PPO BENEFIT SUMMARY
FOR IATSE NATIONAL BENEFIT FUND (LOW OPTION PLAN)
BENEFIT				IN-NETWORK1	OUT-OF NETWORK2
Cost Sharing				Member Pays	Member Pays
	Deductible			Not Applicable	$500/$1,250
	Co-insurance			Not Applicable	30%
	Co-insurance Stop-Loss			Not Applicable	$10,000/$25,000
					($3,000/$7,500 out-of-pocket)
	Dependent Children			To age 19; Full-time students to age 25
	Lifetime Maximum			Unlimited	1000000
Hospital Benefits3				Member Pays	Member Pays
	Inpatient (Except Mental Health)			$250/$625	Deductible & Co-insurance
		Unlimited days, semi-private room
		and board
	Inpatient Physical Therapy, Physical			$250/$625	Deductible & Co-insurance
	Medicine, or Rehabilitation4
		Up to 30 continuous days per
		calendar year
	Mental Health5			$250/$625	Covered in-network only
		Up to 30 days per calendar year
		Up to 7 days for detox for alcohol and
		substance abuse per calendar year
	Outpatient			0	Dedictible & Co-insurance
		Ambulatory surgery4, pre-surgical testing,
		chemotherapy, radiation therapy,
		mammography, and cervical cancer
		screening
	Emergency Room/Facility			$50 copay
		Initial visit for emergency care		(Waived if admitted within 24 hours)
Other Facility Benefits3				Member Pays	Member Pays
	Alcohol/Substance Abuse5			0	Deductible & Co-insurance
		Up to 60 outpatient visits which include 20
		family counseling visits per calendar year
	Home Health Care4			0	Co-insurance
		Up to 200 visits per calendar year			(Deductible does not apply)
	Outpatient Kidney Dialysis			0	Deductible & Co-insurance
	Hospice4			0	Covered in-network only
		Up to 210 days per lifetime
	Skilled Nursing Facility4			0	Covered in-network only
		Up to 60 days per calendar year
NOTE:
	This is a benefit summary only, and is subject to the terms, conditions, limitations, and exclusions set
	forth in the contract.  Failure to comply withour Medical Management or Behavioral Health Care
	Management Programs could result in benefit reductions.
	Version 8/2000				TN 9/25/2000
BENEFIT				IN-NETWORK1	OUT-OF NETWORK2
Medical Benefits3				Member Pays	Member Pays
	Home/Office Visits			$20 copay	Deductible & Co-insurance
	Home Infustion Therapy			0	Covered in-network only
	Annual Physical Exam			$20 copay	Covered in-network only
	Well Child Care			0	Deductible & Co-insurance
		(Up to age 19; including necessary
		immunizations)
	Well Woman Care			$20 copay	Deductible & Co-insurance
	Inpatient Visits			0	Deductible & Co-insurance
	Diagnostic Screening & Mammography			0	Deductible & Co-insurance
	Maternity			0	Deductible & Co-insurance
	Surgery and Surgical Assistant			0	Deductible & Co-insurance
	Anesthesiology			0	Deductible & Co-insurance
	Lab & X-Ray			0	Deductible & Co-insurance
	MRI4			0	Deductible & Co-insurance
	Mental Health5			$25 copay per visit	Deductible & Co-insurance
		Up to 40 outpatient visits in office or
		facility
		Up to 30 inpatient visits		0	Covered in-network only
	Allergy Testing & Treatment			$20 copay	Deductible & Co-insurance
				(Waived for treatment)
	Second Surgical Opinion6			$20 copay6	Deductible & Co-insurance
	Physical Therapy4			0	Deductible & Co-insurance
		Up to 30 visits as an inpatient
		Up to 30 visits combined in home, office,		$20 copay	Covered in-network only
		or outpatient facility
	Other Therapies4			$20 copay	Covered in-network only
		(Occupationsl, speech, vision)
		Combined 30 visits in home, office, or
		outpatient facility
	Cardiac Rehabilitation4			$20 copay	Deductible & Co-insurance
	Medical Supplies			0	0
	Durable Medical Equipment, Prosthetic, &			0	Covered in-network only
	Orthodontics4
	Ambulance			0	0
	Chiropractic Care			$20 copay	Deductible & Co-insurance
(1)		Network provider delivers care
(2)		Subject to balance billing over allowed amount
(3)		Out-of-network services (except Mental Health and Alcohol/Substance Abuse) are those from a provider that
		does not participate with Empire or with another Blue Cross and Blue Shield Plan through the BlueCard
		PPO program.  This does not apply to emergency benefits.  See (5) for Mental Health and Alcohol/Substance
		Abuse services.
(4)		Precertification by out Medical Management Program is required.  If not obtained, penalties will apply.
(5)		Our Behavioral Health Care Management Program must preceritfy all Mental Health and Alcohol/Substance
		Abuse services, except rider-purchased out-of-network mental health visits.
(6)		Copay does not apply if the Second Surgical Opinion is arranged through out Medical Management Program.
Empire Blue Cross and Blue Shield is an independent licensee of the Blue Cross and Blue Shield Association.  The
Cross and the Shield are registered marks of the Blue Cross and Blue Shield Association.