Unless specified, the following benefits apply to Active Employees, Retirees and Dependents

Calendar Year Deductible / Out-Of-Pocket Maximum

PPO Providers

$300 Deductible per person up to $600 family maximum
$1,500 Out-Of-Pocket Maximum (excluding the deductible) per person

Non-PPO Providers

$400 Deductible per person up to $1,000 family maximum
$2,500 Out-Of-Pocket Maximum (excluding the deductible) per person
 

Annual Maximum For All Covered Expenses

Plan pays up to $300,000 per calendar year per person

Co-Payment

Self-Injectable Drugs (Subject to the Deductible, not subject to Out-Of-Pocket maximum)

Plan pays 50% of Reasonable and Customary Charges

All Other Covered Expenses

PPO Providers

Plan pays 90% of Reasonable and Customary Charges

Non-PPO Providers

Plan pays 80% of Reasonable and Customary Charges

Chiropractic Care

Not Subject to the Deductible or Out-Of-Pocket maximum)

Plan pays 100% up to $35 per visit

Annual Maximum

$1,500 per person

X-Ray Annual Maximum

$100 per person

Speech Therapy

Adult Restorative

Plan pays 80% of Reasonable and Customary Charges
Annual Maximum of $1,500 per person

Dependent Child

Plan pays 50% of Reasonable and Customary Charges
Annual Maximum of $500 per person

Mental Health

Mental and Nervous Disorders

Inpatient Treatment - 30 days per person

Outpatient Treatment is covered the same as all other Covered Expenses

Alcohol and Chemical Dependency

Inpatient Treatment - Annual Maximum of $6,000

Outpatient Treatment is not covered

Hearing Aid

For Hearing Loss Due to Accident Only

Hearing Exam (for placement and fitting) - $50
Hearing Aid - $600 per aid
Maximum Benefit - $1,200 during a consecutive 3-year period

Hospice Care

Lifetime Maximum

Plan pays 100% of Reasonable and Customary Charges
Annual Maximum of $10,000 per person

Bereavement Counseling for Immediate Family following the death of a terminally ill person

Plan pays 100% up to $50 per visit, up to six visits per hospice death

Durable Medical Equipment / Corrective Appliances

Plan pays up to $10,000 per person (per limb or device) during a consecutive three calendar year period

Corrective appliances are covered only when ordered by a Physician. Plan maximum also includes necessary supplies, repair and servicing for the appliance. Purchase of Durable Medical Equipment and the cost of maintenance agreements are covered only when the Plan determines that it is cost effective for the Plan. The amount of Plan benefits payable for the purchase of Durable Medical Equipment will be reduced by any benefits paid by the Plan for the rental of the equipment.

Organ Transplant

Center-Of-Excellence Network Facility

Plan pays 100% of Reasonable and Customary Charges

Non-Center-Of-Excellence Network Facility

Plan pays 80% of Reasonable and Customary Charges

Maximums

Annual Maximum is subject to Comprehensive Medical annual maximum

Lifetime Maximum is $500,000 for all transplants combined

Organ Procurement

Plan pays $15,000 per transplant, included in organ transplant lifetime maximum

Anti Rejection Medications:
Not covered after initial prescription

Brand Name Medication Co-Pay:
You pay 20% from a minimum of $20 up to a maximum of $100 per prescription

Generic Medication Co-Pay:
You pay 15% from a minimum of $10 up to a maximum of $100 per prescription

The Plan's annual out-of-pocket maximum does not apply to organ transplant benefits received from a non-Center of Excellence Facility. The amounts you pay for non-Center of Excellence facilities do not accumulate toward your annual out-of-pocket maximum.

Prescriptions

Retail Pharmacy (34 day supply)

Brand Name Medication Co-Pay:
You pay 20% from a minimum of $20 up to a maximum of $100 per prescription

Generic Medication Co-Pay:
You pay 15% from a minimum of $10 up to a maximum of $100 per prescription

Mail Order Program (90 Day Supply)

Brand Name Medication Co-Pay:
You pay 20% from a minimum of $20 up to a maximum of $100 per prescription

Generic Medication Co-Pay:
You pay 15% from a minimum of $10 up to a maximum of $100 per prescription

Dental Benefits
Active Employees and their Dependents only

Calendar Year Deductible

Individual:
$25 per calendar year

Family:
$75 per calendar year

Calendar Year Maximum

$1,750 per person per calendar year

Dental Services Co-Pay

Preventative Service (not subject to Deductible):
Plan pays 100%

Basic Services:
90%

Major Services:
50%

Orthodontic Services (only for dependent children under age 19):
50%

Orthodontic Services Lifetime Maximum:
$1,500

Vision Benefits
Active Employees and their Dependents only

Vision Care Services

Plan pays up to $300 per person per consecutive two calendar year period

Vision Surgical Correction Services (PRK or LASIK only)

Deductible:
$25 per eye

Plan Co-Payment:
Plan pays 100% of Reasonable and Customary Charges

Lifetime Maximum:
$1,600 per eye

Weekly Accident and Sickness
Active Employees only

Weekly Benefit Amount

$300 per week for up to 26 weeks per non-occupational disability
Beginning 1st day of an accident or 8th day of sickness

Death Benefit
Active Employees and Retirees only

Active Employee Benefit

$9,000

Retiree Benefit

$1,500

Accidental Death and Dismemberment (AD&D)
Active Employees only

Benefit

$9,000

Pension Plan

Benefit

The entire cost of the Pension Plan is paid by the participating employers who contribute to the Pension Fund in accordance with their collective bargaining agreements with the union. No contributions are required or permitted from the employee.

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