	1375 Virginia Drive, Suite 102 Ft. Washington, PA 19034 Phone 215-542-8211

Don't Forget!

It's Your responsibility to update the Funds Office with any dependent changes - Birth of a child, Change in Marital Status, etc.

Summary of Medical Plan Benefits

Plan Feature	In-Network	Out-of-Network¹
Annual Deductible	$0	$300 per person/$600 per family
Out-of-Pocket Maximum	None	$2,000 per person/$4,000 per family
Lifetime Maximum	Unlimited	$1,000,000
Physician Services
Office Visits to Primary Care	100% after $10 copay/visit	70% after deductible
Office Visits to Specialist	100% after $20 copay/visit	70% after deductible
Preventive Care (for adults and children)	100% after $10 copay/visit	70% after deductible
Pediatric Immunizations	100%	70% no deductible
Routine Gynecological Exam and Pap test (1 per calendar year for women of any age)	100%	70% no deductible
Mammogram	100%	70% no deductible
Hospital Services
Maternity
First OB visit	100% after $10 copay	70% after deductible
Hospital	100% after $75 copay per day (up to $375 maximum per admission)	70% after deductible
Inpatient Hospital²	100% after $75 copay per day (up to $375 maximum per admission)	70% after deductible
Other Inpatient and Outpatient Services
Outpatient Surgery²	100% after $75 copay	70% after deductible
Emergency Room	100% after $40 copay (copay waived if admitted)	100% after $40 copay (copay waived if admitted)
Outpatient Laboratory	100%	70% after deductible
Outpatient Radiology^{2 3}	100% after $20 copay/visit	70% after deductible

Other Inpatient and Outpatient Services (Continued)
Skilled Nursing Care² (up to 120 days per calendar year)	100%	70% after deductible
Home Health Care²	100%	70% after deductible
Hospice²	100%	70% after deductible
Therapy Services
Physical, Speech, Occupational² (up to 60 visits combined maximum per calendar year)	Visits 1 to 30: 100% after $15 copay/visit Visits 31 to 60: 100% after $25 copay/visit	70% after deductible
Cardiac Rehabilitation² (up to 36 visits per calendar year)	100% after $15 copay/visit	70% after deductible
Pulmonary Rehabilitation² (up to 12 visits per calendar year)	100% after $15 copay/visit	70% after deductible
Chemo/Radiation and Renal Dialysis Therapy	100%	70% after deductible
Restorative Services, including chiropractic care² (up to 30 visits per calendar year)	100% after $20 copay/visit	70% after deductible
Other Services
Outpatient Private Duty Nursing² (up to 360 hours per calendar year)	100%	70% after deductible
Durable Medical Equipment²	100% after $20 copay	70% after deductible
Prosthetics²	100% after $20 copay	70% after deductible
Outpatient Diabetic Education	100%	Not covered

¹Benefits are based on the plan allowance. If the actual charge is greater than the plan allowance, you will have to pay the difference, and these amounts will not be applied to your out-of-pocket maximum.

²Certain services require pre-authorization to determine medical necessity. Failure to pre-authorize will result in a $1,000 penalty for inpatient admissions, a 20% penalty for certain outpatient services, and a 50% penalty for therapy and restorative services. Call the pre-authorization number on the back of your ID card before you receive these services.

³You can eliminate the $20 copay by utilizing the HCSC network. See page 22 for more details.