Comprehensive Medical Benefits

Benefit Amount/Special Limitations

Basic Medical Benefit

$10,000 per person per calendar year (100% covered for eligible expenses)

Annual Deductible

After the Plan pays the first $10,000 of medical expenses, you must pay:
$200 per person per calendar year
$400 per family per calendar year

Coinsurance

After you pay your annual deductible, the Plan pays the applicable Coinsurance rate of the next $7,500 per person of eligible expenses each calendar year; the Plan then pays 100% of additional expenses up to the lifetime maximum

Medical Coinsurance
Network Provider
Non-Network Provider

Plan pays:
90% of covered expenses
80% of covered expenses

Plan Year Maximum

Unlimited

Chiropractic and Spinal Manipulation Annual Maximum

$4,000 per person per calendar year

Home Health Care Services and Skilled Nursing Facility Services Annual Maximum

180 days per calendar year

Infertility Treatment Lifetime Maximum

$25,000 per person (Member and Spouse Only)

Hospice

Subject to deductible and co-insurance:
365 days per lifetime

Prosthetic Devices - Member Only

Plan pays covered expenses up to $25,000 once every 5 years, subject to deductible and co-insurance

Prosthetic Devices - Dependents over age 12

Plan pays covered expenses up to $25,000 once every 5 years, subject to deductible and co-insurance

Prosthetic Devices - Dependents under age 12

Plan pays covered expenses up to $25,000 once every 2 years, subject to deductible and co-insurance

Speech Therapy for Dependents

Plan pays covered expenses for speech therapy for dependent children before 5th birthday and therapy for special diagnosis before 9th birthday subject to any applicable deductible and co-insurance

Transplants

Contact Fund Office to determine coverage

Additional Medical Coverage

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

Diabetes Education

Plan pays 100% of covered expenses

Smoking Cessation Lifetime Benefit

Plan pays 100% of covered expenses up to $1000 (Member and Spouse only) for medical expenses. Medications requiring a prescription are covered under Prescription Drug Benefit.

Nebulizer

Plan pays 100% of covered expenses once every three calendar years

Hearing Aids

Plan pays 100% of covered expenses up to $1,500 every three calendar years per person

Wellness Benefits for Dependents

Plan pays 100% of covered expenses

Wellness Benefits for Members and Spouses

Plan pays 100% of covered expenses

Colonoscopy or Flexible Sigmoidoscopy

Plan pays 100% of covered expenses once every five years per person

Contraceptives (Member and Spouse Only)

Covered the same as any other illness.

Prescription Drug Benefits (Caremark Inc.)

Benefit Amount/Special Limits

Basic Prescription Drug Benefit

$5,000 per person per calendar year (100% covered for eligible expenses) after you pay the copay¹ for each prescription filled. Copays vary depending on the number of days supply the prescription covers.

                                                    30-day      90-day
Generic Drug                                 $5.00        $12.50
Preferred Brand Name Drug            $10.00      $25.00
Non-Preferred Brand Name Drug     $25.00      $62.50

Coinsurance²

After the Plan pays the first $5,000 of prescription drug expenses, the Plan pays 80% of eligible expenses for the remainder of the calendar year up to the lifetime maximum.

¹ You can submit a claim to the Fund Office to have your copay reimbursed to you. When the first $5,000 of annual prescription expenses payable at 100% has been reached, your copays are no longer eligible for reimbursement.

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 basic Prescription Drug Benefit.

Specialty Drug Benefits

Benefit Amount/Special Limits

Coinsurance - In Network

Claimaint 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 plays 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.

Dental Benefits (Delta Dental)

Network Providers

Non-Network Providers

Non-Orthodontic Benefits Calendar Year Maximum

$2,000 per person³

$2,000 per person³

Basic Care (exams, X-rays, cleaning)

100% Covered

100% Covered¹

Fillings

100% Covered

70% Covered¹

Root Canals, Dental Surgery

100% Covered

70% 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%
$3,957.89 per person

Plan pays 100%

$1,000 per person

Delta Dental has two PPO networks, Delta Dental PPO and Delta Dental Premier. To receive the most benefits and the highest level of discounts, your Provider must participate in the Delta Dental PPO network. While you will receive a discount if you go to a Delta Dental Premier dentist, your benefits will be paid at the NON-Network Providers level.

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 calendar year maximum for non-orthodontic benefits does not apply to children ages 17 or younger.

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

$150 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.

Weekly Income Benefits

Members Only

Weekly Income Benefit Maximum
Non-Occupational Injury or Illness
Occupational Injury or Illness

$450 per week
$25 per week

Benefits Begin

On the first day you are unable to work due to an injury;
On the eighth day after you are unable to work due to an illness; or
On the eighth day after your Physician’s first treatment for an illness

Weekly Income Benefit Maximum Period

26 weeks

Extended Weekly Income Benefit
(Non-Occupational Only)

Up to 26 additional weeks per person per lifetime (certain restrictions apply)

Death Benefits

Benefit Amount

Your Death

$50,000 (payable to your beneficiary)

Death of Your Spouse or Child (6 months old or older)

$10,000 (payable to you)

Death of Your Child (less than 6 months old)

$200 (payable to you)

Accidental Dismemberment Benefits

Member

Dependent

For one hand, one foot, or sight of one eye

$11,000

$3,750

For one hand and one foot, one hand and sight in one eye, or one foot and sight in one eye

$22,000

$7,500

For both hands, both feet, or sight in both eyes

$22,000

$7,500

Health Reimbursement Arrangement (HRA) Program (PDF brochure)

Members Only

HRA Calendar Year Maximum

$1,500 each calendar year