BenefitBenefit Amount or Benefit Limitation
Benefits for Active Employees Only
Life Insurance Benefit$20,000
Accidental Death and Dismemberment Insurance BenefitMaximum of $20,000
This Plan provides life and accidental death & dismemberment insurance to Active Employees through a separate insurance policy.  The benefits are described in a separate booklet, which may be obtained through the Fund Office. 
Short‑Term Disability Benefit$300 per Week for a Maximum of 13 Weeks
Benefits Begin OnFirst Day of an Accident and Eighth Day of a SicknessDisabilities will not be considered as beginning more than three days before your first visit to a Physician for treatment of your disability.
Benefits for Active/Retired Employees and Their Eligible Dependents
Calendar Year DeductibleThe Deductible does not apply to charges made by a Preferred Provider Physician for an office visit.  You pay a $20 copayment ($5 for treatment of a Mental and Nervous Disorder or Substance Abuse) per office visit directly to the Physician.  Neither the $20 or $5 office visit copayment nor the remainder of the Physician fees paid by the Plan counts towards your Deductible.
Per Individual$300
Per FamilyThree Individual Deductibles
Calendar Year Out‑of‑Pocket Maximum (including Deductible)In-NetworkOut‑of‑Network
Per Individual$2,300$4,300
Per Family$6,900$12,900
LimitationsThe Calendar Year out‑of‑pocket maximum does not include:1. Copayments you make for Physician office visits;2. Copayments under the Prescription Drug Program;3. Emergency Room/IFED Copayment;4. Vision Care or Dental Care expenses; or5. Expenses incurred as a result of a noncompliance penalty.
Benefit MaximumsPer Person
Calendar Year MaximumUnlimited for all Essential Health Benefits, as defined by the Affordable Care Act
Transplant Expense Maximum$500,000 per Transplant
Chiropractic Care/Massage TherapyThe Plan pays 80% for in‑network providers and 60% for out‑of‑network providers up to $50 per visit
Rehabilitation TherapyA combined limit of 50 visits per calendar year for all inpatient/outpatient: physical, occupational, and speech therapies.  Visits for all therapies combined over 8 visits per Injury or Illness must be pre-certified with Telligen at the number listed in the “Contact Information” page.
Home Health CareEach visit by a member of the home health team is considered one home health care visit.  Four hours of service from a home health aide is considered one home health care visit.  Visits under the Sav‑Rx M2P Program for the purpose of providing home infusion of prescription drugs shall not be subject to the $40 per visit cap.
Per Visit$40
Benefit:PPO ProviderNon‑PPO Provider
Note:  Members pay at the PPO cost-sharing level for Protected Services, Continuing Care Services, and Misidentified Provider Services.
Hospital and Physician Benefits(1)The Plan pays 80% of Covered Charges, after the DeductibleThe Plan pays 60% of  Reasonable and Customary Expenses, after Deductible
Emergency Room/IFED Copayment(1)(Copayment does not apply to Out of Pocket Maximum) $100 (Waived if admitted) then 80% of Covered Charges after the Deductible.$100 (Waived if admitted), then 60% of Reasonable and Customary Expenses after the Deductible.
Doctor’s Office Visits(1)You pay a $20 ($5 for treatment of a Mental and Nervous Disorder or Substance Abuse) copayment; no copayment if visit is for child wellness or adult annual physical exam60% of Reasonable and Customary Expenses, after the Deductible
Benefit:PPO ProviderNon‑PPO Provider
Virtual Consultations with TeladocThe Plan pays 100% and you do not pay a Deductible or copayment for using UHC’s Teladoc program (see item 34 of Covered Charges section—Major Medical Expense Benefit for additional information)Not applicable
Other Virtual Consultations (NOT with Teladoc)The Plan pays the amount that would be payable for an in-person visitThe Plan pays the amount that would be payable for an in-person visit
Treatment of Mental and Nervous Disorders and Substance AbusePPO ProviderNon-PPO Provider
Inpatient Treatment(1)The Plan pays 80% of Covered Charges, after the DeductibleThe Plan pays 60% of Reasonable and Customary Expenses, after the Deductible
Outpatient Treatment(1)Provider Office VisitsYou pay a $5 copaymentThe Plan pays 60% of Reasonable and Customary Expenses, after Deductible
Provider FacilitiesThe Plan pays 80% of Covered Charges, after the DeductibleThe Plan pays 60% of Reasonable and Customary Expenses, after Deductible
Precertification RequirementYou must precertify any hospital stay, any stay at a facility for treatment of mental and nervous disorders and/or substance abuse, any stay at a skilled nursing facility and certain outpatient procedures by contacting UnitedHealthcare Utilization Review at the number listed in the “Contact Information” page at the front of this booklet.You must precertify rehabilitation therapy visits in excess of 8 visits per Injury or Illness by contacting Telligen at the number listed in the “Contact Information” page at the front of this booklet.
Benefit Reduction for Failure to Precertify Services
(Benefit reduction does not apply to:  (i) charges for inpatient services and treatment at a PPO facility; or (ii) charges for outpatient surgery services at a PPO facility)		$200$200
In Vitro Fertilization and Fertility Treatments (see item 25 of the Covered Charges section for additional information regarding covered benefits)The Plan pays 50% up to the Lifetime Maximum per Person
     Lifetime Maximum$15,000 per Person
Transplant Benefits(1) 
OptumHealth Transplant Network ProviderThe Plan pays 90% of $10,000, after the Deductible,  100% thereafter
PPO or Non‑PPO ProviderThe Plan pays 70% of $10,000, after the Deductible,  100% thereafter
Per Transplant Maximum$500,000 per Person per Transplant 

(1) The amount payable by the Plan for PPO Provider services or Continuing Care Services furnished by a Non-PPO Provider, after the deductible is satisfied, is the applicable percentage of the first $10,000 of the PPO negotiated fee (and, if the PPO negotiated fee exceeds the billed charge, the Plan pays 100% of the difference between the billed charge and the PPO negotiated fee if the PPO contract with the provider requires payment of the higher amount), then at 100%, up to any applicable maximums.  The amount you owe for PPO Provider services or Continuing Care Services furnished by a Non-PPO Provider, after satisfying the deductible, is the applicable coinsurance percentage of the next $10,000 of the lesser of (a) the PPO negotiated fee, or (b) the billed charge.  Non-PPO Provider services, other than Protected Services and Continuing Care Services, are paid at the percentage shown of the first $10,000 of Reasonable and Customary Charges after the deductible, then at 100%, up to any applicable maximums.  Non-PPO providers may balance bill members for services other than Protected Services and Continuing Care Services.  The Amount payable by a member for Protected Services or Misidentified Provider Services by a Non-PPO Provider, after satisfying the deductible, is the applicable PPO coinsurance percentage of the next $10,000 of Reasonable and Customary Charges, determined in accordance with the No Surprises Act.  Amounts charged by Non-PPO Providers for Protected Services are subject to the negotiation and dispute resolution process provided for in the No Surprises Act and its implementing regulations.

Prescription Drug Benefits (In‑Network Only)Retail Card ProgramMail Service Program
Copayment  
Brand Name Medication$20$40
Generic Medication$10$20
Amount of Supply30‑Day Supply90‑Day Supply
Specialty Drugs$20 Copayment for up to a 30‑day supply in‑network only
Smoking Cessation Medications$20 Copayment for a 30‑day Brand Name supply and $10 Copayment for a 30‑day Generic supply, in‑network only (a maximum of two 90‑day courses of treatment will be covered each calendar year)
If you choose a brand name drugYou are responsible for the difference in cost between a brand name and a generic drug, unless your Physician indicates on the prescription “DAW” or “Dispense as Written.”
Vision Care Expense Benefit 
Calendar Year Maximum$400(The Calendar Year Maximum does not apply to individuals under the age of 18)
Annual vision examination (not subject to calendar year maximum)The Plan pays 100% of Covered Charges, limited to one (1) vision examination per calendar year.
Under Age 18 Limits: 
Vision ExamLimited to one (1) vision examination per calendar year
Frames$200 per prescription (not to exceed one pair of frames per calendar year)
Lenses$200 per prescription
Contacts (in lieu of frames or lenses)$400 per prescription
Dental Care Expense Benefit 
Calendar Year Maximum$750(Calendar Year Maximum does not apply to preventive care for individuals under age 18)
Orthodontic Limit for Individuals Under Age 18$500 per total course of treatment
Laborers