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 in addition to annual deductible |
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% |
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 |
$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 |
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