Retiree Plan 1 - Benefit Summary
Comprehensive Medical Benefits |
Benefit Amount/Special Limitations |
Annual Deductible |
No deductible after June 1, 2007 |
Emergency Room Deductible |
$50 per visit |
Coinsurance |
The Plan pays: |
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) |
Plan pays: |
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 |
|
Nebulizers |
Plan pays covered expenses once every 3 years per person |
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 |
$3,200 per person per year |
Hospitalizations Hospital Services |
Covered up to 120 days per incident $3,000 |
Emergency Room Treatment |
After a $50 deductible per incident, the Retiree Basic Medical Coverage Plan pays: |
Ambulance |
$50 per trip up to a maximum of 2 trips per incident |
Additional Accident Benefit |
$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 Dependents |
Plan pays 100% of covered expenses |
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 |
|
1 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. |
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 |
You pay: |
|
Orthodontic Benefits |
You pay the first $242.11; then Plan pays 100% |
Plan pays 100% |
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 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) |
|
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. |
Death Benefits |
Benefit Amount |
Your Death (payable to your beneficiary) |
$10,000 effective 06-01-2024 |
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