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One of the following schedules is your Schedule of Benefits, depending on whether you are eligible for Medicare. You will find details about the benefits listed in these Schedules in the sections that follow.

Schedule of Benefits for Non-Medicare Eligible Retirees

Benefit

Amount

Death Benefit (Retiree Only) [1]

$15,000

Accidental Death and Dismemberment Benefit (Retiree Only) 1

For Your Death

$15,000

For Two Dismemberments

$15,000

For One Dismemberment

$7,500

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.

Medical Benefit (Retiree and Dependents)

 

Deductible: Individual/Family (not included in your Out-of-Pocket Maximum)

$350/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
                PPO Provider
                Non-PPO Provider


$2,000 per person each calendar year after Deductible is satisfied
Not applicable[2]

Hospital and Ambulatory Surgical Facilities
                PPO Facilities
                Non-PPO Facilities

Subject to Pre-Admission Authorization

 

80%

70% of the Reasonable and Customary 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 Reasonable and Customary Charge

Chiropractic Services

                PPO Providers

                Non-PPO Providers

                Calendar Year Maximum per Person

 

85%

70% of the Reasonable and Customary Charge

Up to 20 visits annually

Mental Health Treatment

Inpatient

                PPO Facility

                Non-PPO Facility

Outpatient

                PPO Physician

                Non-PPO Physician

 

 

80%

70% of the Reasonable and Customary Charge

 

85%

70%

Substance Abuse Treatment

 

Inpatient

                PPO Facility
                Non-PPO Facility

Outpatient

               PPO Physician

               Non-PPO Physician

 

 

80%
70% of the Reasonable and Customary Charge

 

 

85%

70%

Infertility Treatment Benefits

Coinsurance

Diagnosis and Treatment of Infertility

Treatments to Promote Conception

 

50% of covered expenses

No Maximum

$20,000 (Combined Lifetime Maximum for You and Your Spouse)

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

 Up to 16 days for in-patient services; 80 days for outpatient services

 

 

 

 

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)

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

$50

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 in Prescription Drug Exclusions and Limitations.

Dental Benefits

Amount

Calendar Year Deductible

$50 per person

Type of Services

 

                Preventive Services

45%

                Basic Services

40%

                Major Services

25%

                Dental Anesthesia Services

25%

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

Amount

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

Amount

Hearing Aid

$1,250 maximum per device

Hearing Exam

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.

[2]      The Out-of-Pocket Maximum is also applicable to In-Network both Inpatient and Outpatient services for Mental Health and Substance Abuse.The Out-of-Pocket Maximum is not applicable for covered expenses received at non-PPO Hospitals or non-PPO Ambulatory Surgical Facilities, for services received from a Non-PPO Physician, treatment of infertility, or for non-covered expenses.