Benefit Summary - Retiree Plan 1

Comprehensive Medical Benefits

Benefit Amount/Special Limitations

Annual Deductible

No deductible after June 1, 2007

Emergency Room Deductible

$50 per visit in addition to annual deductible

Coinsurance
  PPO Network Provider
  Non-Network Provider

The Plan pays:
90% of eligible expenses
80% of eligible expenses1

Annual Out-of-Pocket Maximum

Once you pay $2,500 per person per calendar year, the Plan pays 100% of additional expenses up to your lifetime maximum

Plan Year Maximum

$2,000,000 per person

Substance Abuse Treatment (Includes Detoxification)
  PPO Network Provider
  Non-Network Provider
   

Plan pays:

90% of covered expenses
80% of covered expenses

Chiropractic and Spinal Manipulation Annual Maximum

30 visits per person per calendar year

Home Health Care Services and Skilled Nursing Facility Services Annual Maximum

180 days per calendar year

Mental or Nervous Treatment
 
PPO Network Provider
  Non-Network Provider


90% of covered expenses
80% of covered expenses

Nebulizers

Plan pays covered expenses once every 3 years per person

Suicide Attempt Expenses Maximum

One-time only benefit

Transplants

Contact Fund Office to determine coverage

Additional Medical Coverage

Amount Payable by the Retiree Basic Medical Coverage Plan

Outpatient doctor office visits (retiree only)

$10 per visit (maximum 50 visits per year)

Outpatient medical services
(hospital services and supplies received as outpatient, therapeutic treatments, laboratory tests and x-rays)

$3,200 per person per year

Hospitalizations
  Room and Board
  Intensive Care

  Hospital Services
  Doctor visits (retiree only)
  Surgery

Covered up to 120 days per incident
$200 per day
U&C Semi-private room rate

$3,000
$10 per visit, up to 1 visit per day
$750

Emergency Room Treatment

  For Accident

  For Illness

After a $50 deductible per incident, the Retiree Basic Medical Coverage Plan pays:
Up to $3,000 per person per year in combination with hospital services
Up to $3,200 per person per year in combination with outpatient medical services

Ambulance

$50 per trip up to a maximum of 2 trips per incident

Additional Accident Benefit
(for medical services needed as a result of an accident, you must be treated within 90 days of the accident)

$300 per person per incident

Additional Medical Coverage (continued)

The following Additional Medical Coverages are not subject to the Annual Deductible or Coinsurance provisions, except as noted.

Wellness Benefits for Members and Spouses

Plan pays 100% of covered expenses

Wellness Colonoscopy Benefit (Member and Spouses only)

Plan pays 100% of covered expenses once every 5 years

Smoking Cessation Lifetime Benefit

Plan pays 100% of covered expenses up to $1,000 (Member and Spouse only)

Diabetes Education

Plan pays covered expenses up to $400 per calendar year

Hearing Aids

Plan pays covered expenses up to $1,500 every three calendar years

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 Prescription Drug Benefits (Caremark Inc.)

Benefit Amount/Special Limits

Prescription Drug Benefits
 Caremark Network Pharmacy
 Non-Network Pharmacy


Plan pays 80% after your deductible
Plan pays 50%, (your 50% coinsurance does not apply toward your out-of-pocket maximum)

 1 The Prescription Drug Benefit annual deductible is separate from the Comprehensive Major Medical Benefit annual deductible.

 2 If you do not go to a participating Pharmacy or you do not show your ID card when you pick up your prescription, you will pay 50% of the cost for your prescription medication. This amount does not count toward your Prescription Drug Benefit annual deductible.

 

 Specialty Drug Benefits (Caremark Inc.)

Benefit Amount/Special Limits

Coinsurance – In Network

Claimant is required to pay 20% of the cost of specialty drugs up to a maximum of $1,000 out-of-pocket expense per person per year.   After the out-of-pocket maximum is reached, the Plan pays 100% for in network eligible expenses for the remainder of the calendar year up to the lifetime maximum.

Coinsurance– Out-of-Network

The Plan pays 50% for out-of-network eligible expenses up to the lifetime maximum. Claimant is allowed to fill a specialty drug prescription at a retail pharmacy ONE TIME ONLY.

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Dental Benefits (Delta Dental)

Network Providers

Non-Network Providers

Non-Orthodontic Benefits Calendar Year Maximum

$2,000 per person4

$2,000 per person4

Basic Care (exams, X-rays, cleaning)

100% Covered

100% Covered1

Fillings

100% Covered

70% Covered1

Root Canals, Dental Surgery

100% Covered

70% Covered1

Dental Implants

50% Covered

50% Covered1

Dentures2
Complete Upper
Complete Lower

You pay:
$88; then the Plan pays 100%
$88; then the Plan pays 100%


50% Covered1
50% Covered1

Orthodontic Benefits

Lifetime Maximum

You pay the first $242.11; then Plan pays 100%
$3,757.89 per person3

Plan pays 100%

$1,000 per person

1 For services from non-network Providers, the Plan pays this percentage of approved amounts. If your Provider charges more than the approved amount, you will have to pay the difference.

2 The copayments listed are for standard dentures. Partial dentures or special constructions may require a different amount.

3 The lifetime maximum for network orthodontic benefits increases each year; this is the current lifetime maximum. Contact Delta Dental of Illinois for any increases to this maximum.

4 The calendar year maximum for non-orthodontic benefits applies to children age 18 or older, spouses, and members. Dependent children under age 18 do not have a calendar year maximum for non-orthodontic benefits.

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Routine Vision Benefits (VSP)

Benefit Amount/Special Limits

Eye exams (includes refraction, limited to one exam per calendar year)
Standard eye exam
Contact lens exam



100%; one visit per year
100%; one visit per year

Lenses1
Single vision
Bifocal
Trifocal
No line Bifocal
No line Trifocal
Contact Lenses (for correction of vision)
Contact Lenses (after cataract Surgery)
Disposable Lenses2

One pair per calendar year
100%
100%
100%
100%
100%
100% up to $250
100%
100% up to $250

Frames Maximum

$75 per calendar year

1 If you go to a VSP Provider and select lenses from the network “collection,” even if these lenses cost more than the limits specified above, you will not be charged any additional amount. Non-network Provider charges will only be reimbursed up to the limits specified.

2 Disposable lenses are covered up to a maximum amount of $175.00 when received from a non-network Provider.

 

Death Benefits

Benefit Amount

Your Death (payable to your beneficiary)

$6,500 for retirement dates on or after 6-1-2002
$4,000 for retirement dates before 6-1-2002

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