Hylant Indianapolis

Group Health and Vision Care
This is a general outline of covered benefits and does not include all benefits, limitations, and exclusions. Benefits
based upon the benefit contract and not upon this summary. See your proposal/policy for details.

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Available Plans:

Plan (Click on plan for more info)

Description

Benefits

Network

Non-Network

Plan 1 (PPO, Deduction $1,000)

Deduction Single / Family:	$1,000 / $3,000	$2,000 / $6,000
Out-of-Pocket Single / Family:	$3,750 / $7,500	$7,500 / $15,000
Physician PCP / SCP (Primary Care Physician / Specialty Care Physician)	$25 / $25	50%

Plan 2 (PPO, Deduction $2,000)

Deduction Single / Family:	$2,000 / $6,000	$4,000 / $12,000
Out-of-Pocket Single / Family:	$5,500 / $11,000	$11,000 / $22,000
Physician PCP / SCP (Primary Care Physician / Specialty Care Physician)	$25 / $25	40%

Plan 3 (PPO, Deduction $4,000)

Deduction Single / Family:	$4,000 / $8,000	$8,000 / $16,000
Out-of-Pocket Single / Family:	$8,000 / $16,000	$16,000 / $32,000
Physician PCP / SCP (Primary Care Physician / Specialty Care Physician)	$25 / $25	50%

Plan 4 Health Savings Accounts (HSA)

Deduction Single / Family:	$2,500 / $5,000	$2,500 / $5,000
Out-of-Pocket Single / Family:	$5,000 / $10,000	$10,000 / $20,000
Physician PCP / SCP (Primary Care Physician / Specialty Care Physician)	20%	40%

Vision Plan

Vision Examination:

$5 copayment

Not covered

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If You Need Additional Help
If you are not sure where to begin or have questions about this coverage or any other insurance matter, please email us at crmincpa@hylant.com or give us a call. We are available from 8:00am to 4:30pm EST (Indiana) at (800) 442-7475, option 2. Please be aware that submission of email or voice mail does not constitute binding or guarantee of coverage.