Benefit	Amount
Death Benefit (Employee Only) (Section 6)	$15,000
Dismemberment and Accidental Death Benefit (Employee Only) (Section 7)
For Your Death	$15,000
For Two Dismemberments	$15,000
For One Dismemberment	$7,500
Weekly Accident and Sickness Benefit (Employee Only) (Section 8)
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
Wellness Expense Benefits (Employee and Spouse Only) (Section 9)
Physical examination, smoking cessation programs and certain tests and laboratory work	Up to the first $250 available separately to both You and your Spouse every two calendar years
Medical Benefits (Employee and Dependents) (Section 10)
Comprehensive Major Medical Lifetime Maximum Benefit (including Mental Health Benefits)	Unlimited
Deductible: Individual/Family	$250/3 Individual Deductibles per Family
Coinsurance (% the Fund Pays For Most Covered Services, unless otherwise specified)	80%
Out-of-Pocket Maximum	$750 per Person each Calendar Year (1)
Hospital and Ambulatory Surgical Facilities (2) PPO Facilities Non-PPO Facilities	80% 70%

(1) The Out-of-Pocket Maximum is not applicable for covered expenses received at non-PPO Hospitals or non-PPO Ambulatory Surgical Facilities.

(2) See Section 10.5 for information about obtaining prior approval through Blue Cross Blue Shield Medical Service Advisory (MSA) before elective hospitalization or elective inpatient surgery and notifying the MSA of any emergency admission within certain timeframes. If you do not call the Blue Cross Blue Shield MSA for prior approval, your benefits will be reduced by $250.

Benefit	Amount
Physician’s Services PPO Physicians Non-PPO Physicians	85% 80%
Mental Health Treatment Inpatient PPO Facility Non-PPO Facility Outpatient	Limited to 30 Days per Calendar Year 80% 70% 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% 50%
Infertility Treatment Benefits Coinsurance Lifetime Maximum	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 Maximum Benefit	No Deductible or Co-payment Is Required 100% paid by Fund $10,000

Caremark Prescription Drug Program (Section 14)
When To Use It	Retail Program For immediate or short-term medications	Mail Order Program For maintenance or long-term medications
You Pay
Calendar Year Deductible per Family	$25
Generic Drug (Per Prescription)	$ 5	$ 5
Brand Name Drug – No Generic Available (Per Prescription)	$15	$20
Brand Name Chosen Instead of Available Generic (Per Prescription)	$20	$25
Maximum Supply	34 Days	90 Days
Refill Limit	As Prescribed	As Prescribed
For out-of-network benefits, see Prescription Drug Benefits regarding claim procedures and benefit/reimbursement amounts.
Dental Benefits (Section 11)	Amount
Calendar Year Deductible	$25 per Person
Type of Services
Preventive Services	100%
Basic Services	80%
Major Services	50%
Calendar Year Maximum Dental Benefits	$1,500 per Person
Orthodontia Services (to age 19)	50%
Lifetime Maximum Orthodontia Benefits	$1,500 per eligible dependent
Optical (Vision) Benefits (Section 12)	Amount
Lenses, Frames and Eye Examinations	Up to $225 per Person During a Consecutive Two-Year Period
Hearing Aid Benefits (Section 13)	Amount
Hearing Aid	Up to $1,300 per Person ($650 maximum per ear maximum), during a consecutive three-year period.