Local 170 Health and Welfare Fund - Health Plan - Comparison of Covered Services

Fallon BCBS BCBS

Your cost with PCP referral Your cost for self referral
(after your deductible)

To age 19, or
age 23 if full-time student To age 19, or
age 23 if full-time student To age 19, or
age 23 if full-time student

COVERED SERVICES

Outpatient Care

Office Visits

Fallon BCBS BCBS

Your cost with PCP referral Your cost for self referral
(after your deductible)

$10 per visit $10 per visit 20% co-insurance^*

Well-child Care

Fallon BCBS BCBS

Your cost with PCP referral Your cost for self referral
(after your deductible)

$10 per visit $10 per visit 20% co-insurance^**
(up through age 5)

Routine Checkups (Including one GYN exam per calendar year)

Fallon BCBS BCBS

Your cost with PCP referral Your cost for self referral
(after your deductible)

$2 per visit $5 per visit Not covered

Maternity Care

Fallon BCBS BCBS

Your cost with PCP referral Your cost for self referral
(after your deductible)

$10 per visit Covered in full 20% co-insurance*

Allergy Injections

Fallon BCBS BCBS

Your cost with PCP referral Your cost for self referral
(after your deductible)

Covered in full Covered in full 20% co-insurance*

X-rays Laboratory Tests and other tests

Fallon BCBS BCBS

Your cost with PCP referral Your cost for self referral
(after your deductible)

Covered in full Covered in full 20% co-insurance*

Hearing Exams

Fallon BCBS BCBS

Your cost with PCP referral Your cost for self referral
(after your deductible)

$10 per visit $10 per visit Not Covered

Routine Eye Exam and Glasses

Fallon BCBS BCBS

Provided by Davis Vision Provided by Davis Vision Provided by Davis Vision

Davis Vision 1-800-999-5431

Emergency Room Visits
effective 1-01-06

Fallon BCBS BCBS

Your cost with PCP referral Your cost for self referral
(after your deductible)

$100 per visit
(waived, if admitted) when authorized by Plan Physician $100 per visit
(waived, if admitted) 20% co-insurance^***

Family Planning

Fallon BCBS BCBS

Your cost with PCP referral Your cost for self referral
(after your deductible)

$10 per visit $10 per visit Not Covered

Infertility

Fallon BCBS BCBS

Your cost with PCP referral Your cost for self referral
(after your deductible)

$10 per visit $10 per visit Not Covered

Short-term Rehabilitative Therapy

Fallon BCBS BCBS

Your cost with PCP referral Your cost for self referral
(after your deductible)

$10 per visit
(up to 60 non-consecutive visits per calendar year) $10 per visit
(up to 60 consecutive days per condition) 20% co-insurance^*

Speech, Hearing and Language Disorder Treatment

Chiropractor Services

Fallon BCBS BCBS

Your cost with PCP referral Your cost for self referral
(after your deductible)

$10 per visit
(up to 60 non-consecutive visits per calendar year) $10 per visit 20% co-insurance^*

Fallon BCBS BCBS

Your cost with PCP referral Your cost for self referral
(after your deductible)

$10 per visit (up to 20 visits per calendar year) $10 per visit
(up to 20 visits per calendar year for members age 16 or older) 20% co-insurance* ==
(up to 20 visits per calendar year for members age 16 or older)

Home Health Care and Hospice Care

Fallon BCBS BCBS

Your cost with PCP referral Your cost for self referral
(after your deductible)

Covered in Full Covered in Full 20% co-insurance*

Durable Medical Equipment
(such as wheelchairs, crutches, hospital beds and repairs)

Fallon BCBS BCBS

Your cost with PCP referral Your cost for self referral
(after your deductible)

Covered up to $1,500 per calendar year Charges beyond the $1,500 benefit 20% co-insurance* ==

Oxygen and Equipment for its Administration

Fallon BCBS BCBS

Your cost with PCP referral Your cost for self referral
(after your deductible)

Covered in full Covered in full 20% co-insurance*

Prosthetic Devices and Repairs

Fallon BCBS BCBS

Your cost with PCP referral Your cost for self referral
(after your deductible)

Covered under DME benefit 20% co-insurance 20% co-insurance*

Inpatient Care (including Maternity Care)

Hospital Care
(as many days as medically necessary)

Fallon BCBS BCBS

Your cost with PCP referral Your cost for self referral
(after your deductible)

Covered in full Covered in full 20% co-insurance*

Surgical Services

X-rays, Laboratory Tests and Anesthesia

Fallon BCBS BCBS

Your cost with PCP referral Your cost for self referral
(after your deductible)

Covered in full Covered in full 20% co-insurance*

Care in a designated skilled nursing facility
(up to 100 days per calendar year)

Fallon BCBS BCBS

Your cost with PCP referral Your cost for self referral
(after your deductible)

Covered in full Covered in full 20% co-insurance*++

Care in a Rehabilitation Hospital

Fallon BCBS BCBS

Your cost with PCP referral Your cost for self referral
(after your deductible)

Covered in full Covered in full
(up to 60 days per calendar year) 20% co-insurance* ==

Mental Health

Outpatient

Fallon BCBS BCBS

Your cost with PCP referral Your cost for self referral
(after your deductible)

$10 per visit
up to 20 visits per calendar year $10 up to 20 visits per calendar year Not Covered

Inpatient

Fallon BCBS BCBS

Your cost with PCP referral Your cost for self referral
(after your deductible)

Covered in full *Unlimited days in general hospital; up to 60 days, per calendar year, in psychiatric hospital Covered in full
~ *Unlimited days in general hospital; In psychiatric hospital,up to a 30 day lifetime maximum per member Not Covered

Substance Abuse

Outpatient Care for Substance Abuse

Fallon BCBS BCBS

Your cost with PCP referral Your cost for self referral
(after your deductible)

$10 per visit;
unlimited visits $10 up to 20 visits in a calendar year Not Covered

Inpatient

Fallon BCBS BCBS

Your cost with PCP referral Your cost for self referral
(after your deductible)

Covered in full *Unlimited days for detoxification up to 30 days rehabilitation in an inpatient setting Covered in full
*Up to a 30 day lifetime maximum per member Not Covered

Prescription Drug Benefit
Prescription drugs, up to a 30-day supply

Fallon Medco Health Solutions

$10 for each prescription or refill for generic,
$15 for each prescription or refill for brand-name $10 for each prescription or refill for generic,
$15 for each prescription or refill for brand-name

Through Optional Mail-service Drug Program:
up to a 90-day supply-generic or brand-name

Fallon Medco Health Solutions

$5 for each prescription or refill for generic,
$15 for each prescription or refill for brand-name $5 for each prescription or refill for generic,
$15 for each prescription or refill for brand-name

Hearing Aids - 100% up to $2000 Once Every 3 Years

Fallon Medco Health Solutions

Charges beyond the $2000 Maximum Charges beyond the $2000 Maximum

Dental Benefit

Fallon Medco Health Solutions

Provided by Blue Cross Dental Blue Provided by Blue Cross Dental Blue

= Any visit, day, or dollar maximum may be reduced by an benefits provided in the same calendar year under prior Blue Cross & Blue Shield plans as allowed by state law. See your summary plan description for more details.

* In additiona to your deductible and the 20% (or 30%) co-insurance, you may be responsible for any balance of charges above the allowed charges for providers who do not have payment agreements with Blue Cross & Blue Shield.

** This service is provided according to an age-based schedule.

*** If Blue Cross & Blue Shield determines this visit to be for emergency care, you will have to pay only a $50 co-payment.

== Combine amounts for PCP/Plan-Approved benefits and Self-Referred benefits.

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