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

$300 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

The Plan pays 80% for in-network providers and 60% for out-of-network providers 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 Injury or Illness must be precertified.

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. 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 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

Virtual Consultations with MDLIVE

The Plan pays 100% and you do not pay a Deductible or copayment for using BCBSIL’s MDLIVE program see item 34 of Covered Charges section—Major Medical Expense Benefit for additional information)

Not applicable

Other Virtual Consultations (NOT with MDLIVE)

The Plan pays the amount that would be payable for an in-person visit

The Plan pays the amount that would be payable for an in-person visit

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; effective January 1, 2020 – $750 (Calendar Year Maximum does not apply to preventive care for individuals under age 18)

Orthodontic Limit for Individuals Under Age 18

$250 per total course of treatment – effective January 1, 2020 – $500 per total course of treatment