USAirways Proposed Benefits

US Airways National PPO - Plan Design Summary

Eligible Actives, Inactives & Pre-65 Retirees

Benefits	*Option 1*		*Option 2*		*Option 3*
Benefits	In-Network	*Out-of-Network*	*In-Network*	*Out-of-Network*	*In-Network*	*Out-of-Network*
Annual Deductible ^{(1) (2)}
n Single	$300	$600	$150	$300	$150	$300
n Family	$600	$1,200	$300	$600	$300	$600
Coinsurance	80%	60%	90%	70%	100%	80%
Annual Out-of-Pocket Maximum ^{(1) (2) (3)}
n Single	$2,000	$4,000	$1,000	$2,000	N/A	$2,000
n Family	$4,000	$8,000	$2,000	$4,000	N/A	$4,000
Lifetime Maximum ⁽⁴⁾	Unlimited	$1,000,000	Unlimited	$1,000,000	Unlimited	$1,000,000
Medical Office Services
n Office Visits	100% after $15 copay for primary care physicians and $25 copay for specialists⁽¹⁾	Subject to deductible & coinsurance	100% after $15 copay for primary care physicians and $25 copay for specialists⁽¹⁾	Subject to deductible & coinsurance	100% after $15 copay for primary care physicians and $25 copay for specialists⁽¹⁾	Subject to deductible & coinsurance
n Physical Exams	100% after $15 copay ⁽¹⁾	Not covered	100% after $15 copay ⁽¹⁾	Not covered	100% after $15 copay ⁽¹⁾	Not covered
n Well-Child Care	100% after $15 copay ⁽¹⁾	Not covered	100% after $15 copay ⁽¹⁾	Not covered	100% after $15 copay ⁽¹⁾	Not covered
n Gynecological Exams	100% after $15 copay for primary care physicians and $25 copay for specialists⁽¹⁾	Annual well woman exams not covered except for pap smears & mammograms Visits related to illness subject to deductible & coinsurance	100% after $15 copay for primary care physicians and $25 copay for specialists⁽¹⁾	Annual well woman exams not covered except for pap smears & mammograms Visits related to illness subject to deductible & coinsurance	100% after $15 copay for primary care physicians and $25 copay for specialists⁽¹⁾	Annual well woman exams not covered except for pap smears & mammograms Visits related to illness subject to deductible & coinsurance
n X-ray & Lab Tests	100% if performed in physician office as part of office visit, otherwise subject to deductible & coinsurance	Subject to deductible & coinsurance	100% if performed in physician office as part of office visit, otherwise subject to deductible & coinsurance	Subject to deductible & coinsurance	100% if performed in physician office as part of office visit, otherwise subject to deductible	Subject to deductible & coinsurance
n Immunizations	100% after $15 copay ⁽¹⁾	Not covered	100% after $15 copay ⁽¹⁾	Not covered	100% after $15 copay ⁽¹⁾	Not covered
Inpatient Hospital Services ⁽⁵⁾
n Days of Care	Subject to deductible & coinsurance Unlimited number of days	Subject to deductible & coinsurance Unlimited number of days	Subject to deductible & coinsurance Unlimited number of days	Subject to deductible & coinsurance Unlimited number of days	Subject to deductible Unlimited number of days	Subject to deductible & coinsurance Unlimited number of days
n Room Allowance (Semi-private room covered; private room only when medically necessary)	Subject to deductible & coinsurance	Subject to deductible & coinsurance	Subject to deductible & coinsurance	Subject to deductible & coinsurance	Subject to deductible	Subject to deductible & coinsurance
n Intensive & Cardiac Care	Subject to deductible & coinsurance	Subject to deductible & coinsurance	Subject to deductible & coinsurance	Subject to deductible & coinsurance	Subject to deductible	Subject to deductible & coinsurance
n Supplies & Services	Subject to deductible & coinsurance	Subject to deductible & coinsurance	Subject to deductible & coinsurance	Subject to deductible & coinsurance	Subject to deductible	Subject to deductible & coinsurance
n Surgery	Subject to deductible & coinsurance	Subject to deductible & coinsurance	Subject to deductible & coinsurance	Subject to deductible & coinsurance	Subject to deductible	Subject to deductible & coinsurance
n Physician Visits	Subject to deductible & coinsurance	Subject to deductible & coinsurance	Subject to deductible & coinsurance	Subject to deductible & coinsurance	Subject to deductible	Subject to deductible & coinsurance
Outpatient Hospital Services
n Surgery	Subject to deductible & coinsurance	Subject to deductible & coinsurance	Subject to deductible & coinsurance	Subject to deductible & coinsurance	Subject to deductible	Subject to deductible & coinsurance
n X-ray & Lab Tests	Subject to deductible & coinsurance	Subject to deductible & coinsurance	Subject to deductible & coinsurance	Subject to deductible & coinsurance	Subject to deductible	Subject to deductible & coinsurance
n Pre-admission Testing	Subject to deductible & coinsurance	Subject to deductible & coinsurance	Subject to deductible & coinsurance	Subject to deductible & coinsurance	Subject to deductible	Subject to deductible & coinsurance
Emergency Room Care ⁽⁶⁾	Covered in full after $100 copay ^{(1) (6)} (waived if admitted)		Covered in full after $100 copay ^{(1) (6)} (waived if admitted)		Covered in full after $100 copay ^{(1) (6)} (waived if admitted)
Maternity Care
n Obstetric Services (including office visits)	100% after $25 copay (initial visit only) ⁽¹⁾	Subject to deductible & coinsurance	100% after $25 copay (initial visit only) ⁽¹⁾	Subject to deductible & coinsurance	100% after $25 copay (initial visit only) ⁽¹⁾	Subject to deductible & coinsurance
n Hospital Charges (including newborn nursery care)	Subject to deductible & coinsurance	Subject to deductible & coinsurance	Subject to deductible & coinsurance	Subject to deductible & coinsurance	Subject to deductible	Subject to deductible & coinsurance
Mental Health Care ⁽⁷⁾

Benefits

In-Network