BENEFIT

BENEFIT AMOUNT OR BENEFIT LIMITATION

BENEFITS FOR ACTIVE EMPLOYEES ONLY

Life Insurance Benefit

$10,000

Accidental Death and Dismemberment Insurance Benefit

Maximum of $10,000

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

$200 per Week for a Maximum of 13 Weeks

Benefits Begin On

First Day of an Accident and Eighth Day of a Sickness Disabilities 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 Deductible

The 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 Family

Three Individual Deductibles

Calendar Year Out-of-Pocket Maximum (including Deductible)

In-Network

Out-of-Network

Per Individual

$2,300

$4,300

Per Family

$6,900

$12,900

BENEFIT

BENEFIT AMOUNT OR BENEFIT LIMITATION

Limitations

The 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 Copayment;
4. Vision Care or Dental Care expenses; or
5. Expenses incurred as a result of a noncompliance penalty.

Benefit Maximums

Per Person

Calendar Year Maximum

Unlimited for all Essential Health Benefits, as defined by the Affordable Care Act

Transplant Expense Maximum

$500,000 per Transplant

Chiropractic Care/Massage Therapy

Up to $50 per visit

Rehabilitation Therapy

A 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 Calendar Year must be pre-certified.

Home Health Care

Each 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.

Per Visit

$40

Benefit:

PPO Provider

Non-PPO Provider

Hospital and PhysicianBenefits(1)

The Plan pays 80% of Covered Charges, after the Deductible

The Plan pays 60% of Reasonable and Customary Expenses, after Deductible

Emergency RoomCopayment(1)

(Copayment does not apply to Outof 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 exam

60% of Reasonable and Customary Expenses, after the Deductible

BENEFIT

BENEFIT AMOUNT OR BENEFIT LIMITATION

Treatment of Mental and Nervous Disorders and Substance Abuse

PPO Provider

Non-PPO Provider

Inpatient Treatment(1)

The Plan pays 80% of Covered Charges, after the Deductible

The Plan pays 60% of Reasonable and Customary Expenses, after the Deductible

Outpatient Treatment(1) Provider Office Visits

You pay a $5 copayment

The Plan pays 60% of Reasonable and Customary Expenses, after Deductible

Provider Facilities

The Plan pays 80% of Covered Charges, after the Deductible

The Plan pays 60% of Reasonable and Customary Expenses, after Deductible

Precertification Requirement

You must pre-certify any hospital stay, certain outpatient procedures, and rehabilitation therapy visits in excess of 8 visits per calendar year by calling Utilization Review at the number listed in the “Contact Information” page.

Benefit Reduction for Failure to Precertify Services

$200

$200

In Vitro Fertilization

The Plan pays 50% up to the Lifetime Maximum per Person

Lifetime Maximum

$15,000 per Person

Transplant Benefits(1)

Blue Distinction Center
for Transplants® Provider

The Plan pays 90% of $10,000, after the Deductible, 100% thereafter

PPO or Non-PPO Provider

The Plan pays 70% of $10,000, after the Deductible, 100% thereafter

Per Transplant Maximum

$500,000 per Person per Transplant

(1) The percentage coinsurance for PPO Provider services is paid at the percentage shown of the first $10,000 of the PPO negotiated fee after the deductible, then at 100%, up to any applicable maximums. Non-PPO Provider services are paid at the percentage shown of the first $10,000 of Reasonable and Customary expenses after the deductible, then at 100%, up to any applicable maximums. Non-PPO providers may balance bill members.

Prescription Drug Benefits (In-Network Only)

Retail Card Program

Mail Service Program

Copayment
Brand Name
Medication
Generic Medication

$20$10

$40$20

Amount of Supply

30-Day Supply

90-Day Supply

Specialty Drugs

$20 Copayment for up to a 30-day supply in-network only

If you choose a brand name drug

You 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

$200 (The Calendar Year Maximum does not apply to individuals under the age of 18)

Under Age 18 Limits:

Vision Exam

Limited to one (1) vision examination per calendar year

Frames

$100 per prescription (not to exceed one pair of frames per calendar year)

Lenses

$100 per prescription

Contacts (in lieu of frames or lenses)

$200 per prescription

Dental Care Expense Benefit

Calendar Year Maximum

$500 (Calendar Year Maximum does not apply to preventive care for individuals under age 18)

Laborers