| Benefits
for Employees Only |
| Life
Insurance |
$20,000 |
| Accidental
Death And Dismemberment (AD&D) Insurance |
$20,000 |
Loss of
Time Benefit |
| Maximum
period that benefits are payable per sickness/injury |
26 weeks |
| Day
of disability that benefits start: |
| Disabilities
due to Accidental injury |
1st
day |
| Disabilities
due to sickness: |
|
| Outpatient
surgery |
1st
day |
| Not
hospital confined |
8th
day |
| Hospital
Confined |
1st
day of confinement before 8th day |
|
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|
| Benefits
For Retirees Only |
| Retiree
Life Insurance |
$5,000 |
|
Benefits
For Employees, Retirees, and Their Dependents
|
|
Supplemental
Accident Expense Benefit
|
| Maximum benefit payable per
person per accident for covered expenses incurred within 90 days of the
accident |
$250 |
| Plan
co-pay percentage (no deductible applies) |
100% |
| (Excess covered expenses are considered for
payment under the Comprehensive Benefit, subject to the deductibles,
co-pay percentage, out-of--pocket limits, etc.)
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|
|
Routine Physical Examination Expense Benefit
|
| Maximum
benefit payable per person per employee, retiree or dependent spouse for
covered expenses incurred for routine examinations and preventative
services |
$300 |
| Plan
co-pay percentage (no deductible applies) |
100% |
|
Well-Child
Care for Dependent Children--the
Plan will pay 100% (no deductible) up to the following
maximums:
- $1,000 first year of life - child's birth
through day before child's 1st birthday.
- $300 second year of life - child's 1st birthday
through day before child's 2nd birthday.
- $300 third year of life - child's 2nd birthday
through day before child's 3rd birthday.
- $300 fourth year of life - child's 3rd birthday
through day before child's 4th birthday.
- $300 fifth year of life - child's 4th birthday
through day before child's 5th birthday.
- $600 for the period from the child's fifth
birthday through day before child's 13th birthday.
- $600 for the period from the child's 13th
birthday through day before child's 19th
birthday.
These maximum benefits will apply to all covered well-child
care expenses - exams, immunizations and inoculations.
Amounts paid under the prior well-child care benefits will apply
to the new maximums shown above.
Excess charges will carry over to major medical -
Covered expenses incurred on and after January 1, 2008 that are
in excess of the maximums listed above WILL carry over to
the major medical benefit (the "Comprehensive Benefit") and be
paid subject to the deductible and co-payment provisions.
As with other covered expenses, the Plan pays higher benefits
when you use physicians in the Blue Cross PPO Network.
Only charges incurred on and after January 1, 2008 are
eligible for the increased benefits. No additional
benefits are payable for claims incurred prior to that date.
There
is
not a
Routine Physical Examinations Benefit for Dependent Children
over the age of 19.
|
| Plan
co-pay percentage (no deductible applies) |
100% |
|
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|
|
Hearing Care Expense Benefit |
| Maximum benefit
payable per person for covered expenses incurred for hearing care |
$1,500 each ear
every 5 years |
| Plan
co-pay percentage (no deductible applies) |
80% |
|
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|
|
(Excess charges do not carry over to the
Comprehensive Benefit) |
|
Chiropractic Care Expense Benefit |
| Calendar year
maximum benefit payable per person for diagnostic x-rays |
$100 |
| Calendar year
maximum benefit payable per person for all chiropractic treatment,
including up to $100 for x-rays |
$750 |
| Maximum benefit
payable per visit |
$35 |
| Plan
co-pay percentage (no deductible applies) |
100% |
|
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|
(Excess charges do not carry over to the
Comprehensive Benefit) |
|
Comprehensive Medical Expense Benefit
(Comprehensive Benefit) |
- Only the "covered medical expenses" listed on
pages 63-66 will be considered for payment under the Comprehensive
Benefit. Only covered medical expenses can be used to satisfy
deductibles. Only a person's out-of-pocket payments for his co-pay
percentage share of covered medical expenses count toward
out-of-pocket limits. You are responsible for paying all amounts of
charges incurred by you and your dependents that are not considered
medical expenses.
- If non-emergency care is received from a non-PPO provider (hospital
or doctor) and there is no equivalent (same medical specialty) PPO
provider within 10 miles of the non-PPO provider, benefits will be
paid for the non-PPO covered medical expenses as though a PPO provider
had been used.
- Only excess covered expenses incurred under the Supplemental
Accident Expense Benefit and the Routine Physical Examination Expense
Benefit (except well child care) carry over for consideration for
payment under the Comprehensive Benefit. Excess charges incurred under
any of the other health care benefits do not carry over for
payment under the Comprehensive Benefit.
- Payments under this benefit are based only on the amounts of charges
that are considered to be reasonable and customary (R&C) charges (see
page 23).
|
| Lifetime Maximum
Benefit Payable per Person |
$2,000,000 |
| Calendar Year
Maximum Benefit Payable per Person |
$500,000 |
| Deductibles |
| Chemical
dependency deductible per person per calendar year for covered
expenses incurred for chemical dependency treatment. |
$200 |
| (This deductible is in addition to the
calendar year individual deductible and does not apply toward satisfaction
of the family deductible) |
| Calendar year deductibles (amounts of
covered medical expenses applied to PPO deductibles also apply to non-PPO
deductibles and vice versa) |
| PPO deductibles (applied to
covered medical expenses incurred from PPO providers): |
| Individual
deductible |
$200 |
| Family deductible
(satisfied by 2 or more family members) |
$600 |
| (These deductibles apply to covered medical
expenses incurred for prescription drugs, whether or not prescribed by a
PPO doctor) |
| Non- PPO deductibles (applied to covered
medical expenses incurred from non-PPO providers and other non-doctor and
non-hospital providers): |
| Individual
deductible |
$300 |
| Family deductible
(satisfied by 2 or more family members) |
$900 |
Plan Co-Pay/Payment
Percentages subject to all maximum benefits and other stated
limitations (see "Special Limitations" starting on page 15
for exceptions and additional limitations).
- The 80% co-payment shown below does not apply to chemical
dependency or mental/nervous disorders expenses ("Special
Limitations"), and the Plan will not at any time pay 100%
for those types of expenses.
- Amounts of out-of-pocket payments applied toward meeting PPO
out-of-pocket limits will also apply toward meeting the non-PPO
out-of-pocket limits and vice versa.
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|
| Payments for PPO
covered medical expenses during a calendar year: |
| Plan co-pay percentage
per person per family for covered medical expenses incurred during a year
from PPO providers and for prescription drugs after
satisfaction of the PPO individual/family incentive deductible UNTIL
the person/family has met the PPO individual/family out-of-pocket limit. |
80% |
| Plan payment percentage
per person per family for covered medical expenses incurred during a year
from PPO providers and for prescription drugs after satisfaction of
the PPO individual/family incentive deductible AFTER the
person/family has met the PPO individual/family out-of-pocket limit. |
80% |
| Payments for
non-PPO
covered medical expenses during a calendar year: |
| Plan co-pay percentage
per person per family for covered medical expenses incurred during a year
from non-PPO providers and other non-doctor/non-hospital service
providers after satisfaction of the non-PPO individual/family
incentive deductible UNTIL the person/family has met the non-PPO individual/family out-of-pocket limit. |
60% |
| Plan payment
percentage per person per family for covered medical expenses incurred
during a year from non-PPO providers and other non-doctor/non-hospital
service providers after satisfaction of the non-PPO
individual/family incentive deductible AFTER the
person/family has met the non-PPO individual/family out-of-pocket limit. |
100% |
Out-Of
Pocket Limits per Calendar Year after satisfaction of applicable
deductibles.
- Out-of-pocket limits do not include out-of-pocket payments made
to satisfy deductibles or made as a person's co-pay share of
covered medical expenses incurred for chemical dependency or
mental/nervous disorders. (See pages 59-61 for more details).
- Amounts of out-of-pocket payments applied toward meeting PPO
out-of-pocket limits will also apply to the non-PPO out-of-pocket
limits and vice versa.
|
| PPO out-of-pocket
limits: |
| Individual
out-of-pocket limit |
$1,500 |
| Family out-of-pocket
limit (met by 3 or more family members) |
$3,000 |
| Non-PPO
out-of-pocket limits: |
| Individual
out-of-pocket limit |
$3,000 |
| Family out-of-pocket
limit (met by 3 or more family members) |
$4,000 |
|
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| Special Limitations |
| Hospital Room and
Board allowable covered medical expenses: |
| Semi-private or
private room |
Semi-private room rate |
| Intensive Care
Units, Cardiac Care Units, etc. |
Hospital's R&C
charge |
|
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| Treatment of Mental
or Nervous Disorders*:
*Out-of-pocket payments made for a person's co-pay share of expenses
for treatment for these conditions do not apply to any out-of-pocket
limits, and the Plan will not at any time pay 100% for these types of
treatment. |
| Lifetime maximum
allowable number of days pf inpatient hospital treatment per person,
including days of partial hospitalization and day care (intensive
outpatient treatment) |
up to 31 days |
| Calendar year maximum
allowable number of regular outpatient visits per person |
up to 25 visits |
| Maximum allowable
covered expense per visit for regular outpatient visits 11-25 during
a calendar year.
(Benefits which apply to these maximums also apply to the person's
$1,000,000 Comprehensive Benefit lifetime maximum benefit.) |
$50 |
| Plan co-payment
percentages: |
| Inpatient treatment |
80% |
| Regular outpatient
visits: |
| Visits 1 through 10 per
calendar year |
80% |
| Visits 11 through 25
per calendar year |
50% |
|
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| Treatment for
Chemical Dependency*
*Out-of-pocket payments made for a person's co-pay share of expenses
for treatment for these conditions do not apply to any out-of-pocket
limits, and the Plan will not at any time pay 100% for these types of
treatment. |
| Chemical dependency
deductible per person per calendar year |
$200 |
| Lifetime maximum
benefit per person
(Benefits which apply to these maximums also apply to the person's
$1,000,000 Comprehensive Benefit lifetime maximum benefit.) |
up to $15,000
and/or (3) three courses of treatment
|
| Calendar year maximum
allowable days of inpatient and outpatient treatment combined per person |
up to 30 days |
| Plan co-pay percentage
for all inpatient and outpatient treatment |
80% |
|
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| Treatment of
Learning or Behavior Disorders*
(For benefit purposes, the term "learning or behavior
disorders" includes learning disabilities, autism, hyperkinetic
syndromes and developmental conduct or behavioral disorders.)
*Out-of-pocket payments made for a person's co-pay share of expenses
for treatment for these conditions do not apply to any out-of-pocket
limits, and the Plan will not at any time pay 100% for these types of
treatment. |
| Lifetime maximum
benefit per person |
up to $15,000 |
| Calendar year maximum
benefit per person |
up to $3,000 |
| Plan co-pay percentage |
80% |
|
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| Orthotics
-Lifetime maximum benefit payable per person for covered medical expenses
incurred for foot orthotics |
$1,000 |
|
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| Maximum benefits
payable for organ/tissue transplants: |
Covered
Transplant Procedure |
Transplant
Maximum Benefit* |
Follow-up
Maximum Benefit* |
| Heart |
$100,000 |
$15,000 |
| Heart/Lung |
$250,000 |
$20,000 |
| Lung |
$150,000 |
$20,000 |
| Liver |
$125,000 |
$15,000 |
| Pancreas |
$125,000 |
$15,000 |
| Kidney |
$50,000
|
$10,000
|
| Bone Marrow |
$150,000
|
$10,000
|
| Cornea |
$10,000
|
No further coverage
|
| Effective July 1, 2002, the
transplant maximum benefits will not apply when the covered person
contacts and follows the advice of the case management organization. Call
the Fund Office at (630) 978-4600 if you need a transplant. The fund
office will put you in touch with the case management organization who
will work with you, your doctor an the hospital to make sure you receive
effective, quality care.
If you do not call the Fund Office (and then the case manager), or if
you choose not to have your transplant managed by the case management
organization, the maximum benefits shown on page 16 of your SPD will still
apply. (Prescription drugs do not apply to the transplant maximums).
Effective with claims incurred on and after January 17,2001, the second
set of maximums (for follow-up care) will not be subject to the 12-month
time limit. In other words, a transplant recipient may receive benefits
for medically necessary follow-up treatment for an unlimited period of
time after his surgery - as long as he remains eligible and has not
reached the applicable maximum benefit.
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| Infertility |
| CHANGES
TO INFERTILITY BENEFITS |
| $40,000
Lifetime Maximum -The scheduled limits on the numbers of infertility
treatments of infertility treatments covered by
the Plan have been replaced by a $40,000 maximum. This is the most the
Plan will pay for all covered
treatment received by an
eligible employee and his spouse combined during the employee's lifetime.
It applies to all diagnostic procedures and all treatments, including
prescription drugs and surgery. It will not be reinstated if you divorce
and remarry. |
| How
Benefits Will be Paid -Covered infertility expenses in excess of your
calendar year deductible will be paid at 80% up to the $40,000 maximum.
Your 20% co-payments will not apply to the out-of-pocket limit, and the
Plan will not pay 100% for infertility expenses if your out-of-pocket
limit has been met by other claims. |
| Covered
Expenses -The types of covered infertility expenses are not changing.
As before, the Plan covers reasonable and customary charges for: |
- Office visits and consultations
- Hormone Treatments (prescription)
- Surgery
- Gamete intrafallopian transfer (GIFT)
- Intracytoplasmic sperm injection (ICSI)
- Diagnostic tests
- Intrauterine insemination (IUI)
- In Vitro fertilization (IVF)
- Zygote intrafallopian transfer (ZIFT)
|
| Exclusions
-Except for the removal of the frequency limits and the $40,000
maximum, the same limitations, provisions and exclusions will continue to
apply. As before, infertility benefits will be provided for active
employees and their spouses ONLY. No benefits are payable for children, or
retirees and their spouses.
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|
| Effective
date of change – This change was made effective November 1, 2003,
but it applies to charges incurred prior to November 1, 2003. |
|
Prescription
Drug Mail Order Pharmacy Program |
| Plan
payment percentage
for up to a 90-day supply of a covered prescription drug: |
| Generic
equivalent drugs per prescription or refill |
100% after your
$15 co-payment |
| Brand
Name drugs per prescription or refill |
100% after your
$30 co-payment |
How to use the Caremark
Prescription Drug Program (Retail)
- You will be required to pay $5 minimum / 10% of the contracted price to
the participating pharmacy. Contracted prices are usually lower than
the pharmacy's regular retail prices. The Plan will pay the rest.
- For each purchase you make, you will be able to get up to a 30-day
quantity, or the quantity prescribed by the doctor, whichever is less.
- There are no claims to file
- You can use your I.D. card to get the amount of medication
prescribed by your doctor plus 2 refills. After you purchase the
initial supply plus 2 refills if a maintenance drug, you must
use the Mail Order Program for all additional refills. If a doctor
prescribes a drug that must be taken on a long-term basis, ask the
doctor for two prescriptions- one for 30 day supply that you can have
filled immediately at a local participating pharmacy under the Drug
Card Program, and one for up to a 90-day supply (with refills) that
you can obtain through the Mail Order Program.
- Your $5 minimum / 10% co-pay amounts do not apply any Plan deductibles or
out-of-pocket limits.
If you use a non-participating pharmacy- If you purchase a
covered prescription drug at a pharmacy that is NOT in the Caremark
network, you will need to file a claim with the Fund Office for partial
reimbursement under the Comprehensive Benefit.
- The amount you paid the
non-participating pharmacy will be reduced by 50% and the remaining
balance will be paid at 80% (provided your $200 calendar year
deductible has been satisfied).
- Neither the 50% reduction nor your 20% co-pay will apply to any Plan
deductibles or out-of-pocket limits.
- The 50% reduction will not apply if live more than 15 miles from a
participating pharmacy- be sure to note this information on your
claim.
Exclusions and Limitations - You cannot use the Prescription
Drug Card Program for:
- any products, drugs or medications which can be obtained without a
doctor's written prescription
- experimental or investigative drugs or medications
- drugs or medications which are used for or in connection with any
type of treatment or condition for which benefits are excluded under
the Plan, even though such drugs or medications are obtained with a
doctor's prescription
- drugs or medications that are excluded from coverage under any other
provision or rule of this Plan, including but not limited to the
provisions of "What the Plan Does Not Cover" starting on
page 78 of your SPD.
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|
Ph (630) 978-4600