September 9, 2010   TABLE OF CONTENTS   4.1.1 HealthLink Open Access III and Out of Area Deductible Requirement   A. HMO Calendar Year Deductible   Individual Family Maximum   $300 per calendar year $600 per calendar year The HMO calendar year deductible applies to all inpatient and outpatient services received from HMO providers, except Physician office visits. The HMO deductible amount also applies towards satisfaction of the PPO outpatient deductible described below. B. Outpatient Deductible* (for all providers except HMO)   Individual Family Maximum   $400 per calendar year $800 per calendar year *The Outpatient Deductible does not apply to PPO Physicians’ office visits, covered charges for obtaining a second surgical opinion or covered charges in connection with and on the day of certain surgical procedures performed in a Physician’s office (See Section 4.1.3). A Covered Person can satisfy the Outpatient Deductible by incurring, during a calendar year, $400 of covered charges while not confined as a registered inpatient in a licensed Hospital. (Charges for office visits to PPO Physicians are not subject to a deductible, unless otherwise noted). A Covered Person can also satisfy the Outpatient Deductible during a calendar year in any of the following ways: 1. Covered charges incurred within the last three months of any calendar year which were applied toward the Outpatient Deductible for that calendar year, can be applied toward the Outpatient Deductible for the next calendar year. 2. If two or more Covered Persons in the same family are injured in the same accident, with respect to covered charges due to that accident all of them need satisfy only one Outpatient Deductible for the calendar year in which the accident occurs. 3. After two or more Covered Persons in the same family unit have incurred a total of $800 of covered charges which are applied toward the Outpatient Deductible during the same calendar year, all Covered Persons in that family unit will be deemed to have satisfied their respective Outpatient Deductibles for that entire calendar year. 4. Covered charges applied to the HMO calendar year deductible will be applied towards the PPO outpatient deductible. C. Inpatient Deductible (for all providers except HMO)   Individual Family Maximum PPO $300 per calendar year $600 per calendar year Non-NetworkPO $500 per stay N/A PPO $400 per stay $800 per stay All covered inpatient medical charges, except as shown in the Schedule of Benefits, are subject to the deductibles outlined above. (Note: "Inpatient" refers to charges while confined as a bed patient in a Hospital; "Outpatient" refers to all other charges including Outpatient Hospital Charges.) A Covered Person can satisfy the Inpatient Deductible by incurring, during a calendar year, $300 of covered charges while confined as a registered inpatient in a PPO Hospital ($400 in an Out of Area Hospital) or $500 of covered charges per confinement in a Non-Network Hospital. A Covered Person can also satisfy the Inpatient Deductible during a calendar year in the following ways: Covered charges incurred within the last three months of any calendar year which were applied toward the PPO or Out of Area Inpatient Deductible for that calendar year, can be applied toward the Inpatient Deductible for the next calendar year. If two or more Covered Persons in the same family are injured in the same accident which results in a Hospital confinement, with respect to covered charges due to that accident, all of them need satisfy only one Inpatient Deductible for the calendar year in which the accident occurs. 3After two Covered Persons in the same family unit have satisfied their PPO or Out of Area Inpatient Deductibles during a calendar year, all Covered Persons in that family unit will be deemed to have satisfied their respective PPO or Out of Area Inpatient Deductibles for that entire calendar year. (This provision does not apply to confinements in a Non-Network Hospital).   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.