Benefits as of April 1, 2014

NATIONAL ALLIED WORKERS UNION LOCAL 831

SCHEDULE OF MEDICAL BENEFITS

PLAN 3

PPO / NON-PPO
Plan year Deductible:
Per Participant / $1000 / $1500
The deductible applies to all charges that are covered by the Plan, except for those charges that are paid at 100% and have a Plan co-payment.
Benefit Percentage:
Medical Plan Pays
Patient Pays / 80%
20% / 60%
40%
Out-of-Pocket Maximum:
Per Participant / $6,000 / $12,000
The charges for the following do not accrue to the Out-of-Pocket Maximum:
·  Deductible
·  Mental Health Treatment Expenses
·  Substance Abuse Treatment Expenses
·  Ambulance Services Expenses
·  Urgent Care Facility Expenses
·  Emergency Room Expenses
·  Cost Containment Penalties
·  Co-payments
·  Amounts in excess of covered expenses/amounts in excess of benefit limits
·  Benefits that are excluded

Penalty for Failure to Pre-Certify Hospital Admissions and Other Specified Services will result in a 50% reduction in expenses covered by the plan; regular fixed co-pays, deductibles and Plan payment percentages apply to remaining 50%

Benefits and Services / PPO Provider
Plan Pays
(After Deductible) / Non-PPO Provider
Plan Pays
(After Deductible) / Comments
HOSPITAL BENEFIT
Inpatient Hospital Services
Semi-Private Room
Surgical Services
Anesthesia Services
Outpatient Hospital Services
Surgical Services
Anesthesia Services
Physician Charges
(separate) / $850 Co-Pay
80%
(deductible waived)
$600 Co-Pay
per admission
80%
(deductible waived)
80% / $2000.00 co-pay
60%
$1000.00 co-pay
60%
60% / Pre-certification required.
Benefit based on Semi-private room rate.
Pre-certification is required
Pre-certification required
Intensive Care Unit / $1000 Co-Pay
80% / $1000.00 co-pay
60% / Pre-certification required.
Benefits and Services / PPO Provider
Plan Pays
(After Deductible) / Non-PPO Provider
Plan Pays
(After Deducible) / Comments
Skilled Nursing Facility / Not Covered / Not Covered
Urgent Care Center / $200 co-payment
80%
Deductible Waived / $200 co-payment
60%
Deductible Waived
Emergency Room / $300 co-payment
80%
Deductible Waived / $300 co-payment
80%
Deductible Waived
MENTAL HEALTH & SUBSTANCE ABUSE
Inpatient Mental Health & Substance Abuse Treatment / Not Covered / Not Covered
Outpatient Mental Health & Substance Abuse Treatment / Not Covered / Not Covered
MISCELLANEOUS SERVICES & SUPPLIES
Home Health Care / Not Covered / Not Covered
Hospice Care / Not Covered / Not Covered
Ambulance Service
Air Ambulance / $100 Co-Pay
Deductible Waived
80%
Not Covered / $100 Co-Pay
Deductible Waived
80%
Not Covered
Durable Medical Equipment / Not Covered / Not Covered
Outpatient Hospital Diagnostic Studies, Laboratory and X-ray
Independent Laboratory Charges / 80%
80% / 60%
Not Covered
PPO Provider
Plan Pays
(After Deductible) / Non-PPO Provider
Plan Pays
(After Deductible) / Comments
MRI
CAT Scans / 100%
100% / Not Covered
Not Covered / Pre-certification required
Pre-certification required.
Sleep Apnea Treatment
Treatment of Aids or related illness
Maternity Care
Prenatal & Post natal
Hospital services for mother and child
Birthing Center
Premature Births / Not Covered
80%
$750.00 co-pay
80% / Not Covered
60%
$1000.00 co-pay
60% / Pre-certification required
Pre-certification required.
PROFESSIONAL SERVICES BENEFIT
Physician’s visits
·  Office Visit
·  Office Surgery
● Specialist Visit / $30 Co-Pay
80%
$50 Co-pay / 60%
60%
60%
Allergy Testing
Allergy Treatment / Not Covered
Not Covered / Not Covered
Not Covered
Office Diagnostic & Laboratory Expenses
Office Minor Surgical Expenses / 80%
80% / 60%
60%
Chiropractic
Podiatry
Dental
Vision
Hearing
Pharmacy / Not Covered
Not Covered
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
PPO Provider
Plan Pays
(After Deductible) / Non-PPO Provider
Plan Pays
(After Deductible) / Comments
REHABILITATION THERAPY
Outpatient Therapies
·  Occupational Therapy
·  Physical Therapy
·  Speech Therapy
·  Chemotherapy
·  Radiation Therapy
·  Cardiac Rehab / $40 co-pay
100%
$40.00 co-pay
100%
Not Covered
80%
80%
80%
/ Not Covered
Not Covered
Not Covered
60%
60%
60% / Limited to 5 visits per calendar year
Maximum 10 visits per year.
PREVENTIVE CARE After a 90 waiting period
Well Baby/Child Care
Office Visit
Immunizations, lab, x-rays / $35 co-pay
80% / 60%
60%
Well Adult Care
·  Age 18+
·  Routine pap smear, x-rays, lab, PSA testing, physicals
·  Immunizations
·  Flu Vaccinations /
$35 co-pay
80%
Not Covered
Not Covered / 60%
60%
Not covered
Not Covered
Mammogram Screening
Mammogram Diagnostic / $40.00 co-pay
80%
$40.00 co-pay
80% / $50.00 co-pay
60%
$50.00 co-pay
60% / Not part of wellness

This is a Grandfathered Plan under Health Care Reform