|Features||Choice PPO||Economy PPO||High-Deductible Health Plan (PPO or Traditional Indemnity)||Traditional Indemnity|
|Physician office visit copay||$25 or $50||$50||No copay||No copay|
|Deductible range||$500 - $25,000||$1,000 - $25,000||$2,000 - $25,000 for individuals, $4,000-$25,000 for families (not all deductibles meet federal guidelines for HSA qualification)||$500 - $25,000|
Medical services and supplies have a separate out-of-pocket amount from inpatient facility and surgical services
|Hospital or skilled nursing facility deductible per confinement||$250||$500||None||$250|
|Emergency room deductible per visit||$100||$100||None||$100|
For PPO plans, benefits/features listed are for in-network charges. Out-of-network benefits differ from in-network benefits. This is a brief description of some important features of coverage. The product is not available in all states and benefits, plan options, exclusions and limitations may vary based on state of residence. Please refer to the product brochure (IHCHS 539 0709) for additional information. For a full explanation of benefits, exclusions and limitations refer to the Certificate of Coverage (CLI CH 3010 CERT or CLI CH 3030 PPO Cert) or in Kansas and Montana, the Policy (CLI CH 3130 IND or CLI CH 3140 PPO). The Freedom Health Plan is underwritten by Companion Life Insurance Company.