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...At a Glance

The following Schedule of Benefits briefly highlights the benefits available through the Plan and shows the payment percentages for both In-Network and Out-of-Network expenses.  By utilizing providers which are In-Network, you will have lower out-of-pocket expenses as the Plan will process eligible expenses at a higher payment percentage.  In-Network providers have also agreed to accept the allowable charges for eligible expenses, therefore you will not be responsible for the difference between the actual charge and the allowable charge. 

As this schedule is only a summary, please refer to the appropriate sections of this booklet for more detailed information including any requirements for eligible expenses, as well as any limitations or exclusions from coverage.  Benefits are subject to change.  Please contact your Fund Office for the most up to date information regarding eligibility and covered expenses.
 

Schedule of Benefits


  Comprehensive Major Medical
  Annual Deductible
 		  Individual
 Family

  $250
  $500
  Maximum for all Covered Expenses
 		  Annual
 Lifetime

  $300,000
  $750,000
  Maximum Out of Pocket Expenses

  The Plan's payment factor will be increased to 100% for
  Covered Expenses in excess of $20,000 per calendar year
  (does not include the annual deductible).
 

  Annual

 

 

   $3,000
      to
  $6,000

 
  Dental Benefit
 		  Maximum Reimbursement
 100% Payment Factor


  $300
  Preventive Care Benefit
 		  Maximum Reimbursement
 100% Payment Factor


  $1,000

 


  Annual Co-Insurance Factor Summary
 		 In-Network Out-of-Network
     Physician and Other Medical Services
          Payment Factor for first $20,000 per calendar year........
          Payment Factor for charges over $20,000.....................
85%
100%
70%
100%
     Hospital Services
          Payment Factor for first $20,000 per calendar year........
          Payment Factor for charges over $20,000.....................
80%
100%
70%
100%


  Benefits and Payment Factors
 

In-Network

Out-of-Network
  Hospital In-Patient Charges  (Pre-Admission Certification Required)
     Room & Board charges
     Miscellaneous charges
 
80% of allowable
charge		 70%
  Hospital Out-Patient Charges
     Pre-Admission Testing, Anesthesiologist, Laboratory,
     Pathology, Radiology, Surgery and Testing charges
 		 80% of allowable
charge		 70%
  Emergency and Urgent Care Services
     Hospital Emergency Room
     Physicians Office
     Urgent Care facility
 		 85% of allowable
charge		 70%
  Ambulance Fees

  Durable Medical Equipment

  Orthotic and Prosthetic Devices
 		 85% of allowable
charge		 70%
  Physician Services
      Allergy Treatments
     Emergency and Urgent Care
     Mammograms
     Office Visits
     Pre-Admission Testing
     Second Opinions
     Specialists
 		 85% of allowable
charge		 70%
  Laboratory Services
     LabOne Lab Card Service

     Other Laboratory Service
     (billed through an independent facility)
 		 85% of allowable
charge		 70%
  Radiology Services
     X-Rays, MRIs, MRAs, CAT Scans and PET Scans
     (billed through an independent facility)
 		 85% of allowable
charge		 70%
  Chiropractic Treatment
     Limited to twenty (20) visits or a maximum of $800 per calendar
      year  (including x-rays)
 		 85% of allowable
charge		 70%
  Physical Therapy and Speech Therapy
     Limited to a maximum of twenty (20) visits per calendar
     year and must be medically necessary and not for
     developmental or educational expenses
 		 85% of allowable
charge		 70%
  Alcohol and Substance Abuse Treatment
     Allowable charge of $80 per day
     Limited to a lifetime maximum of $50,000 per individual,
     further limited to one (1) visit per day and fifty-two (52)
     visits per calendar year
 		 60% of allowable
charge		 50%
  Mental Health Care Treatment
     Inpatient Expenses
 		 80% of allowable
charge		 70%
  Mental Health Care Treatment
     Outpatient Expenses     Allowable charge of $80 per day
     Limited to a lifetime maximum of $50,000 per individual,
     further limited to one (1) visit per day and fifty-two (52)
     visits per calendar year
 		 60% of allowable
charge		 50%
  Maternity Care
     Physician charges
     All prenatal and postnatal visits

     Delivery charges
 		 85% of allowable
charge

See Hospital In-patient

 70%
 

See Hospital In-patient

  Weekly Disability Benefit
 

  Weekly Disability Benefit
     Waiting period for injury
     Waiting period for illness
     Maximum Benefit Period
 

  $200 per week
   0 days
   7 days
 26 weeks
 		  
No benefits are payable for a work related injury or illness.  This benefit is subject to FICA and Medicare taxes.  A Form W-2 will be provided annually for all benefits paid.

The weekly disability benefit is for active participants only and does not apply to a retiree, spouse or an eligible dependent.
 

 


  Prescription Drugs and Medicines Benefit
Annual Deductible..............................................................
 		 $100
 
Retail Drug Program     30 Day Supply per fill of a prescription
     Generic ..........................................................................
     Preferred Brand Name .....................................................
     Non-Preferred Brand Name ...............................................

     The maximum co-payment for any one prescription ............
 		 10% of cost or minimum co-pay of $  7.50
20% of cost or minimum co-pay of $20.00
30% of cost or minimum co-pay of $35.00

$100
 
Mail Order Drug Program     90 Day Supply per fill of a prescription
     Generic...........................................................................
     Preferred Brand Name......................................................
     Non-Preferred Brand Name ..............................................
 		 $20.00 per prescription
$40.00 per prescription
$80.00 per prescription
 

Please refer to the Prescription Managers booklet for a listing of the Preferred Brand Name Drugs.

Should you receive a Brand Name drug when a Generic equivalent is available, you will be required to pay the difference between the cost of the Brand Name and the cost of the Generic.
 

 


  Life Insurance Schedule of Benefits
Participant
     Life Insurance Benefit...............................................................................................................................
     Accidental Death and Dismemberment (AD&D) Benefit...................................................................
     Accidental Death, Dismemberment and Loss of Sight Benefit
           Loss of two (2) arms or legs, sight of both eyes, or one arm or leg and sight of one eye.....
          Loss of one (1) arm, one (1) leg, or sight of one (1) eye..............................................................
 		 $25,000
$25,000

$25,000
$12,500
 
Dependents
     Life Insurance Benefit
          Spouse...................................................................................................................................................
          Children
               24 hours after live birth but less than 19 years of age
              (or to 24 if continue to meet the dependent definition)..............................................................
 		 $10,000


$  5,000
The Life Insurance, AD&D and Dependent Life Insurance Benefits are underwritten by an insurance company.  The current underwriter is Boston Mutual Life Insurance.