National Allied Workers Union Local 831

NATIONAL ALLIED WORKERS UNION LOCAL 831 SCHEDULE OF MEDICAL BENEFITS PLAN 2

Benefits as of April 1, 2014

PPO Non-PPO Plan 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 80% 70% Patient Pays 20% 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 Penalty for failure to Pre-Certify Hospital Admissions and Other Specified Services results is 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 Non-PPO Provider Comments Plan Pays Plan Pays HOSPITAL BENEFIT (After deductibles and/or co-pays) Inpatient Hospital Services $800 co-pay $1600 co-pay Pre-certification required. Surgery Services 100% 70% Benefit based on Semi-private Anesthesia Services room rate. Room and Board Diagnostic Services

Intensive Care $ 800 co-pay $ 1600 co-pay Pre- certification required. 100% 70% Outpatient Hospital Services Surgical Service $500 co-pay $750 co-pay Pre-certification required. Anesthesia 100% 70%

Physician Charges (separate) 80% 70% Pre Certification required PPO Provider Non-PPO Provider Benefits and Services Plan Pays Plan Pays Comments

Skilled Nursing Facility Not Covered Not Covered

Urgent Care Center (facility only) $100 co-pay $100 co-pay 100% 70% Physician charges separate Emergency Room (facility only) $200 co-pay $200 co-pay 100% 70% Physician charges separate

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 $50 co-pay 100% 70% 20 visits maximum per year.

Inpatient Substance Abuse Not covered Not covered Treatment

Outpatient Substance Abuse $25 co-pay $50 co-pay 20 visits maximum per year. Treatment 100% 70%

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 80% 70% Deductible Deductible Waived Waived Air Ambulance Not Covered Not Covered

Durable Medical Equipment 80% 70% PPO Provider Non-PPO Provider Benefits and Services Plan Pays Plan Pays Comments

Diagnostic Studies, Laboratory and X-ray (Not including 80% 70% MRI/CAT Scan)

Independent Laboratory Expenses 80% 70%

MRI (Limited to 6 Per Year) 100% 70% Pre-certification required.

CAT Scan (Limited to 3 Per Year) 100% 70% Pre-certification required.

Sleep Apnea Not Covered Not Covered

HIV/STD Treatment 80% 70% .

Maternity Care $800 co-pay $1600 co-pay Prenatal and Postnatal 80% 70% Hospital Services for Mother and Child, Birthing Center &Pre- mature births PROFESSIONAL SERVICES BENEFIT (after deductible and/or co-pay)

Physician’s visits $25 co-pay $40 co-pay  Office Visit 100% 70%

 Specialists office visit $40 co-pay $55 co-pay (lab & x-ray services separate) 100% 70% Allergy Testing $25 co-pay per visit $40 co-pay 100% 70%

Allergy Treatment $25 co-pay per visit $40 co-pay 100% 70% Office Diagnostic Laboratory 80% 70% Expenses

Office Minor Surgical Expenses 80% 70% PPO Provider Non-PPO Provider Benefits and Services Plan Pays Plan Pays Comments

REHABILITATION THERAPY (after deductible and/or co-pay) Outpatient Therapies:

Occupational Therapy $40 co-pay per visit $55 co-pay per visit Limited to 10 visits per calendar 100% 70% year.

Physical Therapy $40 co-pay per visit $55 co-pay per visit Maximum 20 visits per year. 100% 70%

Speech Therapy $40 co-pay per visit $55 co-pay per visit Maximum 10 visits per year. 100% 70%

Speech Testing $40 co-pay per visit $55 co-pay per visit 100% 70%

Radiation Therapy 80% 70%

Chemotherapy 80% 70%

PREVENTIVE CARE 90 day waiting period These Benefits are not available until after three (3) months of coverage. Wellness is not subject to deductible. Please refer to your Plan Documents for coverage under wellness. Well Baby/Child Care

Office Visit $25 co-pay $40 co-pay 90 Day Waiting Period for 100% 70% Wellness

Immunizations, lab work, x- 80% 70% rays Well Adult Care

Office Visit $25 co-pay $40 co-pay  Age 18+ 100% 70% 90 Day Waiting Period for Wellness Routine pap smear, PSA testing, lab work, x-rays, 80% 70% physicals.

Adult Immunizations Not Covered Not Covered Includes Flu shot Mammogram Screening $25 co-pay $40 co-pay 80% 70%

Mammogram Diagnostic $25 co-pay $40 co-pay Not Covered under wellness 80% 70%

Chiropractic Not Covered Not Covered

Podiatry Not Covered Not Covered

Dental Not Covered Not Covered Covered through a separate Discount Program

Vision (Eye Care) Not Covered Not Covered Covered through a separate Discount Program

Pharmacy Not Covered Not Covered Covered through a separate Discount Program Hearing Not Covered Not Covered

This is a Grandfathered Plan under Healthcare Reform