Group Medical Insurance

Summary	Details	Booklet	Deductibles
Plan 1	Plan 1	Plan 1	$500 Ind./$1,000 Family
Plan 2	Plan 2	Plan 2	$1,000 Ind./$2,000 Family
Plan 3	Plan 3	Plan 3	$1,500 Ind./$3,000 Family
Plan 4	Plan 4	Plan 4	$2,000 Ind./$4,000 Family
Plan 5	Plan 5	Plan 5	$1,500 Ind./$3,000 Family
Plan 6	Plan 6	Plan 6	$2,500 Ind./$5,000 Family
Plan 7	Plan 7	Plan 7	$2,500 Ind./$5,000 Family
Plan 8	Plan 8	Plan 8	$3,000 Ind./$6,000 Family
Plan 9	Plan 9	Plan 9	$2,000 Ind./$4,000 Family
Plan 10	Plan 10	Plan 10	$3,500 Ind./$7,000 Family
Plan 11	Plan 11	Plan 11	$4,000 Ind./$8,000 Family
Plan 12	Plan 12	Plan 12	HSA $2,800 Ind./$5,600 Fam.
Plan 13	Plan 13	Plan 13	HSA $3,000 Ind./$6,000 Fam.
Plan 14	Plan 14	Plan 14	HSA $4,000 Ind./$8,000 Fam.
Plan 15	Plan 15	Plan 15	HSA $4,000 Ind./$8,000 Fam.
Plan 16	Plan 16	Plan 16	HSA $6,350 Ind./$12,700 Fam.
HIA Plan 1	HIA Plan 1	HIA Plan 1	HIA $2,000 Ind./$4,000 Fam.
HIA Plan 2	HIA Plan 2	HIA Plan 2	HIA $3,500 Ind./$7,000 Fam

Dental and Vision Benefits

Voluntary Open Access Dental Plan 1
Group Open Access Dental Plan 1
Voluntary Select PPO Dental Plan 2
Group Select PPO Dental Plan 2

Vision Benefits

Important Notices and Claim Forms

Notice of Privacy Practices
Summary Plan Description
My Health Toolkit
Claim Form - Columbia Service Center
Claim Form - Greenville Service Center
Minimum Essential Coverage Notice
Medicare Creditable Coverage

Fax completed Medical Change Form to Capstone Administrators at 317-222-3003

Mr. Mark Brown, Director of Operations, 803-750-2277 or 800-327-2598 in SC

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