Schedule Medical Benefits

SCHEDULE OF MEDICAL BENEFITS

Enhanced PPO

Basic PPO

Medical Plan Features

For NETWORK providers the Plan pays . . .

For NON-NETWORK providers the Plan pays . . .

For NETWORK providers the Plan pays . . .

For NON-NETWORK providers the Plan pays . . .

Nurseline: Pin185
1-888-609-5880 A Nurse is available to provide immediate medical info & support 24 hrs/day; 100% covered.

Preventive Care

routine physical

immunization

pap test

mammogram

100% after $15 copay/office visit

up to $300/person maximum per cal year
(deductible does not apply)

Not covered

Preventive not covered except: 80% for one Pap test/cal yr,
80% for mammogram per age schedule.
Office visit not covered.
(deductible applies)

Not covered

Well Baby Care

100% after $15 copay/office visit
up to 2^nd birthday
(deductible does not apply)

Not covered

Physician Services

Office Visits

Hospital Visits

Inpatient Surgery

Outpatient Surgery

Hospital Newborn Care

Spinal Adjustments
(up to 12 visits/cal. year)

100% after $15 copay/office visit

100% hospital visits and surgery

(deductible does not apply)

60% of R&C¹

(deductible applies)

80%

(deductible applies)

60% of R&C¹

(deductible applies)

Health Care Facility

Hospital Outpatient (minor surgery, radiation therapy)

Hospital Inpatient²
(room and board, x-rays, intensive care, newborn routine nursery care)

Skilled Nursing Facility² (room&board up to semiprivate room rate, up to 120 days/cal year)

Home Health Care²
(up to 130 visits/cal year)

Hospice Care²
(up to $5,000 maximum)

100%
(deductible does not apply)

60% of R&C¹
(deductible applies)

80%
(deductible applies)

60% of R&C¹
(deductible applies)

X-Ray and Lab

Anesthesiology

100%
(deductible does not apply)

100% when ordered by a network provider

(ded. does not apply)

60% of R&C¹when ordered by a non-network provider

(deductible applies)

80%
(deductible applies)

80% when ordered by a network provider

(deductible applies)

60% of R&C¹when ordered by a non-network provider

(deductible applies)

Hospital
Emergency Room

100% after $75 copay
for emergencies
(deductible does not apply)

80% after $75 copay for non-emergencies (deductible applies)

(copayment is not waived even if admitted)

100% of R&C¹after $75 copay for emergencies
(ded does not apply)

60% of R&C¹after $75 copay for non-emergencies (deductible applies)
(copayment is not waived even if admitted)

80% for
emergencies
(deductible applies)

60% for non-emergencies (deductible applies)

80% of R&C¹for emergencies
(deductible applies)

60% of R&C¹for non-emergencies (deductible applies)

^{1 Reasonable & customary
charges. ²Pre-notification with UHC is required for you to receive
full plan benefits and avoid penalty.}

Enhanced PPO

Basic PPO

Medical Plan Features

For NETWORK providers the Plan pays . . .

For NON-NETWORK providers the Plan pays . . .

For NETWORK providers the Plan pays . . .

For NON-NETWORK providers the Plan pays . . .

Urgent Care Centers

100% after $30 copayment/visit (deductible does not apply)

60% of R&C¹
(deductible applies)

80%
(deductible applies)

60% of R&C¹
(deductible applies)

Other Covered Health Services:

Ambulance Service

Durable Medical Equipment

80%
(deductible applies)

80% of R&C¹
(deductible applies)

80%
(deductible applies)

60% of R&C¹
(deductible applies)

		Rehabilitation Therapy: Physical, Speech, Occupational and Respiratory therapy
		Infertility Treatment (maximums apply; see Covered Health services –Infertility section)

80%
(deductible applies)

60% of R&C¹
(deductible applies)

Outpatient
Prescription Drugs

100% after copay
$10 generic / $30 brand

Mail Order
(90-day supply)
100% after copay
$20 generic/$60 brand
(deductible/out-of-pocket maximum do not apply)

Not covered

80% generic /
60% brand name

Mail Order
(90-day supply)
80% gen/60% brand
of 60-day cost

(deductible/out-of-pocket maximum do not apply)

Not covered

Mental Health and Substance Abuse³

Inpatient Care³
(maximums apply; see Mental Health and Substance Abuse section)

100%
(deductible / out-of-pocket maximum do not apply)

50% of R&C¹
(deductible / out-of-pocket maximum do not apply)

80%
(deductible / out-of-pocket maximum do not apply)

50% of R&C¹
(deductible / out-of-pocket maximum do not apply)

Outpatient Care³
(maximums apply; see Mental Health and Substance Abuse section)

100%, after $15 copayment
(deductible / out-of-pocket maximum do not apply)

50% of R&C¹
(deductible / out-of-pocket maximum do not apply)

80%
(deductible / out-of-pocket maximum do not apply)

50% of R&C¹
(deductible and out-of-pocket maximum do not apply)

Intermediate Care³

100%
(deductible and out-of-pocket maximum do not apply)

50% of R&C¹
(deductible and out-of-pocket maximum do not apply)

80%
(deductible and out-of-pocket maximum do not apply)

50% of R&C¹
(deductible and out-of-pocket maximum do not apply)

Annual Deductible

$100/person; $200/family
(applies except where specified)

$500/person; $1000/family
(applies except where specified)

Out-Of-Pocket
Maximum

$1,000/person;
$2,000/family

(except where specified)

$5,000/person;
$10,000/family

(except where specified)

$3,500/person;
$7,000/family

(except where specified)

$5,000/person;
$10,000/family

(except where specified)

Non-Notification Penalty

$200 penalty applies to health facility services requiring pre-notification with UHC
$300 penalty applies to Mental Health/Substance Abuse services requiring UBH pre-notification

Maximum Lifetime Benefit

$2,000,000/person

^{1 Reasonable & customary
charges. ³ Pre-notification with UBH is required to receive full plan
benefits and avoid penalty.

NOTE: Copayments do not apply towards deductible or out-of-pocket maximum

Go to www.myUHC.com
to review your claims, check eligibility of your dependents, order an ID card,
locate network providers, and research information on many health topics.

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ABX Air, Inc. All Rights Reserved.

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Revised:
January 13, 2005
.}

Revised: January 13, 2005 .