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PFT HEALTH AND WELFARE FUND

Benefit Comparison Chart

This chart is for active employees and any retiree that purchased basic health care through The School District of Philadelphia COBRA Plan.

This chart is only an overview of the benefits available. Please see plan brochures for more details.

Note: Changes to the Plans effective November 1, 2004 appear in gray.

Benefit	Indemnity	Personal Choice Plan 15/25/70 w/ Variations		Keystone (Flex) POS 10c		Keystone 10	Benefit
Deductible Individual/Family	Blue Cross Blue Shield	In-Network $0/$0	Out of Network* $500 Indiv/$1000 Family	In Network/ Referred N/A	Out of Network/Self-referred** $300 Indiv/ $900 Family	(Effective November 1, 2004, all new employees shall be enrolled in Keystone 10 for a period of four (4) years from the date of appointment.) N/A	Deductible Individual/Family
Benefit	Indemnity	Personal Choice Plan 15/25/70 w/ Variations	Keystone (Flex) POS 10c	Keystone 10	Benefit	Benefit	Indemnity
Coinsurance	As of November 1, 2004, those enrolled in the Indemnity plan will be placed in the Personal Choice 15/25/70 with variations. There will not be any employee contributions for those moved from the Indemnity to Personal Choice	100%	70%	N/A	80%	N/A	Coinsurance
Out of Pocket/ Individual/Family		NA	$3,000 Indiv/ $6,000 Family	N/A	$2,000 Indiv/ $6,000 Family	Co-payment maximums individual $1,000 / family $2,000	Out of Pocket/ Individual/Family
Overall Lifetime Maximum		Unlimited	$1,000,000	N/A	$1,000,000	N/A	Overall Lifetime Maximum
Office Visits		Primary Care (See A below) $15 copay Specialist $25 copay	70%	$10 $15 after hour/home	Primary and preventive care covered as referred service only/specialist visits covered	$10 PCP; $15 Specialist	Office Visits
Pediatric Immunization		100%	70% (no deductible)	100% after $15 copay	Covered as referred service only 100%	100%, subject to office visit copay	Pediatric Immunization
Mammogram		100%	70% (no deductible)	100%	80% of Allowed Charges after deductible	100%	Mammogram
Maternity		First OB visit $15	70%	$5 for first visit/subsequent visits 100%	80% of Allowed Charges after deductible	$15 first visit	Maternity
Inpatient Hospital Days		100% up to 365 days	70% up to 70 days	100%; Unlimited	80% of Allowed Charges after deductible	100%; Unlimited	Inpatient Hospital Days
Hospital Care Inpatient and Outpatient		100%	70%	100%	80% of Allowed Charges after deductible	100%	Hospital Care Inpatient and Outpatient
Emergency Room		$40 (waived if admitted)	$40 (waived if admitted)	$35 (waived if admitted)	$35 (waived if admitted)	$35 (waived if admitted)	Emergency Room
Laboratory		100%	70%	100%	80% of Allowed Charges after deductible	100%	Laboratory
Outpatient X Ray Radiology		$25 copay (See B below)	70%	100%	80% of Allowed Charges after deductible	100%	XRay
Physical, Speech & Occupational Therapy		$15 copay (visits 1 - 30) $25 copy (visits 31 - 60) (60 visits/year)	70% (60 visits/year in combination)	100% (up to 60 consecutive days per condition covered if subject to significant improvement)	80% of Allowed Charges after deductible	100% (up to 60 consecutive days per condition covered if subject to significant improvement)	Physical, Speech & Occupational Therapy
Chemo/Radiation Therapy		100%	70%	100%	80% of Allowed Charges after deductible	100%	Chemo/Radiation Therapy
Cardiac Rehabilitation		$15 copay 36 visits/year	70% 36 visits/year in combination	100%	80% of Allowed Charges after deductible	100%	Cardiac Rehabilitation
Psychiatric/ Outpatient Visits (non serious mental illness)		30 visits/yr † $25 copay	20 visits/year † 50%	20 visits per year ($25 copay)	50% of Allowed Charges after deductible; 20 visits per calendar year	$25	Psychiatric/ Outpatient Visits
Psychiatric Inpatient Days (non serious mental illness)		Combined number of inpatient days is 30 of which a maximum of 20 days may be outside of the network. (See F below.) 100%	Combined number of inpatient days is 30 of which a maximum of 20 days may be outside of the network. (See F below.) 70% after deductible	100%; 35 days per year	50% of Allowed Charges after deductible; 35 days per year	100% 35 days per calendar year	Psychiatric Inpatient Days
Psychiatric/ Outpatient Visits (serious mental illness)		60 days/visits per year (see E below) $25	60 days/visits per year 50% after deductible	60 days/visits per year $25 copay	Covered 50% of Allowed Charges after deductible, 60 days/visits per year	60 visits per year	Psychiatric/ Outpatient Visits (serious mental illness)
Psychiatric Inpatient Days (serious mental illness)		100% 30 days/year (see F below) (combination on in and out of network)	70% 30 days/year (combination on in and out of network)	100% 30 Inpatient days	Covered 50% of Allowed Charges after deductible / 60 days, $30 per visit max	100% 30 days / year	Psychiatric Inpatient Days (serious mental illness)
Substance Abuse Detoxification		100% 7 days/adm	70% 7 days/adm	100% 7 days/adm	80% of Allowed Charges; 7 days/adm		Substance Abuse Detoxification
Substance Abuse Inpatient		100% 30 days/year	70% 30 days/year	100% 30 Inpatient days	80% of Allowed Charges after deductible; 30 days/year	100% 30 Inpatient days/90 days/life	Substance Abuse Inpatient
Substance Abuse Outpatient Visits		100% 30 visits/year	70% 30 visits/year	$15 copay 60 Outpatient visits	80% of Allowed Charges after deductible; 60 visits/year	60 Outpatient visits, w/ $15 co-payment; 120 lifetime max	Substance Abuse Outpatient Visits
Surgical/Anesthesia		100%	70%	100%	80% of Allowed Charges after deductible	100%	Surgical/Anesthesia
Transplants		100%	70%	100%	80% of Allowed Charges after deductible	100%	Transplants
Skilled Nursing Facility		100% (120 days/yr)	70% (120 days/yr)	100% up to 180 days per calendar year	80% of Allowed Charges after deductible; 240 days	100% up to 180 days per calendar year	Skilled Nursing Facility
Private Duty Nursing		100% 360 hours/yr	70% 360 hours/yr	100% when authorized by PCP and Keystone, 180 days per year	80% of Allowed Charges after deductible, 240 days per year	100% when authorized by PCP and Keystone	Private Duty Nursing
Birth Center		100%	70%	100%	80% of Allowed Charges after deductible	100%	Birth Center
Hospice and Home Health		100%	70%	100% when authorized by PCP and Keystone	80% of Allowed Charges after deductible	100% when authorized by PCP and Keystone	Hospice and Home Health
Durable Medical Equipment & Prosthetics		$25 copay	70%	100% when authorized by PCP and Keystone	80% of Allowed Charges after deductible	100% when authorized by PCP and Keystone	Durable Medical Equipment & Prosthetics
Ambulance		100%	70%	100%	80% of Allowed Charges after deductible	100%	Ambulance
Vision		N/A	N/A	$15 copay + $100 every 2 calendar years for corrective lenses/ frames	Covered as a referred service only	$15 Exam+ $100 every 2 calendar years for corrective lenses / frames	Vision
Special Clubs and Programs		See C below for Spinal manipulation. See D below for Cardiac Rehab Therapy. This plan includes several wellness programs to keep you healthy: Fitness club membership discounts Up to $150 fitness club reimbursement Smoking cessation programs Weight management programs through Weight Watchers Baby Blue Prints prenatal program Bike Safety program Stress Management program Poison prevention program Child Safety program Red Cross program discounts Better Sleep program		This plan includes several wellness programs to keep you healthy: Fitness club membership discounts Up to $150 fitness club reimbursement Smoking cessation programs Weight management programs through Weight Watchers Baby Blue Prints prenatal program Bike Safety program Stress Management program Poison prevention program Child Safety program Red Cross program discounts Better Sleep program		This plan includes several wellness programs to keep you healthy: Fitness club membership discounts Up to $150 fitness club reimbursement Smoking cessation programs Weight management programs through Weight Watchers Baby Blue Prints prenatal program Bike Safety program, Stress Mgmt. program Poison prevention program Child Safety program Red Cross program discounts, Better Sleep program	Special Clubs and Programs
Eligible Dependents - All Plans	Spouse and unmarried children up to the age 19. Unmarried children who are enrolled in and regularly attending full-time an accredited school, college, or university and are solely dependent upon subscriber for support up to age 25. Handicapped children over age 19 who are unable to work and are unmarried dependents of the subscriber are also eligible for enrollment as long as the member is enrolled in these programs.						Eligible Dependents - All Plans

* In Personal Choice Plan, out-of-network providers who are non-Blue Shield participating providers may bill subscribers for the difference between PPO reimbursement and actual charge.
In Personal Choice Plan, out-of-network Blue Shield participating providers may not bill subscribers for the difference between PPO reimbursement and actual charge.
** In Keystone POS 10C Flex Plan, all out-of-network providers, both participating Blue Shield providers and non-participating providers, may bill subscribers more than the allowable charge.
† Combined number of visits is 30; of which a maximum of 20 may be outside of the network.

Includes General Practice, Internal Medicine, Family Practice, OB-Gynecology, Pediatrics, Nurse or Midwife.
No copay for inpatient hospital, outpatient surgery, emergency room, in physicians’ office, maternity office visits. One co-payment for multiple procedures if in the same visit.
Spinal Manipulation $25 copay (30 visits/yr.) Out of network 70% after deductible.
Cardiac Rehab Therapy $15 copay (increased to 36 visits/yr.) Out of network 70% after deductible.
No more than 60 visits/yr combined in network and out of network.
For serious mental illness, out of network visits may include the total 30 days.