HEALTH BENEFITS CHART OF OUT-OF-POCKET EXPENSES 5/1/09 - 4/30/10
	Plan 1		Plan 2		Plan 3
Benefits	In-Network	Non-Network	In-Network	Non-Network	In-Network	Non-Network
Calendar Year Deductible	$5,000/person $10,000/family	$10,000/person $20,000/family	$3,000/person $9,000/family	$3,000/person $9,000/family	$1,000/person $3,000/family	$1,000/person $3,000/family
Out-of-Pocket Maximum	$0/person $0/family	$10,000/person $20,000/family	$5,000/person $15,000/family	$10,000/person $30,000/family	$0/person $0/family	$8,000/person $24,000/family
Maximum Policy Benefit	$5 Million	$5 Million	$5 Million	$5 Million	$5 Million	$5 Million
ER: Injury & Emergency Facility Charges Additional Co-Pay	0% of Eligible Expenses^1 n/a	0% of Eligible Expenses^1 n/a	30% of Eligible Expenses^1 $100	30% of Eligible Expenses^1 $100	$100	$100
Hospital - Inpatient	0% of Eligible Expenses^1	30% of Eligible Expenses^1	30% of Eligible Expenses^1	50% of Eligible Expenses^1	0% of Eligible Expenses^1	30% of Eligible Expenses^1
Lab / X-Ray	0% of Eligible Expenses^1	30% of Eligible Expenses^1	Covered 100%	30% of Eligible Expenses^1	Covered 100%	30% of Eligible Expenses^1
Mental Health Outpatient - 30 visits	0% of Eligible Expenses^1	30% of Eligible Expenses^1	$40	30% of Eligible Expenses^1	$20	30% of Eligible Expenses^1
Mental Health Inpatient - 45 days/year	0% of Eligible Expenses^1	30% of Eligible Expenses^1	30% of Eligible Expenses^1	50% of Eligible Expenses^1	0% of Eligible Expenses^1	30% of Eligible Expenses^1
Substance Abuse Inpatient/Outpatient	0% of Eligible Expenses^1	30% of Eligible Expenses^1	30% of Eligible Expenses^1	50% of Eligible Expenses^1	0% of Eligible Expenses^1	30% of Eligible Expenses^1
Outpatient Surgery	0% of Eligible Expenses^1	30% of Eligible Expenses^1	30% of Eligible Expenses^1	50% of Eligible Expenses^1	0% of Eligible Expenses^1	30% of Eligible Expenses^1
Physician's Office Services	0% of Eligible Expenses^1	30% of Eligible Expenses^1	$40	30% of Eligible Expenses^1	$20	30% of Eligible Expenses^1
Professional Fees - Surgical & Medical	0% of Eligible Expenses^1	30% of Eligible Expenses^1	30% of Eligible Expenses^1	50% of Eligible Expenses^1	0% of Eligible Expenses^1	30% of Eligible Expenses^1
Rehabilitation Services	0% of Eligible Expenses^1	30% of Eligible Expenses^1	30% of Eligible Expenses^1	50% of Eligible Expenses^1	0% of Eligible Expenses^1	30% of Eligible Expenses^1
Physical Therapy
Occupational Therapy
Spinal Therapy
$1,500 maximum per Calendar year
Skilled Nursing Facility / Home Health Care / Hospice Care	0% of Eligible Expenses^1	30% of Eligible Expenses^1	0% of Eligible Expenses^1	30% of Eligible Expenses^1	0% of Eligible Expenses^1	30% of Eligible Expenses^1
Urgent Care Center	0% of Eligible Expenses^1	30% of Eligible Expenses^1	$65	30% of Eligible Expenses^1	$45	30% of Eligible Expenses^1
^1 After payment of deductible
PRESCRIPTION DRUGS
	Plan 1		Plan 2		Plan 3
Type of Drug	In-Network	Non-Network	In-Network	Non-Network	In-Network	Non-Network
Generic	0% after Deductible	0% after Deductible	$20.00	20% of Eligible Expenses^1	$15.00	20% of Eligible Expenses^1
Preferred Brand			$40.00	20% of Eligible Expenses^1	$30.00	20% of Eligible Expenses^1
Non=Preferred Brand			$60.00	20% of Eligible Expenses^1	$45.00	20% of Eligible Expenses^1
These charts offer an overview of benefits and their respective out-of-pocket expenses under BlueCross BlueShield’s Plan 1, Plan 2 and Plan 3. Please refer to your Summary Plan Descriptions for a detailed description of benefits. You may contact Gallagher Benefit Services at 512.499.8005 with questions.