September 6, 2010   TABLE OF CONTENTS   4.1 HealthLink Open Access III and Out of Area Schedule of Benefits for Employees and Dependents   SERVICE PERCENTAGE PAYABLE HMO PPO Non-Network Out of Area Doctors Office: The following "Doctors Office" benefits apply only to services performed in a Physician’s office or freestanding medical clinic. Services (including, but not limited to, lab, x-ray, diagnostic testing and physical therapy) performed in the outpatient department of a Hospital are subject to the "Hospital Outpatient" benefits and co-payments. Office visit–Primary Care Physician (regular hours) 100% after $20 co-pay 100% after $20 co-pay 50%* 80%* Office visit–Specialist 100% after $25 co-pay 100% after $25 co-pay 50%* 80%* Lab and X-rays 100%* 90%* 50%* 80%* Allergy Injections 100% after $5 co-pay 90%* 50%* 80%* Surgery-Primary Care Physician 100% after $20 co-pay 90%* 50%* 80%* Surgery-Specialist 100% after $25 co-pay 90%* 50%* 80%* Specified Surgical Procedures (listed in section 4.1.3) 100% 100% 100% 100% Chiropractic Care Up to a maximum of 40 visits or $1,500 per Calendar Year (not including x-rays) 100% after $25 co-pay 90%* 50%* 80%* Physical Therapy 100% after $10 co-pay* 90%* 50%* 80%* Durable Medical Equipment 100%* 90%* 70%* 80%* Hospital Inpatient Semiprivate Room & Board and other Inpatient Charges 100% after $100 per stay co-pay (maximum $500 per stay)* 90%* 50%* 80%* Surgery 100%* 90%* 50%* 80%* Doctor's Visits 100%* 90%* 50%* 80%* Hospital Outpatient Surgery-Facility Charges 100% after $10 co-pay* 90%* 50%* 80%* Surgery-Physician Charges 100% after $100 co-pay* 90%* 50%* 80%* Emergency Room 100% after $10 co-pay (waived if admitted)* 90%* 50%* 80%* Cardiac Rehabilitation 100% after $10 co-pay per visit* 90%* 50%* 80%* Pulmonary Rehabilitation 100% after $10 co-pay per visit* 90%* Not Covered Not Covered Other (including, but not limited to, lab, x-ray, diagnostic testing and physical therapy) 100% after $100 co-pay per visit* 90%* 50%* 80%* Maternity Care Prenatal and Postnatal visits 100% after $25 co-pay 100% after $25 co-pay 50%* 80%* Other Maternity Care Charges 100%* 90%* 50%* 80%* Hospital and Obstetrical 100% after $100 per co-pay per day* 90%* 50%* 80%* Well Child Care and Immunizations 100% after $20 per co-pay* Not Covered Not Covered Not Covered **Subject to applicable deductible (see section 4.1.1) and additional payment (see section 4.1.2) MENTAL ILLNESS AND CHEMICAL DEPENDENCY BENEFITS SERVICES PERCENTAGE PAYABLE Participating Providers/ Hospitals Non-Participating Hospitals Referred by EAP Not Referred by EAP   Physician Limited to $100 per visit 70%** 50%** 50%** Licensed Clinical Psychologist, Counselor or Social Worker Limited to $80 per visit 70%** Not Covered Not Covered Outpatient Treatment Program 80%** of the cost of care that is Medically Necessary 60%** of the cost of care that is Medically Necessary 50%** of the cost of care that is Medically Necessary Hospital Inpatient 80%** of the cost of care that is Medically Necessary 60%** of the cost of care that is Medically Necessary 50%** of the cost of care that is Medically Necessary **Subject to applicable deductible (see section 4.1.1 on pages 63-65). Mental Illness and Chemical Dependency Maximums Lifetime Maximums Chemical Dependency $50,000 per person Mental Illness and Chemical Dependency Combined 75 days of inpatient hospitalization. Two days of partial or day hospitalization are considered one inpatient day. Calendar Year Maximums All Chemical Dependency Charges $10,000 per person Chemical Dependency Physician Services $2,000 per person* Mental Illness and Chemical Dependency Combined 30 days of inpatient hospitalization. Two days of partial or day hospitalization are considered one inpatient day.* The Physician services and inpatient hospitalization limits are included within (and are not in addition to) the $10,000 calendar year and $50,000 lifetime Chemical Dependency maximums. Chemical Dependency Limitation No further treatment will be covered unless patient completed a follow-up program recommended by the Fund's EAP (i.e., aftercare).   TABLE OF CONTENTS   St. Louis Graphic Arts Joint Health & Welfare Fund 14323 South Outer Forty Rd. - Suite S106 Chesterfield, Missouri 63017 Fund Office: (314) 878-1579 twesthues@slgahw.org Fax: (314) 275-2640   If you have any comments about this web site, please contact us at twesthues@slgahw.org.   Site Concept and Design ©2002 jWeb. Maintenance and Hosting provided by jWeb.