Schedule of Benefits

The following is your Schedule of Benefits. You will find details about the benefits listed in this Schedule in the sections that follow.

Benefit	Amount
Death Benefit (Employee Only)	$15,000
Accidental Death and Dismemberment Benefit (Employee Only)
For Your Death	$15,000
For Two Dismemberments	$15,000
For One Dismemberment	$7,500
Weekly Accident and Sickness Disability Benefit (Employee Only)
Weekly Benefit	$250 per week for up to 26 weeks
Benefit Begins on	First day after an Accident Eighth day after Sickness
Maximum Duration of Benefit	26 Weeks or 130 Working Days per Injury or Sickness, in accordance with the Disability Section on page 53.
Wellness Expense Benefit (Employee and Spouse Only)
Physical Examination, Smoking Cessation Programs and Certain Tests and Laboratory Work	Up to the first $250 for you and your spouse every two calendar years. Deductible and coinsurance do not apply.
Medical Benefit (Employee and Dependents)
Comprehensive Major Medical Lifetime Maximum Benefit (including Mental Health Benefits)	Unlimited
Deductible: Individual/Family (not included in your Out-of-Pocket Maximum)	$250/Maximum of 3 individual deductibles per family each calendar year
Coinsurance (% the Fund Pays for Most Covered Services, Unless Otherwise Specified)	80%
Out-of-Pocket Maximum (after payment of Deductible)	$750 per person each calendar year
Hospital and Ambulatory Surgical Facilities PPO Facilities Non-PPO Facilities	80% 70% of the allowable charge
Copayment for Failure to Obtain Pre-Admission Authorization of Elective Hospitalization, Elective Inpatient Surgery, Dialysis Facility, Skilled Nursing Facility, or Failure to Report Emergency Admission Within 2 Business Days	You must pay an additional $250 copayment

 

Benefit	Amount
Physician’s Services PPO Physicians Non-PPO Physicians	85% 70% of the allowable charge
Chiropractic Services PPO Providers Non-PPO Providers Calendar Year Maximum per Person	85% 70% of the allowable charge $1,250
Mental Health Treatment Inpatient PPO Facility Non-PPO Facility Outpatient	Limited to 30 days per calendar year 80% 70% of the allowable charge 50% Up to 45 visits per calendar year
Substance Abuse Treatment   Inpatient PPO Facility Non-PPO Facility Outpatient	$15,000 per person per calendar year $30,000 per person Lifetime Maximum   80% 70% of the allowable charge 50%
Infertility Treatment Benefits Coinsurance Combined Lifetime Maximum for You and Your Spouse	50% of covered expenses $20,000
Organ and Tissue Transplants	Treated the same as other medical expenses. (However, no deductible or coinsurance is applied if you use a Blue Cross Blue Shield Centers of Excellence Facility.)
Hospice Care Benefits Coinsurance Bereavement Counseling Maximum Benefit	No deductible or copayment Is required 100% paid by Fund Limited to 6 visits; Maximum of $50 per visit $10,000 per person
Substance Abuse Employee Assistance Program
Telephone Counseling and Referral Program	No charge

 

CVS Caremark Prescription Drug Program	Retail Program	Mail Order Program
You should use the Prescription Drug Program in the following manner:	For immediate or short-term medications	For maintenance or long-term medications
You Pay
Generic Drug (Per Prescription)	30%	30%
Brand Name Drug – No Generic Available (Per Prescription)	30%	30%
Brand Name Chosen Instead of Available Generic (Per Prescription)	35%	35%
Maximum Supply	34 days	90 days
Refill Limit	As prescribed	As prescribed
Calendar Year Deductible per Person, not included in the Out-of-Pocket Maximum	$25
Calendar Year Out-of-Pocket Maximum per Person, After Payment of Deductible	$2,000
Calendar Year Out-of-Pocket Maximum per Family, After Payment of Deductible	$4,000
Reimbursement of Non-Network Pharmacy Expenses is explained on page 48.
Dental Benefits	Amount
Calendar Year Deductible	$25 per person
Type of Services
Preventive Services	100%
Basic Services	80%
Major Services	50%
Dental Anesthesia Services	50%
Calendar Year Maximum Dental Benefits	$1,500 per person
Orthodontia Services for Your Eligible Dependent Children (to age 19)	50%
Lifetime Maximum Orthodontia Benefits	$1,500 per Eligible Dependent Child
Optical (Vision) Benefits	Amount
Lenses, Frames and Eye Examinations	Up to $225 per person during a consecutive two-year period
Hearing Aid Benefit	Amount
Hearing Aid	Up to $1,300 per person ($650 maximum per year), during a consecutive three-year period

The Out-of-Pocket Maximum is not applicable for covered expenses received at non-PPO Hospitals or non-PPO Ambulatory Surgical Facilities or for services received from a Non-PPO Physician.

See the Pre-Admission Authorization Section for information about obtaining prior approval through Blue Cross Blue Shield Medical Service Advisory (MSA) before elective hospitalization or elective Inpatient surgery and requirements for notifying the MSA of any emergency admission within certain timeframes. If you do not call the Blue CrossBlue Shield MSA for prior approval or within two days of an emergency admission, you must pay an additional $250 copayment.