (limited benefit)
Mental and Nervous Disorders (including substance abuse)	No charge after deductible (Limited benefit)	You pay: 30% after deductible (Limited benefit)	You pay: chosen coinsurance after deductible (limited benefit)
Inpatient Expense Benefits
Room and Board, Intensive Care Unit, Operating Room, Recovery Room, Prescription Drugs, Physician Visit, and Professional Fees of Doctors, Surgeons, Nurses	No charge after deductible	You pay: 30% after deductible	You pay: chosen coinsurance after deductible
Other Covered Inpatient Services	No charge after deductible	You pay: 30% after deductible	You pay: chosen coinsurance after deductible