NATIONAL ALLIED WORKERS UNION LOCAL 831
SCHEDULE OF MEDICAL BENEFITS
JANUARY 1, 2009
PLAN ΙΙ
Maximum Lifetime Benefit for Medical Care $2,000,000
PPO / Non-PPOPlan year Deductible:
Per Covered Person / $300 / $1500
Unless specifically stated, the deductible does not apply to those charges that are subject to a plan co-payment…
Benefit Percentage:
Medical Plan Pays
Patient Pays / 80%
20% / 70%
30%
Out-of-Pocket Maximum:
Per Covered Person / $6,000 / $9,000
The charges for the following do not accrue to the Out-of-Pocket Maximum:
· Deductible
· Mental Health Treatment Expenses
· Substance Abuse Treatment Expenses
· Amounts in excess of covered expenses/ amounts in excess of other benefit limits
· Urgent Care Facility Expenses ( in-network)
· Emergency Room Expenses (in-network)
· Cost Containment Penalties
· Co-payments
· Benefits that are excluded
Benefits and Services /
PPO Provider
Plan Pays /
Non-PPO Provider
Plan Pays / Comments
HOSPITAL BENEFIT (After deductibles and/or co-pays)
Inpatient Hospital Services
Surgery Services
Anesthesia Services
Room and Board
Diagnostic Services
Outpatient Hospital Services
Surgical Service
Anesthesia
Physician Charges
(separate) / $800 co-pay
100%
$500 co-pay
100%
80% / $1600 co-pay
70%
$750 co-pay
70%
70% / Pre-certification required.
Benefit based on Semi-private room rate.
Pre- certification required.
Pre-certification required.
Intensive Care Unit / $800 co-pay
100% / $1600 co-pay
70% / Pre-certification required. based on Hospital’s ICU charge
Benefits and Services / PPO Provider
Plan Pays / Non-PPO Provider
Plan Pays / Comments
Skilled Nursing Facility / Not Covered / Not Covered
Urgent Care Center
Physician charges separate / $100 co-pay
100% / $100 co-pay
70%
Emergency Room
Physician charges separate / $200 co-pay
100% / $200 co-pay
70%
MENTAL HEALTH & SUBSTANCE ABUSE (after deductible and/or co pays)
Inpatient Mental Health Treatment / Not Covered / Not Covered
Outpatient Mental Health Treatment / $25 co-pay
100% / $50 co-pay
70% / 20 visits maximum per year.
Inpatient Substance Abuse Treatment / Not covered / Not covered
Outpatient Substance Abuse Treatment / $25 co-pay
100% / $50 co-pay
70% / 20 visits maximum per year.
MISCELLANEOUS SERVICES AND SUPPLIES (after deductible and/or co-pays)
Home Health Care / 80% / 70% / Limited to 40 visits maximum per year.
Hospice Care / Not Covered / Not Covered
Ambulance Service
Air Ambulance / 80%
Deductible Waived
Not Covered / 70%
Deductible
Waived
Not Covered / Limited to $1000 per trip
Durable Medical Equipment / 80% / 70% / Limited to $2000 paid per calendar year.
Benefits and Services / PPO Provider
Plan Pays / Non-PPO Provider
Plan Pays / Comments
Diagnostic Studies, Laboratory
and X-ray (Not including MRI/CAT Scan)
Independent Laboratory Expenses
MRI
CAT Scan / 80%
80%
100%
100% / 70%
70%
70%
70% / Pre-certification required.
Max. $1000 per calendar year.
Pre-certification required.
Max. $600 per calendar year.
Sleep Apnea
HIV/STD Treatment
Maternity Care
Prenatal and Postnatal
Hospital Services for Mother and Child, Birthing Center &Pre-mature births / Not Covered
$2500 yearly limit
$25,000 lifetime limit
$800 co-pay
80% / Not Covered
$2500 yearly limit
$25,000 lifetime limit
$1600 co-pay
70% / .
PROFESSION SERVICES BENEFIT (after deductible and/or co-pay)
Physician’s visits
· Office Visit
· Specialists office visit
(lab & x-ray services separate) / $25 co-pay
100%
$40 co-pay
100% / $40 co-pay
70%
$55 co-pay
70%
Allergy Testing
Allergy Treatment / $25 co-pay per visit
100%
$25 co-pay per visit
100% / $40 co-pay
70%
$40 co-pay
70% / Limited to $1000 paid per calendar year.
Limited to $1000 paid per calendar year.
Office Diagnostic Laboratory Expenses
Office Minor Surgical Expenses / 80%
80% / 70%
70%
Benefits and Services / PPO Provider
Plan Pays / Non-PPO Provider
Plan Pays / Comments
REHABILITATION THERAPY (after deductible and/or co-pay)
Outpatient Therapies:
Occupational Therapy
Physical Therapy
Speech Therapy
Speech Testing
Radiation Therapy
Chemotherapy / $40 co-pay per visit
100%
$40 co-pay per visit
100%
$40 co-pay per visit
100%
$40 co-pay per visit
100%
80%
80% / $55 co-pay per visit
70%
$55 co-pay per visit
70%
$55 co-pay per visit
70%
$55 co-pay per visit
70%
70%
70% / Limited to 10 visits per calendar year.
Maximum 20 visits per year.
Maximum 10 visits per year.
$1,000 maximum per year.
PREVENTIVE CARE 90 day waiting period These Benefits are not available until after three (3) months of coverage. Wellness is not subject to deductible
Well Baby/Child Care
Office Visit
Immunizations, lab work, x-rays / $25 co-pay
100%
80% / $40 co-pay
70%
70% / Limited to $1000 per child per plan year.
Well Adult Care
Office Visit
· Age 18+
Routine pap smear, PSA testing, lab work, x-rays, physicals
Adult Immunizations including flu shots / $25 co-pay
100%
80%
Not Covered / $40 co-pay
70%
70%
Not Covered / limited to $500 per adult per plan year.
Mammogram Screening
Mammogram Diagnostic / $25 co-pay
80%
$25 co-pay
80% / $40 co-pay
70%
$40 co-pay
70%
Chiropractic
Podiatry
Dental
Vision
Pharmacy / Not Covered
Not Covered
Not Covered
Not Covered
Not Covered / Not Covered
Not Covered
Not Covered
Not Covered
Not Covered / Covered through a separate
Discount Program
Covered through a separate Discount Program
Covered through a separate Discount Program