120 Days per 12 consecutive month period Semi-private Accommodations (See Hospital Review Program, Page 18):

		Maximum
Maternity	Paid	While medically necessary
Pre-Admission Testing	Paid
Rehabilitation	Paid	30 days per 12 consecutive month period, charged to the 120 day maximum
Dialysis	Paid	First 30 months only, from date of first treatment
Emergency Room	$100 Copay	Unless admitted
Mental or Nervous Disorder	Paid	charged to the 120 day maximum hospital benefit
Detoxification	Paid	charged to the 120 day maximum
All Hospital Benefits	Paid	120 days per 12 consecutive month period is the sole and exclusive coverage under the Plan for Hospital Benefits.

As a registered bed patient in any general hospital, You and Your enrolled dependents are each eligible to receive the following benefits:

DAYS OF CARE

120 Days Covered in Full

Your days of care may be used during one confinement or during several

BED, BOARD AND GENERAL NURSING CARE

Semiprivate Accommodations

If You are a hospital patient in a semiprivate room, Your bed, board (including special diets) and general nursing care are covered in full for 120 days.

PRIVATE ACCOMODATIONS

If You occupy a private room, You receive for the 120 day period, a daily allowance equal to the hospital’s average semiprivate room charge toward the cost of bed, board and general nursing
care.

COVERED EXPENSES

You are covered in full for the following services, regardless of the class of accommodations occupied, if they are necessary for the diagnosis and treatment of the condition for which You
are hospitalized:

• Use of operating, cystoscopic, recovery rooms and equipment
• Use of intensive care or special care units and equipment
• X-ray examinations
• Laboratory and pathological examinations
• Blood, use of blood transfusion equipment and administration of blood or blood derivatives when given by a hospital employee
• Use of cardiographic equipment and supplies
• Anesthesia supplies and use of anesthesia equipment
• Oxygen and use of equipment for its administration
• Dressings and plaster casts
• Any additional medical services and supplies customarily provided by the hospital
• Hospital room and board up to the semiprivate room rate charged by the Hospital in which You or Your Dependent are confined; if hospital only has private rooms, we will cover 80% of charges
• Charges for local licensed ambulance service only to a hospital, due to accident or acute illness, or from a Skilled Nursing Facility to a hospital, due to accident or acute illness
• Charges made for diagnostic testing
• Charges made for radiation and chemotherapy treatment
• Charges made for prescription drugs (except birth control drugs and vitamins), not covered under the Fund’s prescription drug program; the drug must be Federal Drug Administration approved for the illness being treated
• Charges made for rental (or if cheaper, purchase) of durable medical equipment such as wheelchairs, hospital type bed, etc.

Benefits for cancer chemotherapy (including medications) will be provided when given in the hospital on an outpatient basis.

MATERNITY CARE

Maternity benefits are provided for expenses incurred in a hospital for all Participants and spouses of Participants. There are no maternity benefits provided for dependent children.

Regular hospital benefits will be provided for hospital stays involving any pregnancy-related condition. Additionally, benefits for routine nursery care of the newborn child are provided during the mother’s normal covered hospital stay for delivery. There is no coverage if the pregnancy is terminated due to elective abortion.

The Plan may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a normal vaginal delivery, or less than 96 hours following a cesarean section, or require that a provider obtain authorization from the plan or insurance issuer for prescribing a length of stay not in excess of the above periods.

NEWBORN CHILDREN

Under family coverage, benefits are available from birth for:

• The treatment of illness or injury, or
• Nursery care in an approved premature unit for an infant weighing less than 2,500 grams (5.5 pounds) or
• Incubator care, regardless of the infant’s weight

OUTPATIENT SERVICES

Covered-in-full benefits, subject to a $100 co-payment, are provided when You are not admitted as an inpatient but receive care in the hospital’s emergency room or operating room for:

Emergency Treatment/Surgery

1. Emergency first aid during the initial visit for treatment of an accidental injury within 72 hours following such injury, or
2. Emergency care during the first visit for treatment within 12 hours of the onset of sudden or serious illness, or
3. Minor surgery

PRE-ADMISSION TESTING

Diagnostic tests prescribed by Your doctor and completed in a Hospital as an outpatient, as a preliminary to admission in that hospital, if done within 7 days of admission.

OUTPATIENT CHEMOTHERAPY

Benefits for cancer chemotherapy (including medications) will be provided when given in the hospital on an outpatient basis.

HOME CARE

Home Care benefits are available, within seven (7) days following discharge from a hospital, under a physician-approved plan of treatment when the necessary services are rendered through a New York State licensed and federally certified home health agency. Benefits will be provided only if hospitalization or confinement in a skilled nursing facility would have otherwise been required.

Covered services include: part-time professional nursing; part-time home health aide services (up to 4 hours of such care is equal to one home care visit); physical, occupational or speech therapy; medical supplies, drugs and medicines prescribed by a physician; and necessary laboratory services. In no event will coverage be provided for more than 200 visits in any calendar year.

When care is rendered without prior hospitalization, or if not begun within seven (7) days from hospital discharge, after a $400 deductible, You will receive an allowance equal to 80% of the agency’s reasonable charges, for up to a maximum of 40 home care visits per calendar year.