Summary Plan Description

Teamsters Local 805 Welfare Fund

BENEFITS AT A GLANCE

	GHI Network	Out-of-Network Providers
Inpatient Visits	Fund pays 100%	Deductible and Coinsurance
Physician Visit	Fund pays 100% of Negotiated Charge after your $20 co-payment	Fund pays 70% of Reasonable & Customary charges after Calendar Year Deductible; participant pays difference
Annual Physical Exam	Fund pays 100% of Negotiated Charge after your $20 co-payment	Fund pays 70% of Reasonable &Customary charges. Not subject to the Calendar Year Deductible
Well Child Care 1st Year – 6 visits 2nd Year -4 visits 3rd Year – 2 visits Thereafter – 1 visit Up to age 19; including necessary immunization	Fund pays 100% of Negotiated Charge after your $20 co-payment	Fund pays 70% of Reasonable & Customary after deductible.
Chiropractic Care/Services Maximum of 30 visits per year.	Fund pays 100% of Negotiated Charge after your $20 co-payment	Fund pays 70% of Reasonable & Customary charges after Calendar Year Deductible; participant pays difference
Mental Health Visits Maximum of 40 (Outpatient) visits per year.	Fund pays 100% of Negotiated Charge after your $20 co-payment.	Covered in-network only.
Physical Therapy, Physical Medicine, & Rehabilitation Speech Therapy Maximum of 30 visits per year.	Fund pays 100% of Negotiated Charge after your $20 co-payment (out-patient)
Surgery	Fund pays 100% of Negotiated Charge	Fund pays 70% of Reasonable & Customary charges after Calendar Year Deductible; participant pays difference
Out Patient Surgery	Fund pays 100% of Negotiated Charge	Fund pays 70% of Reasonable & Customary charges after Calendar Year Deductible; participant pays difference
Anesthesia	Fund pays 100% of Negotiated Charge (no co-payment)	Fund pays 100% of Reasonable & Customary charges (no deductible)
Laboratory Services	Fund pays 100% of Negotiated Charge (no co-payment)	Fund pays 70% of R&C charges after Calendar Year Deductible; participant pays difference
Radiology-X-rays, MRI, Sonograms, C-scan	Fund pays 100% of Negotiated Charge (no co-payment)	Fund pays 70% of R&C charges after Calendar Year Deductible; participant pays difference
Hospitalization	Fund pays 100% of the Negotiated Charge	Fund pays 100% of R&C charges; $400 penalty for failure to precertify
Emergency Room	Fund pays 100% of Negotiated Charge after a $75 Co-pay Waived if Admitted	Fund pays 100% of Reasonable & Customary charge after a $75 Co-pay. Waived if Admitted
Ambulance	Fund pays 100% of the Negotiated Charge	70% of Reasonable & Customary after deductible
Hospice Pre-Certification Required	Fund pays 100% up to a maximum of 90 days. Precertification required.	Covered in-network only.
Home Health Care Pre-Certification Required. Up to 200 visits per calendar year	Fund pays 100% of the Negotiated Charge. Precertification required.	Covered in-network only.
Skilled Nursing Facility Up to 60 days per calendar year	Fund pays 100% of the Negotiated Charge. Precertification required.	Covered in-network only.
Durable Medical Equipment	Fund pays 100% of Negotiated Charge.	Covered in-network only
Alcohol & Substance Abuse	Up to 40 sessions per year at Teamster Center Services Up to a maximum of $45 Per session, plus $20 co-pay.	Outpatient only