Motion Picture Industry (MPI) Active Health Plan Medical Plan Benefit Comparison At-A-Glance Hospital Services Room and Board Intensive Care Ancillary Services Semi-Private Room Extended Care Room and board in a skilled nursing facility Other services and supplies Emergency Services Within or Outside Service Area ** Professional Physician Visits: Hospital/Office Surgeon Assistant Surgeon Anesthesia ** In-network: $100 inpatient admission + 10% for unlimited number of days Out-of-network: $100 + 50% of allowable amount for unlimited number of days. Personal items are not covered 90 days for Participants 60 days for dependents 10% if contracting, 50% if non-contracting. All covered services when medically necessary are available anywhere in the world from any licensed physician, surgeon or general hospital $100 co-pay In-network: 10% Out-of-network: 50% for unlimited number of days for 100 days each $35 co-pay (waived if admitted to a hospital) $15 co-pay for office visit only for unlimited number of days (up to 100 days per benefit period) Emergency Room - Kaiser Medical Centers, 24 hours a day, 7 days a week. $35 co-pay (waived if admitted to a hospital) Outpatient: $15 co-pay In Network: $0 co-pay In Network: $0 co-pay per continuous confinement $25 per visit (waived if admitted to a hospital) In Network: $15 co-pay
Page 2 of 5 In-home Nursing Care ** Ambulance Services (including air ambulance) ** Laboratory Tests and Diagnostic Imaging ** Injectable Drugs Eye Examinations In-network: 10% Out-of-network: 50% Covered through Medco only Eye examinations and corrective lenses are available for all eligible Participants and their eligible dependents through VSP for injections, allergy injection services or testing (Injections for infertility are paid at 50 %.) Allergy serum is covered in full $15 co-pay Also available through VSP (See Vision Service Plan section) As medically necessary (some limitations) within service area if authorized Prior approval from Kaiser is required in nonemergency situations $15 office visit No charge for lab tests or x-rays $15 office visit co-pay Most injectable drugs including allergy tests, provided at no charge if administered in the medical office $15 for each visit Also available through VSP (See Vision Service Plan section) Considered Home Healthcare In Network: $15 co-pay, 60 visits/year, 4 hours/visit Out-of-Network: 30% co-pay, 60 visits/year, 4 hours/visit In Network: $0 co-pay when medically necessary Out-of-Network: Covered services will be covered as in network (Non-emergency Air Transportation is not always covered.) In Network: $0 co-pay at participating laboratories Subject to office visit co-pay Most injectable drugs including allergy tests, provided at no charge if administered in the medical office Discounts available on eye wear and eye care through General Vision Services Also available through VSP
Page 3 of 5 Chiropractic Services ** Physical Therapy ** Physical Examination ** Home Health Services Physician Home Visits** Home Health Nurse ** Maternity ** Maximum of 20 visits per Maximum of 16 visits per $15 co-pay Available through ASH Networks only $15 co-pay Available through ASH Networks only $15 for each visit $15 co-pay for Annual periodic health evaluations $30 per visit $10 co-pay on and after the 31st calendar day $15 for each examination $15 office visit co-pay in hospital In Network: $15 per visit, visits are subject to medical necessity, visits are subject to medical necessity In Network: Outpatient (through Ortho-Net); 90 visits/condition/ lifetime $15 co-pay Inpatient: 60 days/condition/ lifetime; $0 co-pay. Outpatient: 90 days/condition/ lifetime Inpatient: 60 days/condition/ lifetime Comprehensive Physical Exam age 13 and older: In Network: $0 co-pay Out-of-Network: Not covered In Network: $15 co-pay, 60 visits/year, 4 hours/visit, 60 visits/year, 4 hours/visit In Network: $15 per initial visit only, 60 visits/year, 4 hours/visit In Network: $15 co-pay
Page 4 of 5 Interrupted Pregnancies ** Family Planning Services Vasectomy Not covered $50 Tubal Ligation Not covered $150 Elective Abortion ** Intrauterine Device (IUD) ** Mental Health Outpatient Covered under Optum Health Behavioral Solutions $150 for elective abortion (No charge for medically necessary abortions) Fitting and insertion only $30 per visit up to 20 outpatient mental health consultation per unlimited days for conditions considered severe mental health illnesses $15 for each visit co-pay in hospital Outpatient: $15 co-pay Outpatient: $15 co-pay Outpatient: $15 co-pay Provided at reasonable rates $5 co-pay Up to 20 visits per (Visit limit does not apply to certain mental health care) $2 co-pay/visit for group therapy Treatment in the office is subject to office visit co-pay Inpatient Treatment: Inpatient hospital coverage Covered as medically necessary (This is separate from Terminations of Pregnancies) In Network: No charge, reversal not covered In Network: No charge, reversal not covered, reversal not covered In Network: Maximum allowance of $350 per abortion. Maximum allowance of $350 per abortion, once/year Not covered 40 visits per In Network: $15 co-pay per visit Out-of-Network: deductible plus 30% co-insurance per visit
Page 5 of 5 Mental Health Inpatient Covered under Optum Health Behavioral Solutions Non-severe No charge/30 days per Severe No charge/unlimited days per Up to 30 days per (Day limit does not apply to certain type of mental health care) 30 days per In Network: $15 co-pay per visit Out-of-Network: deductible plus 30% co-insurance per visit
Page 1 of 1 Motion Picture Industry (MPI) Active Health Plan Dental Plans Benefit Comparison At-A-Glance Delta Dental PPO (Available Nationwide) DeltaCare USA (Available in ) Dentists Available The dentist of your choice, anywhere in the world. Using Delta PPO dentists may reduce your out-ofpocket expense. Must use selected DeltaCare affiliated dentist only; dentists located throughout California Cost to You For Most Services You pay 20% of the usual, customary and reasonable charges No cost to you Deductible $25 annually per person, up to a maximum of $50 per family No deductible Maximum $2,000 per person, per No annual maximum Orthodontics Eligible dependent children only Pays 50% of usual, customary and reasonable charges $1,000 lifetime maximum Eligible dependent: Children: $1,100 Adults: $1,500 Start-up fee: $ 250