MODEL 101: ACTIVE RAILWAY EMPLOYEES

(AND OTHER MEMBERS WHO QUALIFY FOR ACTIVE BENEFITS)

Plan payment may never exceed, usual, customary and reasonable (UCR) charges

Plans 1,3,5,17,22

Allergy Testing & Injections 100%

Ambulance Transportation in Emergency Base Rate 100%
Mileage & Ancillary Chgs. 100%
Hospital to Hospital transfer for special facilities 100%

Anesthesia 100% in-network
85% non-network

Appliances/Braces/Trusses 100% up to $125.00 per item

Cardiac/Pulmonary Rehabilitation 100% up to 30 outpatient treatments or 30 inpatient days

Chemotherapy/Radiation Therapy for cancer 100%

Chiropractic Care 80% up to $600.00 per year

Colostomy Bags (Only) 50% reimbursement

Dental Care required due to accidental injury 100% up to $300.00 per year

Diagnostic Testing (outpatient lab, x-ray, scans, MRI's, sonograms, mammograms (excluding treadmills) 100% up to $3,000.00, then 80% to max. of $10,000.00 per year

Dialysis 100% up to $5000.00, then 80% to total of $10,000.00 per year

Short term peritoneal dialysis 100% up to $4000.00 per year

Dietary Consultation up to $50.00 once per year

Eye Exam $40.00 once per year (Does not apply to Active Railway Employees covered by VSP)

Hearing Aids (hearing loss must be greater than 35 dB) 80% to maximum of $300.00 per item (renewable after 5 years)

Hearing Test (must be under physician supervision) 100% in-network
85% out-of-network

Home Health Care 100% for up to 40 visits per year
No limit on visits if patient is terminal

Hospice - Home Care Covered under Home Health Care 100% up to $3,000.00

Hospital Emergency Room 100% if life threatening and/or a medical emergency 80% if deemed non-emergent
Emergency Room Physician 100%

Hospital:

Inpatient (must pre-notify Assn. at 1-888-800-9161)  100% at semi-private rate for up to 183 days per calendar year in-network
80% at semi-private rate for up to 183 days per calendar year out-of-network

Outpatient (excluding Diagnostic Testing covered under 100% in-network separate benefit) 80% out-of-network

Injections 100% (purchased through Pharmacy)
Lab & X-ray Professional Fees when confined as a hospital inpatient  100% in-network

Oxygen - when ordered by a physician for patients who meet medical necessity guidelines 100% to a maximum of $3,000.00 per calendar year

Penile Erection Device (external) 75%
Penile Implant 80%

Physical Therapy 100% up to 15 treatments per calendar year, with doctor's order additional treatments must be pre-certified.

Physician Services: (office visits, hospital visits, surgery, podiatry, etc.) 100% in-network
85% out-of-network

Prescription Medications (must be FDA approved)   Gen. $2 retail 30 days

                                                                                                    $4 M.O. 90 days

                                                                                        Brand $15 retail 30 days*

                                                                                                    $30 M.O. 90 days*

                                                                                        Pays 100% after $2000 annual out-of-pocket member cost.

                                                                                        Call EHO (1-800-650-9161) For additional details

                                                                                        * (or the greater of 20%)

Preventive Services (routine physicals, immunizations e.g., flu, pneu, childhood shots) 100% in-network
85% out-of-network

Prosthetics: artificial limb 60% to a maximum of 4,000.00 after a deductible of $500.00 per item
(renews after 5 years)

breast prosthesis 80% after $100.00 deductible

Psychiatric
Inpatient: (must be pre-certified) Same as any other illness
Outpatient: maximum of 15 visits per year paid at: 100% in-network
85% out-of network

Skilled Nursing Facility 80% for 31 days per year after a $100.00 deductible. Must be within 14 days of a hospital inpatient stay of at least 3 days.

Sterilization (Surgical, male or female) 100% in-network
85% out-of-network

Stress Tests (including Thallium Stress Test) 100% in-network
85% out-of-network

Substance Abuse/Chemical Dependency: (must be pre-certified)
(Maximum of two admissions per lifetime) First Admission: 100% up to $5,000.00, then 80%
limited to 30 days
Second Admission: 100% up to $3,000.00, then 80%
limited to 30 days

Temporomandibular Joint Syndrome (TMJ) Treatment 50% to a lifetime maximum of $1,250.00 after a $50.00 deductible
Surgery 100% in-network
85% out-of-network

Transplantation of Vital Organs Coverage is the same as for any other illness to a maximum benefit of $200,000.00 per case

Weight Loss Program (must be medically supervised) 80% up to a maximum of $3,000.00 after a $100.00 deductible, 1 lifetime benefit.