Schedule of Benefits for Medicare Eligible Retirees



Death Benefit (Retiree Only) [1]


Accidental Death and Dismemberment Benefit (Retiree Only) 1

For Your Death


For Two Dismemberments


For One Dismemberment


Wellness Expense Benefit (Retiree and Spouse Only)

Physical Examination, Smoking Cessation Programs and Certain Tests and Laboratory Work

Unlimited. Deductible and coinsurance do not apply.

Hospice Care Benefits

Hospice Care Benefits


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


OptumRx 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)



Brand Name Drug – No Generic Available (Per Prescription)



Brand Name Chosen Instead of Available Generic (Per Prescription)



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


Calendar Year Out-of-Pocket Maximum per Person, After Payment of Deductible


Calendar Year Out-of-Pocket Maximum per Family, After Payment of Deductible


Reimbursement of Non-Network Pharmacy Expenses is explained in Prescription Drug Exclustions and Limitations.

Dental Benefits


Calendar Year Deductible

$50 per person

Type of Services


                Preventive Services


                Basic Services


                Major Services


                Dental Anesthesia Services


Calendar Year Maximum Dental Benefits

$1,500 per person (No Maximum for children up to age 19 for pediatric preventive care and screenings)


Optical (Vision) Benefits


Lenses, Frames and Eye Examinations

Up to $425 per person (for PPO services) during a consecutive two-year period. (No maximum for children up to age 19 for pediatric preventive care and screenings.) The EyeMed program provides additional benefits.

Hearing Aid Benefit


Hearing Aid

Hearing Exam

$1,250 maximum per device

Up to $150 per exam once per calendar year for Members and each Dependent




[1]      If you were covered under the Active Plan immediately prior to being covered under this Plan, your eligibility for the Plan’s Death Benefit and Dismemberment and Accidental Death Benefit will continue for six (6) consecutive months after the effective date of your retirement.