ACTIVE MEMBERS
SUPERIOR OFFICERS COUNCIL
ACTIVE - HEALTH & WELFARE FUND
SCHEDULE OF BENEFITS – 07/1/05

Who is covered? Member, spouse or qualified domestic partners, dependent children to age 19 and full-time students ages 19-23

1. OPTICAL BENEFIT
The fund provides an eye exam and one pair of glasses each year, paid in full, administered by DAVIS VISION, Inc. ( A PREFERRED PROVIDER )

2. PRESCRIPTION DRUG BENEFIT
The Fund provides a Prescription Drug Benefit less a $5 co-payment, for all eligible prescription drugs with a cost up to $25, and 85/15 co-insurance for all drugs costing more than $25.
(This benefit was improved as of September 1,1999, decreasing the co-payment from 80/20 to 85/15)

There is no co-payment for maintenance drugs secured through the Central Fill Mail Order ( 6 month supply, i.e. 90 days and one refill). The Prescription Drug Program is a MANDATORY GENERIC program with a $15,000 Annual Family Cap. (This benefit was improved as of April 1, 2005, increasing the annual family cap from $10,000 to $15,000).

P. I. C. A. Drug coverage--- Effective July 1, 2005. Injectables and Chemotherapy medications will continue to be covered through the PICA program and be administered by NPA. Continue to use the same prescription drug card you have been using to fill these prescriptions. Psychotropic and Asthma medication will no longer be available through the PICA program. These two medications will be obtained through our Health & Welfare drug program. If you encounter a problem the pharmacist should call NPA’s Customer Service at 1 800-467-2006.

All other drugs, except diabetes medication, can be obtained through the SOC prescription drug program as described above. Diabetes medication must be obtained through the member’s underlying health care plan (example GHI, HIP, Aetna, etc.)

3. DENTAL BENEFIT PLANS
The Fund provides two types of dental plans – the Self Indemnity (fee for service) Program and the Comprehensive. The Fee for Service is a choice of your own dentist and reimbursement is made on a fee schedule; The Comprehensive Plan is a preventative dental program with most services provided with minimal co-pays for prosthetics and anesthesia, you will be assigned to one of the conveniently located private dental offices. There is one Comprehensive dental program, the Healthplex Dentcare Delivery Systems. ( DentAll Blue Cross Blue Shield is closed to new subscribers )

4. SOC CATASTROPHIC COVERAGE
After a $3000 annual family deductible, GHI pays 100% of reasonable and customary charges based on a current profile with a maximum lifetime payment up to $250,000 per person.
Limitations: Private Duty Nursing Care – first $25,000 paid, thereafter 50% of the remainder with a lifetime cap of $50,000 per person and Mental Health- $10,000 individual lifetime maximum for in hospital mental health charges.

5. SOC CATASTROPHIC $1,000 REIMBURSEMENT BENEFIT
A self-funded $1,000 direct reimbursement benefit is provided and payable to the member upon attaining $3,000 out-of-pocket eligible incurred expenses for services rendered on and after January 1, 1999. Eligible out-of-pocket expenses are those medical and hospital charges that are considered reasonable and customary by the Plan and not fully reimbursed by the City Health Plan or private group insurers. The subscriber must produce a statement of services, Explanation of Benefits Form and cancelled checks. The exclusions and restrictions are the same as the requirements for the Catastrophic Coverage benefit.

6 HEARING AIDS
Active members and their dependents are eligible for a maximum of $300 towards the purchase of a hearing aid for each ear requiring a device ONCE EVERY FIVE YEARS.. This benefit is payable once when the need is determined by a medical doctor or audiologist.

7. HIP/HMO SUPPLEMENT RIDER
For those enrolled in HIP/HMO the Fund provides coverage for private duty nursing and appliances.