VIVA HEALTH

PLAN COMPARISON OF COMMONLY USED SERVICES VIVA ACCESS NO Referrals Required

For Employers with 2-50 Employees

Limitations and Coverage Maximums Apply. Please see Attachment A and the Certificate of Coverage for each plan for more detail.

**NEW** FOR 2009

BENEFITS
Plan Year Deductible Primary Care Services: Specialty Care:
Surgical & Medical Physician Services X-Ray and Laboratory Procedures Ob/Gyn Services One routine vision exam every 12 months Other eye care office visits Preventative Care & Other Office Visits

AC28
$0

AC38
$0

AC48
$0

AC58
$0

AC90
$250 single $750 family $20 $20

$10 $25

$15 $30

$20 $35

$25 $40

Vision Care:

$25

$30

$35

$40

$20

Allergy Services:
Physician Visits Testing

$25 80% $100

$30 80% $150

$35 80% $250

$40 80% 80%

$20 90%* 90%*

Diagnostic Services:
(Including but not limited to CT Scan, MRI, PET/SPECT, ERCP)

Outpatient Services:

Surgery & Other Outpatient Services

$100

$150

$250

80%

90%*

Physician Services Semi-private Room

Hospital Inpatient Services: 100% $100 $25 $100 $50 80% 80% 100% $250 $30 $250 $75 80% 80% 100% $500 $35 $500 $100 80% 80% 100% $750 $40 $750 $125 80% 80% 90%* 90%* $20 90%* $100 90%* 90%*

Maternity Services:
Physician Copay Prenatal, delivery, and postnatal care Maternity Hospitalization

Emergency Room Services

(Copay waived if admitted through ER)

Emergency Ambulance Services Durable Medical Equipment & Prosthetic Devices Skilled Nursing Facility Services

100%

100%

80%

80%

90%*
(11/08)ACsgsmry2009

AC28
Rehabilitation Services Home Health Care Services 100% Mental Health & Substance Abuse:
Inpatient Mental Health Outpatient Mental Health Substance Abuse: (Detox Only)

AC38
80%

AC48
80%

AC58
80%

AC90
90%*

80%

100%

80%

80%

90%*

50%
$50 per visit

50%
$50 per visit

50%
$50 per visit

50%
$50 per visit

50%
$50 per visit

50%

50%

50%

50%

50%

Prescription Drug Rider Retail (30 Day Supply)

Generic Preferred Non-Preferred

$12 $30 $50

$12 $30 $50

$12 $30 $50

$12 $30 $50

$15 $30 $60

Mail Order (90 day supply)

Generic Preferred Non-Preferred

$30 $75 $125

$30 $75 $125

$30 $75 $125

$30 $75 $125

$38 $75 $150

Maximum prescription coverage per member per calendar year

$2500

$2500

$2500

$2500

$3000

Diabetic Supplies:
Insulin covered under prescription drug rider

100% 90%

100% 90%

100% 90%

100% 90%

90%* 90%

Biological Drugs, Biotechnical Drugs, and Specialty Pharmaceuticals Mental and Nervous Drugs

50%

50%

50%

50%

50%

Out-Of-Pocket Maximum

N/A

N/A

N/A

N/A

$2,000 single $4,000 family

Lifetime maximum benefit per member: $1,000,000 for all plans

*Subject to plan year deductible.

$5,000 Maximum Coinsurance per Member per Calendar Year for Outpatient & Diagnostic Services and $10,000 Maximum Coinsurance per Family per Calendar Year for Outpatient & Diagnostic Services

(11/08)ACsgsmry2009