Apprentices Health & Welfare

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Plan Summary - Medical

Deductibles & Maximums
	LEVEL ONE	LEVEL TWO
	PPO PROVIDERS	OUT OF NETWORK
Deductible Individual	$0 (eff. 1/1/10)	$500
Deductible Family	$0 (eff. 1/1/10)	$1000
Annual Out-of-Pocket Maximum	The out of pocket maximum is $1,250 per individual and $2,500 per family. Deductible and office visit copayments do not apply to the out of pocket maximum. *	The out of pocket maximum is $4,500 per individual and $9,000 per family. Deductible and office visit copayments do not apply to the out of pocket maximum. *
LIFETIME MAXIMUM	$2,000,000 per individual	$2,000,000 per individual
	BENEFITS FOR COVERED SERVICES	BENEFITS FOR COVERED SERVICES
Physician Services
Office visits	$20 COPAYMENT	$20 COPAYMENT
Hospital/Skilled Nursing visits	90%	60%
Specialists	$20 COPAYMENT	$20 COPAYMENT
Surgeon/Asst. Surgeon	90%	60%
Anesthesiologist	90%	60%
Diagnostic X-ray & Labs	90%	60%
Preventative Care
Routine Physical Exam	90%, up to $200 annual maximum	60%, up to $200 annual maximum
Well Baby Care	90%, Covered from birth to age 3	60%, Covered from birth to age 3
Immunizations	90%, Covered from birth to age 3	60%, Covered from birth to age 3
Hospital/Surgical Services
Inpatient***	90%	60%
Outpatient	90%	60%
Emergency Services
Ambulance	90%	60%
Emergency Room	90% after $100 co pay, Waived if Admitted	60% after $100 co pay, Waived of admitted
Maternity Services:
Hospital Benefits – Delivery***	90%	60%
Outpatient Physician Services	90%	60%
Surgical Services	90%	60%
Mental and Nervous (severe mental disorders)
Hospital Benefits – *******	90%, max 30 days per calendar year	60%, max 30 days per calendar year
Outpatient Physician Services	90%**	60% **
Hospital Benefits – ******* and Outpatient Physician Services	Combined maximum payment of $5,000	Combined maximum payment of $5,000
Hospital Benefits – ******* and Outpatient Physician Services	No benefit if not utilizing a Beat It Provider.	No benefit if not utilizing a Beat It Provider.
Mental and Nervous (excludes severe mental disorders)
Hospital Benefits – *******	90%, max 30 days per calendar year	60%, max 30 days per calendar year
Outpatient Physician Services	90%**	60% **
Chiropractic Services and Acupuncture Services
	90%**	60%**
Continued Care Services
Home Health Care	90%**	60%**
Skilled Nursing Facility	Following discharge from an acute care facility, plan pays 90%.	Following discharge from an acute care facility, plan pays 60%.
Physical Therapy
	90%**	60%**
Speech Therapy
	90%**	60%**
Prescription Drugs
Retail Purchase - Generic or Brand	$10 Generic/$25 Preferred Brand/$40 Non-Preferred Brand
Mail Order Purchase	$20 Generic and $50 Preferred Brand/$80 Non-Preferred Brand 90 day supply
Prescription Drugs are provided by US Rx-Care

*Note: The calendar year out of pocket maximum will run July 1, 2008 through December 31, 2008 with no carryover. A new calendar year maximum will apply beginning January 1, 2009.

** Note: There is a 20 visit per calendar year limit for these services

*** Note: Precertification of services is required for non-emergency hospital admissions.