Active Plan 1 - Benefit Summary
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: |
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 |
Plan pays: |
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: |
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 |
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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 |
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. |
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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 |
You pay: |
|
Orthodontic Benefits |
You pay the first $242.11; then Plan pays 100% |
Plan pays 100% |
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. |
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Routine Vision Benefits (VSP) |
Benefit Amount/Special Limits |
Eye exams (includes refraction, limited to one exam per calendar year) |
|
Lenses1 |
One pair per calendar year |
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 |
|
|
Benefits Begin |
On the first day you are unable to work due to an injury; |
|
Weekly Income Benefit Maximum Period |
26 weeks |
|
Extended Weekly Income Benefit |
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 |
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