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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

$300 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.

Wellness Expense Benefit (Employee and Spouse Only)

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

Unlimited 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[1]

Hospital and Ambulatory Surgical Facilities[2]

                PPO Facilities

                Non-PPO Facilities

 

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


 

 

[1]      The Out-of-Pocket Maximum is also applicable to In-Network Inpatient and Outpatient Mental Health and Substance Abuse Benefits. 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.

[2]      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 Cross Blue Shield MSA for prior approval or within two days of an emergency admission, 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
Substance Abuse Employee Assistance Program

Telephone Counseling and Referral Program

No charge
 
 

 

 

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

$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 in Mail Order Prescription Drug Service and Prescription Drug Exclusions and Limitations.

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

$1,750 per person (No Maximum for children up to age 19 for pediatric preventive care and screenings)

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 $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.