GHI Benefits Summary

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					GHI Benefits Summary
TC pays GHI directly for employee or family coverage

TC reimburses ee's up to $1000 per year of actual
premium expenses incurred by an eligible retiree up to a
total annual reimbursement of $40,000 annually.



CATEGORY                                                      IN-NETWORK                     OUT-OF-NETWORK
Base Medical Coverage                                         In-network provider is paid    After satisfaction of
                                                              directly by GHI based upon a   deductible, member is
                                                              negotiated rate(s) and/or a    reimbursed at 75% of Ingenix
                                                              schedule of allowances. In-    at the 80th percentile until the
                                                              network providers accept       maximum eligible Out-of-
                                                              these rates or allowances as   Pocket expenses limit is
                                                              payment in full.               reached. Thereafter, member
                                                                                             is reimbursed at 100% of
                                                                                             Ingenix at the 80th percentile
                                                                                             for the balance of the
                                                                                             calendar year.
Annual Deductible (per calendar year)                         None                           $250 per person; $500 per
                                                                                             family
Medical Coinsurance                                           None                           Member reimbursed 75% of
                                                                                             Ingenix at the 80th percentile
Maximum Eligible Out-of-Pocket Expenses (excludes annual      None                           $2,000 per person
deductible)
Annual Maximum Reimbursement                                  None                           $100,000 per person
Lifetime Maximum Reimbursement                                None                           $1,000,000 per person
General Medical Care (including home and office visits, OPD   $10 copay per provider per     Base Medical Coverage
clinic visits and ER professional charges)                    date of service
Preventive Care
Annual Physical Check-up                                             Covered subject to $10 copay   Not covered
Well Baby Care                                                       Covered in full                Base Medical Coverage
Well Child Care- to age 19                                           Covered in full                Base Medical Coverage
Pediatric Immunizing Agent                                           Covered in full                Base Medical Coverage
Well Woman Care-                     Pap smear                       Covered subject to $10 copay   Base Medical Coverage
screening                  Mammography Screening
Prostate Screening                                                   Covered subject to $10 copay   Base Medical Coverage

In-Hospital and Out-of-Hospital Surgery       includes pre and       Covered in full                Base medical coverage
post operative visits
In-Hospital Medical Care                    includes routine         Covered in full                Base medical coverage
medical and psychiatric care
Maternity Care                                                       Covered in full                Base medical coverage
Chemotherapy Treatment                                               Covered in full                Base medical coverage
Chemotherapy Treatment Visits                                        covered subject to $10 copay   Base medical coverage
Diagnostic Procedures                   includes diagnostic          covered subject to $10 copay   Base medical coverage
lab tests and radiology procedures. Does not include MRI,
CAT-scan and Sonogram
MRI, CAT-scan and Sonogram testing                                   covered subject to $10 copay   Base medical coverage
Specialists Out-of-Hospital Consultation      one per specialty      Covered in full                Base medical coverage
per calendar year
Allergy Visits                             16 visits per calendar    covered subject to $10 copay   Base medical coverage
year
Chiropractic Care                                                    covered subject to $10 copay   Base medical coverage
Routine Podiatric Care                      4 visits per calendar    covered subject to $10 copay   Base medical coverage
year
Speech Therapy                              16 visits per calendar   covered subject to $10 copay   Base medical coverage
year
Physical and Occupational Therapy           8 visits per calendar   covered subject to $10 copay   Base medical coverage
year
Diabetes Management                                                 covered                        covered

Ambulance Service                         Emergency Service         Out-of-network benefit only    Member reimbursed 75% of
only                                                                                               submitted charges
Mental Health Treatment                    physician,               Not covered                    Member reimbursed 50% of
psychologist, certified social worker                                                              GHI Allowed charge.
                                                                                                   Maximum 30 visits per person
                                                                                                   per calendar year.
Private Duty Nursing Services                                       Out-of-network benefit only    Member reimbursed 75% of
                                                                                                   submitted charges
Durable Medical Equipment                                           Out-of-network benefit only    Member reimbursed 75% of
                                                                                                   submitted charges


GHI HOSPITAL SERVICES
SUMMARY
Inpatient Hospital Services
CATEGORY                                                            IN-NETWORK                     OUT-OF-NETWORK

Base Hospital Coverage                           120 days per       Covered in full                GHI pays 100% of the
single confinement. Covered charges for semi-private room                                          average in-network hospital
and board, medical supplies, facilities, services and equipment                                    payment
customarily furnished by hospitals including routine nursery
care
Hospital Deductible                                                 None                           None
Admissions primarily for diagnostic purposes e.g. x-rays            Not covered                    Not covered
Limitation for Admissions primarily for Medical Rehabilitation -    Covered in full                Base hospital coverage
30 days per calendar year
Limitation for Admissions for mental health care- 30 days per       Covered in full- GHI-BMP       GHI pays 80% of the average
calendar year                                                                                      in-network hospital payment
Limitation for Admissions for chemical dependency treatment      Covered in full- GHI-BMP      GHI pays 80% of the average
De-tox- (Part of Mental health care days) 5 days per calendar                                  in-network hospital payment
year for alcohol detox and 14 days per calendar year for
substance abuse Rehab (subscriber only)- 30 days per
calendar year



Outpatient Hospital Services
CATEGORY                                                         IN-NETWORK                    OUT-OF-NETWORK
Emergency Care Facility Charges                                  Covered in full               Base Hospital Coverage
Pre-surgical testing                                             Covered in full               Base Hospital Coverage
Chemical Dependency Treatment- 60 visits per calendar year,      Covered in full               GHI pays 80% of the average
one visit per day, up to 20 visits for family therapy                                          in-network hospital payment
Preferred Ambulatory Care:                                   -   Not covered                   Not covered
lab tests; physical therapy; diagnostic radiology; radiation
therapy; chemotherapy
Preventive Mammography Screening                                 Covered in full               Base Hospital Coverage
Preventive Pap Smear Screening                                   Covered in full               Base Hospital Coverage



GHI Dental Plan
Module I                                                         In-Network                    Out-of-Network
Preventive and Diagnostic
                                                                                               Member is reimbursed 100%
                                                                 In-network provider is paid   of the Preferred Schedule.
                                                                 directly by GHI based on      Member is responsible for
                                                                 100% of the Preferred         any dental charges which
Base Coverage Level                                              Schedule as payment in full   exceed this payment
Examinations up to two per calendar year                         Covered in full               Base coverage
Cleanings up to two per calendar year                            Covered in full               Base coverage
X-Rays up to 4 bitewing x-rays per calendar year. 1 panoramic
film every 3 years                                              Covered in full               Base coverage
Fluoride Treatments One per calendar year up to age 19          Covered in full               Base coverage
Space maintainers and mouth guards- 1 per child per lifetime
up to age 19                                                    Covered in full               Base coverage
Emergency treatment- 1 visit per person per calendar year
Sealant Coverage- every 3 years up to age 14                    Not covered                   Not covered

Module II                                                       In-Network                    Out-of-Network
Limited Basic Services
                                                                                              Member is reimbursed 100%
                                                                In-network provider is paid   of the Preferred Schedule.
                                                                directly by GHI based on      Member is responsible for
                                                                100% of the Preferred         any dental charges which
Base Coverage Level                                             Schedule as payment in full   exceed this payment
Extraction and fillings                                         Covered in full               Base Coverage
Repair of dentures                                              Covered in full               Base Coverage
Consultations                                                   Covered in full               Base Coverage

Module III                                                      In-Network                    Out-of-Network
Full Basic Services
                                                                                              Member is reimbursed 100%
                                                                In-network provider is paid   of the Preferred Schedule.
                                                                directly by GHI based on      Member is responsible for
                                                                100% of the Preferred         any dental charges which
Base Coverage Level                                             Schedule as payment in full   exceed this payment
Endodontics- Root canal therapy                                 Covered in full               Base Coverage
Periodontal treatment                                           Covered in full               Base Coverage
Oral surgery                                                    Covered in full               Base Coverage

Module IV                                                       In-Network                    Out-of-Network
Prosthetic services and Appliances
                                                                                             Member is reimbursed 50%
                                                                                             of the Preferred Schedule.
                                                              In-network provider is paid    Member is responsible for
                                                              directly by GHI based on 50%   any dental charges which
Base Coverage Level                                           of the Preferred Schedule      exceed this payment
Full dentures and partial dentures                            Base Coverage                  Base Coverage
Fixed bridges                                                 Base Coverage                  Base Coverage
Crowns and inlays                                             Base Coverage                  Base Coverage

Module V                                                      In-Network                     Out-of-Network
Orthodontic Services                                          Not Covered                    Not Covered

General Plan Features
Dependent children coverage to END OF YEAR in which they
reach the age of 19
Dependednt student coverage to END OF MONTH in which
they reach the age of 22
Pre-determination of benefits offered for any non-emergency
dental surgery, prosthetic or orthodontic procedure when
covered
Combined annual in and out-of-network deductible- excluding
orthodontics                                                  None
Combined annual maximum benefit per person- excluding
orthodontics                                                  $3,000 per person per year



VISION CARE- EYE MED
TC pays for single coverage for vision. EE may elect and
purchase family coverage by paying the established
premium contribution beyond the cost for individual
coverage
In addition to EyeMed coverage, TC reimburses ee up to
$75/ year for out-of-pocket cost for vision care not
covered under EyeMed with appropriate documentation.
This is done with a Cash Reimbursement form.


                                                                                 Out of Network
Vision Care Services                                     Member Cost             Reimbursement
Exam with dilation as necessary                          $0 copay                up to $35
Exam Options:
Standard Contact lens fit and follow-up                  up to $55               N/A
Premium contact lens fit and follow up                   10% off retail price    N/A

                                                         $75 allowance; 80% of
Frames (Any available frame at provider location)        balance over $75        Up to $38

Standard Plastic Lenses:
Single vision                                            $0 copay                Up to $25
Bifocal                                                  $0 copay                Up to $40
Trifocal                                                 $0 copay                Up to $55

Lens Options (Paid by the member and added to the base
price of the lens):
Tint (solid and gradient)                                $15                     N/A
UV Coating                                               $15                     N/A
Standard Scratch-resistance                              $15                     N/A
Standard Polycarbonate                                   $40                     N/A
Standard Anti-Reflective                                 $45                     N/A
Standard Progressive (Add-on to Bifocal)                 $65                     N/A
Other Add-Ons and services                               20% off retail price    N/A

Contact Lenses (allowance covers materials only):
                             $0 copay, $75 allowance;
Conventional                 15% off balance over %75         Up to $55
Disposables                  $0 copay, $75 allowance          Up to $55
Medically necessary          $0 copay, paid in full           up to $200


Life Insurance
Eligibility                  Active full time
                             secretarial/clerical employees
                             working minimum of 20 hours
                             per week
Eligibility effective date   3 months
Basic Life Amount            $15,000 (flat)
Basic AD&D Amount            Equal to basic life amount