VEHI

Comparison of All VEHI Health Benefit Plans *
Selected Services	JY Plan	Comprehensive No Deductible	Comprehensive $100 Deductible	Comprehensive Plus $1,000 Deductible	VEHI Dual Option Plan
					$250 Comprehensive	Vermont Health Partnership
						Preferred Benefits
Managed Benefits Program	You must get Preadmission Review from Blue Cross and Blue Shield of Vermont prior to being admitted to a hospital as an inpatient. Notification of emergency or obstetrical admission is required within 48 hours after admission. This program applies to all plans VEHI offers.
Primary Care Physician	You need not designate a Primary Care Physician.	You need not designate a Primary Care Physician.	You need not designate a Primary Care Physician.	You need not designate a Primary Care Physician.	You need not designate a Primary Care Physician.	You must designate a network Primary Care Physician upon enrollment.
You Pay *	.$10 Visit Fee for office visits. .For certain services, $100 annual deductible (up to three per family), then 20% of the Allowed Price. .See next page for payment terms for your prescription drug plan.	.The appropriate deductible ($0 or $100, up to two per family). .20% of the Allowed Price, up to your $500 individual or $1,000 family out-of-pocket limit. Then, you pay no coinsurance for the rest of the year.		.$20 Visit Fee for primary care office visits. This Visit Fee does not apply to your out-of-pocket limit. .$1,000 individual deductible, and $2,000 family deductible. .20% of the Allowed Price, up to your $1,500 individual or $3,000 family out-of-pocket limit. Then, you pay no coinsurance for the rest of the year.	.$250 deductible (up to $500 per family. .20% of the Allowed Price, up to your $500 individual or $1,000 family out-of-pocket limit. Then, you pay no coinsurance for the rest of the year.	.$ 5 Visit Fee for office visits. .$15 Visit Fee for visits with all specialty providers.
Your Plan Pays	.All but $10 for office visits. .100% of necessary hospital charges .100% of the allowed price for Physician fees. .Certain services at 80% of the Allowed Price after you meet the $100 deductible. .Unlimited lifetime benefits maximum. .See next page for payment terms for your prescription drug plan.	.80% of the Allowed Price for all covered services after you meet the appropriate deductible until you reach your out-of-pocket limit. .100% of the Allowed Price for the rest of the year after you reach your out-of-pocket limit. .Up to $1 million in lifetime benefits.		.100% of the Allowed Price for primary care office visits (visits with family practitioners, general practitioners, pediatricians or internists), less your visit fee. .80% of the Allowed Price for all covered services after you meet the appropriate deductible until you reach your out-of-pocket limit. .100% of the Allowed Price for the rest of the year after you reach your out-of-pocket limit . .Up to $1 million in lifetime benefits.	.80% of the Allowed Price for all covered services after you meet the deductible. .100% of the Allowed price for the rest of the year after you reach your out-of-pocket limit. .Unlimited lifetime benefits maximum.	.100% of the Allowed Price for most covered services, less your Visit Fee. .If you do not use your Primary Care Physician or a network specialty provider you may pay a larger share of the cost. .Unlimited lifetime benefits maximum.
Prescription Drugs	You pay a $100 prescription drug deductible each year. Then you pay: .a $6 co-payment for generic drugs, .a $12 co-payment for Brand-Name drugs that are on our Preferred Brand-Name Drug List (on the back of this brochure), or .a $24 co-payment for Brand-Name drugs that are not on our Preferred Brand-Name Drug List (Non-Preferred drugs). You must use a Network Pharmacy.
* Your Prescription Drug program deductible is a separate deductible. Your out-of-pocket limit does not include your office visit fees or co-payments and deductibles you pay as part of the Prescription Drug program.
Selected Services	JY Plan	Comprehensive No Deductible	Comprehensive $100 Deductible	Comprehensive Plus $1,000 Deductible	VEHI Dual Option Plan
					$250 Comprehensive	Vermont Health Partnership
						Preferred Benefits
Hospital Outpatient	We pay 100% of our Allowed Price.	.You pay the appropriate deductible ($0 or $100, up to two per family), then 20% until you reach your $500 individual or $1,000 family out-of-pocket limit.		.You pay the $1,000 deductible, then 20% until you reach your $1,500 individual or $3,000 family out-of-pocket limit.	.You pay a $250 deductible* (or up to a $500 family deductible), then 20% coinsurance until you reach your $500 individual or $1,000 family out-of-pocket limit.	We pay 100% of our Allowed Price.
Hospital Inpatient	.We pay 100% of our Allowed Price.					.We pay 100% of our Allowed Price. .Standard Benefits are available for out-of-network services.
Physician's Office Visits	.We pay all but your $10 office visit fee.					.$5 Visit Fee for visits with your Primary Care physician. .$15 Visit Fee for visits with a specialty provider. .We cover the rest. .Standard Benefits are available for out-of-network services.
Emergency Room	.Covered in full.					.Covered in full. .You do not need a referral from your Primary Care Physician. .No Standard Benefits are available.
	Emergency room care is covered only if your symptoms are severe enough that the absence of immediate medical attention could reasonably be expected to: .Place your physical or mental health in serious jeopardy; or .Cause serious impairment to bodily functions; or .Cause serious dysfunction of any bodily organ or part. These guidelines apply to all plans.
Inpatient Mental Health Services	.We pay 100% of our Allowed Price You may need to contact the mental health network to initiate mental health care.	.You pay the appropriate deductible ($0 or $100, up to two per family), then 20% until you reach your $500 individual or $1,000 family out-of-pocket limit. You may need to contact the mental health network to initiate mental health care.		.You pay the $1,000 deductible, then 20% until you reach your $1,500 individual or $3,000 family out-of-pocket limit. You may need to contact the mental health network to initiate mental health care.	.You pay a $250 deductible (or up to a $500 family deductible), then 20% coinsurance until you reach your $500 individual or $1,000 family out-of-pocket limit. You must contact the mental health network to initiate mental health care.	.We pay 100% of our Allowed Price. .You must contact the mental health network to initiate mental health care. .No Standard Benefits.
Outpatient Mental Health Services	.Same as Physician's Office Visits (above). You may need to contact the mental health network to initiate mental health care.**					.You pay a $15 Visit Fee each time you visit your provider's office. We cover the rest. .You must call to initiate treatment and use network providers. .No Standard Benefits.
Chiropractic Services	.$10 Visit Fee .You must use a participating provider and get prior approval for any visits after 12 in a calendar year.	.Covered as other services (above). .You must use a participating provider and get prior approval for any visits after 12 in a calendar year			.Covered as other services (above). .You must use a participating provider and get prior approval for any visits after 12 in a calendar year.	.$15 Visit Fee for each visit. .You must use a network provider. .You also need prior approval for any visits after 12 in a calendar year. .No Standard Benefits.
** Depending on local, negotiated agreements, your benefits for mental health services may differ. Call your school's business office if you have questions.