KPS health plans

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Benefit Schedules:
Centric | Centric Enhanced | Healthy Investor HSA
Rate Schedules:
Centric | Centric Enhanced | Healthy Investor HSA

	Sound Harbor Enterprise
Annual Deductible* - Individual	$3,000*	$5,000*
Annual Deductible* - Family	$9,000	$15,000
Annual Coinsurance Maximum - Individual** (Does not include deductible, unless otherwise stated)	$6,000	$6,000
Annual Coinsurance Maximum - Family** (Does not include deductible, unless otherwise stated)	$18,000	$18,000
Lifetime maximum	$2,000,000/person
Preventive Care: (Not subject to deductible) Annual Routine Physical Exam Well-Baby Exam (up to 24 months of age) Annual Routine Eye Exam	$350 maximum per year total for all preventive care 70% 70% 70%
Professional Services Office, home, naturopath or urgent care visits	100% after $30 per-visit copay for first 3 visits combined (no deductible), subsequent visits 70% subject to deductible
Other outpatient professional services	70%
Outpatient Lab & X-Ray Mammography Services and Prostate Cancer Screening-Routine Mammography Services and Prostate Cancer Screening-Diagnostic	70% 70% (not subject to deductible) 70% (not subject to deductible)
Facility/Hospital Inpatient	70%
Facility/Hospital Outpatient	70%
Emergency Room & Supplies	70% after $100 copay per visit (copay waived if admitted)
Acupuncture (12 treatments per year maximum)	See Professional Services
Ambulance Services Air and Ground Combined - $7,000 max per year	70%
Home Health and Hospice Home Health – 130 visits maximum & subject to deductible Hospice – 6 months maximum per year & subject to deductible	70%
Maternity	Not a benefit
Medical Equipment & Supplies $2,500 per calendar year maximum & subject to deductible	70%
Mental Health Inpatient (prior authorization required)-10 days per year maximum Outpatient-12 visits per year maximum	70% See Professional Services
Nutritional Guidance $400 maximum per year	70%
Outpatient Rehabilitation (Physical, Speech, Massage & Occupational Therapy)	70% ($1,000 maximum per year)
Prescriptions	$2,000 maximum per year, except for diabetes
Tier 1: Generic	Tier 1: $15 copay or the cost of the drug, whichever is less
Tier 2: Preferred Brand Name	Tier 2 : Pharmacy Discount Program
Tier 3: Non-Preferred Brand Name	Tier 3: Pharmacy Discount Program
Skilled Nursing Facility (in lieu of hospitilization)	70%
Spinal & Extremity Manipulations (12 manipulations per year maximum)	See Professional Services
*In the case of accidental injury, charges for medically necessary covered services directly related to the treatment of the injury are exempt from the deductible for a period of up to six (6) months, provided initial treatment for the injury is received within seventy-two (72) hours of the onset of the injury. After six (6) months, the condition is considered to be chronic and charges related to the treatment of the injury would be applied to any outstanding deductible. All other applicable benefit limitations and maximums apply.

All benefits are subject to annual deductible unless otherwise stated. This benefit comparison contains only a brief explanation of the more important coverage features offered. It does not constitute a contract. Complete coverage details, including waiting periods and other limits and exclusions, are in the Benefits Booklet. In the event of discrepancies, the Benefits Booklet shall govern.

*In the case of accidental injury, charges for medically necessary covered services directly related to the treatment of the injury are exempt from the deductible for a period of up to six (6) months, provided initial treatment for the injury is received within seventy-two (72) hours of the onset of the injury. After six (6) months, the condition is considered to be chronic and charges related to the treatment of the injury would be applied to any outstanding deductible. All other applicable benefit limitations and maximums apply.

**After member satisfies the annual deductible and coinsurance maximum, KPS pays 100% of covered benefits for the remainder of the calendar year, with some limitations. If you choose a non-participating provider, your coinsurance costs are higher. In addition, it is your responsibility to pay the difference between any amounts billed by the non-participating provider or facility and the amount paid by KPS.

+The Healthy Investor ^TM family plans are designed for two or more family members. The entire family deductible must be satisfied before benefits are paid, annual routine physical exams, well-baby exams, routine mammograms, and routine prostate cancer screening are not subject to the annual deductible.

Note: This summary contains a brief explanation of the coverage features offered through KPS Health Plans. It does not constitute a contract. Complete coverage details are in the Benefit Booklet. In the event of discrepancies, the Benefit Booklet shall govern. There are exceptions, limitations, and reductions which may affect your coverage.