Benefits Summary Personal Choice^® PPO (Guaranteed Enrollment)

Medical Plan Benefit

Plan Overview	Deductible Individual/ Family	Office Visit	Specialist Visit	Hospitalization	Summary of Benefits and Coverage (SBC)
Basic I	$500/$1,000	$30 copay, no deductible	$50 copay, no deductible	20%, after deductible	Basic I
Basic II	$1,000/$2,000	$35 copay, no deductible	$60 copay, no deductible	20%, after deductible	Basic II
Value HSA	$5,000/$10,000	$0, after deductible	$0, after deductible	$0, after deductible	Value HSA
Hospital Care I	None	$40 copay¹	$75 copay¹	$1,000 per admission	Hospital Care I
Hospital Care II	$1,000/$2,000	$40 copay,¹ no deductible	$75 copay,¹ no deductible	20%, after deductible	Hospital Care II
Hospital Care III	$2,000/$4,000	$40 copay,¹ no deductible	$75 copay,¹ no deductible	40%, after deductible	Hospital Care III

Compare all plans in this Benefits at a Glance.

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¹ Limited to three office visits per year for a primary care physician and specialist (combined in- and out-of-network).