USCFL HEALTH PLAN (Select Provider Organization)

(For Non-Play Related Health Care)

Note: Reserve players may opt to select the Preferred Provider Organization plan, which offers a lower premium, but also has increased out-of-pocket expenses for covered services.

Plan Name	USCFL Health Plan-Part A
Activity	Benefit
All USCFL Practices, Scrimmages, and Competition Related Health Care	100% Coverage for all Services

Plan (for USCFL Health Plan-Part B, Schedule 1)	Annual Premium (You Pay)
Starter (Individual)	$0
Starter plus Spouse or Dependant Coverage (1)	$840 ($35 per pay period)
Starter plus Family Coverage (1)	$1,680 ($70 per pay period)
Reserve (Individual)	$840 ($35 per pay period)
Reserve plus Spouse or Dependant Coverage	$1,680 ($70 per pay period)
Reserve plus Family Coverage	$2,400 ($100 per pay period)

Plan Name	USCFL Health Plan-Part B, Schedule 1
	In Network You Pay	Out of Network You Pay
Cash Deductible per Plan Year (Individual) (2)	$0	$200
Cash Deductible per Plan Year (Family) (2)	$0	$600
Maximum Out-of-Pocket Expense per Plan Year (Individual)	$2,000	$3,500
Maximum Out-of-Pocket Expense per Plan Year (Family)	$4,000	$7,000
Outpatient Services	In Network You Pay (Co-payment)	Out of Network You Pay (Co-insurance)
Office Visits (Primary Care) (3)	$25	$30 (no deductible)
Office Visits (Specialist) (4)	$40	$50 (no deductible)
Emergency Room (5)	$200	$200
Emergency Room (Non-emergency)	$300	30% (after deductible)
Ambulance (5)	$200	$200
Ambulance (Non-emergency)	$300	30% (after deductible)
Urgent or Convenient Care	$30	20% (after deductible)
Urgent or Convenient Care (Non-urgent)	$50	30% (after deductible)
Routine Prenatal Care	$25	20% (after deductible)
Preventive Physicals	$0	$0
Wellness Services	$0	$0
Mammography	$0	$0
Outpatient & Diagnostic testing	$0	20% (after deductible)
Outpatient Surgeries/Procedures	$200	20% (after deductible)
Spinal Manipulations	$40	20% (after deductible)
Outpatient Mental Health Care (6)	$40	$50 (no deductible)
Durable Medical Equipment	10% or $100 (7)	20% or $200 (7)
Inpatient Services	In Network You Pay (Co-payment)	Out of Network You Pay (Co-insurance)
Hospitalization	$400	20% (after deductible)
Maternity	$400	20% (after deductible)
Extended Care/Rehabilitation	$400	20% (after deductible)
Mental Health Care	$400	20% (after deductible)
Substance Abuse Treatment	$400	20% (after deductible)
Prescription Drug Pharmacy Services	In Network You Pay (Co-payment)	Out of Network You Pay (Co-insurance)
Cash Deductible per Plan Year (Individual)	$0	$50
Cash Deductible per Plan Year (Family)	$0	$150
Generic Prescriptions	$10	10% (after deductible)
Name-Brand Preferred Prescriptions	$20	20% (after deductible)
Name-Brand Non-preferred Prescriptions	$30	30% (after deductible)

(1) Children of members may remain on their parents' plan until age 26, regardless of student or employment status.
(2) Annual deductible does not apply towards out-of-pocket maximum.
(3) This plan does not require members to select a Primary Care Physician, although members are encouraged to do so. Members may self-refer to specialists, although it is advised that a Primary Care Physician be seen before visiting a specialist.
(4) Women over the age of 18 may visit a gynecologist without incurring specialist co-payment.
(5) Emergency Room and Ambulance co-payment is waived if patient is admitted to a hospital within 24 hours.
(6) Limited to 20 visits per plan year. Providers includes psychiatrists (M.D.), clinical psychologists (Ph.D. or Psych.D), social workers (M.S.W.), and other master's level providers.
(7) Whichever is less. Deductible applies if out-of-network provider is used.

To USCFL Preferred Provider Organization Plan