Schedule of Benefits
Active Employee Benefit Plan and Retiree Comprehensive Plan

The benefits shown on this schedule apply only to persons who are eligible for the applicable benefits and are subject to all limitations and exclusions.

INSURED BENEFITS (For Active Employees only)
Life Insurance Benefit Amount	$15,000
Accidental Death & Dismembership Insurance (full amount)	$10,000
RETIREE DEATH BENEFIT (For Eligible Retirees only)
Death benefit amount	$1,000
DEATH & DISMEMBERMENT BENEFITS (For Dependents of Active Employees only)
Death Benefit for spouse and children age 14 days but less than 19 years	$1,000
Accidental Death & Dismemberment Benefit (full amount)	$2,000
For Eligible Dependents - Full Amount	$2,000
WEEKLY DISABILITY BENEFIT (For Active Employees Only)
Weekly Benefit Amount	$250
Maximum Period Benefits are payable	Up to 26 weeks
When disability benefits start	8th day after first day of treatment
NEWBORN CARE BENEFIT (For Covered Dependent Children of Active Employees Only)
Maximum benefit for hospital and physician expenses for routine newborn care (in-hospital or follow-up office visits) during the first 7 days of life for a well newborn	$2,500
Plan payment percentage	100%
(Covered medical expenses for hospital and physician care of a sick newborn are covered under the Comprehensive Benefit)
WELLNESS BENEFIT (For Covered Dependent Children of Active Employees Only)
Maximum benefit for for exams and tests per person per calendar year:
Employees, retirees. spouses, and children from birth through age 5	$300
Routine childhood immunizations (birth through age 5) (Plan benefits for immunizations do not apply toward the $300 maximum.)	100%
Children age 6-22	$100
Plan payment percentage	$100
(Wellness Benefits are for routine examinations and tests. No Wellness Benefits are payable when the treatment is for a sickness or injury, or when the person has symptoms of a sickness or injury.)
COMPREHENSIVE BENEFIT
Benefit Reductions and Exclusions Certain benefit reductions and exclusions apply when the precertification is not obtained.
Lifetime maximum benefit per person	$1,000,000
Deductibles: Calendar year deductibles:
Individual deductible	$250
Family deductible (can be satisfied by 3 or more family members)	$750
Out-of-network hospital deductible	$250
(The out-of-network hospital deductible applies to each non-emergency hospital confinement and each occurrence of non-emergency outpatient treatment in an out-of-network hospital (some exceptions apply). Any such deductibles are in addition to the calendar year deductibles.)
Out-of-pocket limit per person per calendar year after the calendar year deductible is met	$2,000*
*$2,250 including deductible. This could be less if all or part of your deductible is waived due to meeting the family deductible limit, or if part of your deductible was carried over from the prior year.
(Only PPO covered medical expenses apply toward your out-of-pocket limit. Amounts in excess of reasonable and customary charges or any other non-covered charges do not apply.)
Plan co-pay/payment percentages payable per person for covered medical expenses incurred during a calendar year:
Second or third surgical opinions recommended by Med-Care (ONLY when recommended by Med-Care)	100%
Hearing Aids (Active Plan only)	50%
All other covered medical expenses (unless an exception is given in the "Special Benefits and Limitations" section below)
UNTIL out-of-pocket limit is reached	90%
AFTER out-of-pocket limit is reached	100%
Special Benefits and Limitations
Chiropractic care* - calendar year maximum benefit per person (includes x-rays, lab and all chiropractic-related physical therapy)	$750
Podiatry*
Calendar year maximum benefit per person for all professional podiatry fees, surgical and non-surgical treatment combined	$750
Calendar year maximum benefit for all surgical facility fees Facility fees must be precertified by Med-Care	$3,000
TMJ* - calendar year maximum benefit per person:
Non-surgical treatment	$750
Surgical treatment Maximums do not apply to covered hospital expenses.	$3,000
Speech therapy* - maximum benefit per person (does not apply if therapy is required due to an organic cuase):
Per calendar year	$1,500
Per lifetime	$3,000
Hospice care* - lifetime maximum benefit per person	$10,000
Hearing aids:
Active Plan: Maximum benefit payable per person In a 5-year calendar period	$2,500
Plan co-payment percentage	50%
Retiree Comprehensive Plan - Maximum benefit payable per person	$500 (lifetime)
Calendar year deductible does not apply. Out-of-pocket expenses do not apply to the out-of-pocket limit, and will not be paid at 100% if the person’s out-of-pocket limit was previously met.
* Must be precertified by Med-Care. Calendar year deductible does not apply. Out-of-pocket expenses do not apply to the out-of-pocket limit, and will not be paid at 100% if the person’s out-of-pocket limit was previously met.
Smoking cessation - lifetime maximum benefit per person Calendar year deductible does not apply.	$500
Chemical dependency and mental/nervous disorders:*
Maximum allowable number of outpatient/office treatments per person per calendar year (for mental/nervous disorders and chemical dependency combined)	60
Mental/nervous disorders only: Lifetime maximum allowable number of days of hospital inpatient and/or intensive outpatient treatment	30 days
Chemical dependency only: Lifetime maximum benefit payable per family for all inpatient and outpatient treatment	$50,000
(Amounts applied to this maximum, plus benefits paid for outpatient professional treatment, also apply to the Comprehensive Benefit lifetime maximum benefit.)
Maximum allowable course of inpatient and/or intensive outpatient treatment:
During a 24-month period	2
During a person's lifetime	4
Maximum benefits payable for outpatient/office professional treatment:
During a calendar year	$1,250
During a person's lifetime	$5,000
* Must be precertified by Med-Care. Out-of-pocket expenses do not apply to the out-of-pocket limit, and will not be paid at 100% if the person’s out-of-pocket limit was previously met. The out-of-network hospital deductible does not apply to inpatient confinements for these conditions.
PRESCRIPTION DRUG PROGRAMS
Sav-Rx Drug Card Program for up to a 30-day supply of a covered prescription drug obtained from a participating pharmacy: Calendar year deductible:
Per person	$50
Per family (can be satisfied by 2 or more family members)	$100
Plan co-pay percentage per person per calendar year after satisfaction of the deductible	90%
Refill limits under the Drug Card Program
Short-term or acute drugs	2 refills
Maintenance or long-term drugs	no refills
(If the prescribing doctor allows use of a generic drug and you get a brand name drug when a generic equivalent is available, you pay 10% of the cost of the generic drug plus the difference in cost between the brand name drug and the remaining generic cost. The amounts paid out-of-pocket for the difference in cost don’t count toward satisfying the $50 deductible.)
Sav-Rx Mail Service and Walgreens Walk-in Programs - Dispensing fee per prescription for up to a 90-day supply for both generic and brand name drugs (the Plan pays the rest)	$5 per prescription
(If the prescribing doctor allows use of a generic drug and you get a brand name drug when a generic equivalent is available, you pay the difference in cost between the brand name drug and the generic drug in addition to the $5 dispensing fee.)
Maximum for Retirees and Their Dependents - Maximum benefit per calendar year per person for ALL prescription drugs (applies to Card, Mail and Walk-In Programs)	$4,000
VISION BENEFIT
Maximum payable per person per calendar year: Complete vision examination	$40
Frame	$50
Eyeglass lenses (per pair):
Single vision ($20 each)	$40
Bifocal ($30 each)	$60
Trifocal ($35 each)	$70
Contact lenses in lieu of eyeglasses (per pair, or for all sets of disposable contacts purchased during a calendar year)	$90
DENTAL BENEFIT
Dental HMO Plan (First Commonwealth Dental HMO)
Diagnostic and preventive sevices (check-ups and cleanings) and x-rays	Provided at no charge
All other covered dental procedures	Provided in full after a scheduled co-payment per procedure
(When you enroll in the First Commonwealth Dental HMO, you will be sent a brochure that has a fee schedule showing the exact co-payment that covered persons must pay for each covered dental procedure.)
Dental Indemnity Plan
Calendar year maximum benefit payable per person	$1,500
Lifetime maximum benefit payable per person for orthodontia	$2,000
Calendar year deductible per person (does not apply to diagnostic and preventive care)	$25
Plan co-pay percentage	80%

Schedule of Benefits
Basic 65 Plan For Qualifying Retirees and their Spouses

(The benefits shown on this Schedule apply only to persons who are eligible for the applicable benefits and are subject to all applicable Plan limitations and exclusions.)
Death Benefit (for retirees and their spouses)	$1,000
Basic 65 Medical Benefits (for retirees and their spouses) Basic 65 medical benefits are payable for medically necessary services provided for sickness or injury. No benefits are payable for pregnancy
Inpatient hospital benefits:
Room and board - Maximum benefit payable while confined as a hospital inpatient	$14 per day, for up to 31 days per period of confinement
Ancillary hospital services - Maximum benefit payable per period of confinement	$140
Surgery Benefits:
Amount payable for each surgical procedure	See Schedule of Surgery Benefits
Maximum benefit payable per disability	$250