Health and Welfare

Summary Plan Description Table of Contents

  1. Important Contact Information
  2. Introduction
  3. Table of Contents
  4. Plan A Schedule of Benefits
  5. Plan B Schedule of Benefits
  6. Plan C Schedule of Benefits
  7. Plan 11 Schedule of Benefits
  8. Plan 11-C Schedule of Benefits
  9. Eligibility for Active Participants
  10. Eligibility for Retiree Coverage
  11. Insurance Coverage
  12. Weekly Loss of Time Benefit
  13. Medical Benefits
  14. Prescription Drug Program
  15. Medicare Part D Prescription Drug Plan (PDP) for Retirees
  16. Members Assistance Program (MAP)
  17. Dental Benefit
  18. Vision Benefit
  19. Hearing Benefit
  20. Special Fund Program
  21. General Plan Exclusions and Limitations
  22. Other Limitations on Your Benefits
  23. Definitions
  24. Claim and Appeal Procedures
  25. General Plan Provisions
  26. Information About the Plan
  27. Board of Trustees

Plan 11-C Schedule of Benefits

FOR ELIGIBLE PLAN 11 PARTICIPANTS AND DEPENDENTS WHO ARE NOT COMPLIANT WITH THE WELLNESS PROGRAM

INSURANCE BENEFITS
Life Insurance - Active participant

$10,000
Accidental Death/Dismemberment Insurance - Active participant under age 70

$10,000
PREVENTIVE BENEFIT

In-Network

Out-of-Network

Plan payment percentage for covered preventive services

(See list of preventive services starting on page 47.)

100%

50% after

deductible
MAJOR MEDICAL BENEFIT
Deductible per calendar year

Per person

$800

Per family

$1,600

Utilization review noncompliance penalty

(Inpatient confinements, including residential treatment facilities and skilled nursing facilities, and outpatient or inpatient surgery)

$100

In-Network

Out-of-Network
Plan payment percentages

70%

 50%
Out-of-pocket limits

Per person

 $4,000

$8,000

Per family

 $8,000

$16,000
(In- out-of-network limits must be met separately.)
SPECIAL BENEFITS AND LIMITATIONS
Chiropractic care

$1,000 per calendar year
Congenitally missing teeth - maximum benefit for treatment and/or replacement of congenitally missing teeth

$5,000 per lifetime
Emergency room (waived if visit meets definition of an “emergency,” or if admitted) $200 deductible per occurrence; calendar year deductible and coinsurance also apply
Foot orthotics

2 pairs every 3 calendar years
Home health care

100 visits per calendar year
Hospice care 180 days per lifetime
Absolute Solutions Blue Cross Blue Shield

Out-of-

Network
Imaging (MRIs, CT scans, PET scans)

100%

70%

 50%
no deductible

after deductible
Infertility treatment - Maximum benefit for participant and spouse (only)

$10,000 per lifetime
Obesity (non-surgical treatment) - participant & spouse (only) $1,000 per lifetime

Office visit with in-network (PPO) physician

(Deductible does not apply. Co-pay applies only to the charge for the visit itself. All other services subject to deductible and coinsurance.)

 100% after $25 copay
Out-of-network (non-PPO) surgical center not covered

Partial inpatient/intensive outpatient treatment for substance abuse and mental/nervous disorders

(Additional visits may be covered if pre-certified by the review organization.)

 12 visits per disability

Physical/occupational therapy

(Additional visits may be covered if pre-certified by the review organization.)

 12 visits per disability
Refractive surgery such as Lasik not covered
Residential treatment facility 45 days for all related confinements
Skilled nursing facility 45 days for all related confinements
Speech therapy for children under age 12 40 visits per calendar year
PRESCRIPTION DRUG BENEFIT
The following benefits do not apply to retirees and dependents enrolled in this Plan’s Medicare Part D plan. Participants in that plan will receive benefits information from UHC and Sav-Rx. Participant Pays
30-day retail

Generic drugs

 lesser of 20% or $5

Preferred brands

 20%

Non-preferred brands

 20%
90-day retail

Generic drugs

 lesser of 20% or $15

Preferred brands

 20%

Non-preferred brands

 20%
Mail-order

Generic drugs

 lesser of 20% or $10

Preferred brands

 20%

Non-preferred brands

 20%
  • Use of 30-day retail is mandatory for first two fills of a long-term or maintenance medication.
  • Mail-order or 90-day retail is mandatory for the 4th and all subsequent fills.
  • Patient pays difference in cost plus non-preferred brand co-pay if generic substitution is declined.
  • Additional requirements apply – see “Clinical Management Programs” starting on page 52.
Out-of-pocket limit for prescription drug co-pays per calendar year (participant co-pay maximum)

$4,600 per person $9,200 per family
DENTAL BENEFIT
Maximum benefit

Per person

 $750 per calendar year
Annual maximum waived for preventive and routine services (those paid at 100%) for children under age 19.
Plan payment percentages

Preventive and routine

 100%

Minor restorative

 80%

Major restorative

 50%
Orthodontia (for children age 18 and under only)

Plan payment percentage

 50%

Maximum benefit

 applies to $750 annual maximum shown above
VISION BENEFIT
NVA Network Out-of-Network
Eye exam, one per calendar year Provided in full $35
Eyeglass lenses, one pair per year Provided in full (plastic lenses)

Single vision, per pair

 $50

Bifocal or trifocal, per pair

 $65
Frame, one every two calendar years $50 wholesale allowance $35
Contact lenses in lieu of eyeglasses, per calendar year $100 allowance $90
Safety glasses for active participants only, one per year $100 allowance $100
HEARING BENEFIT
Exam $75 every two calendar years
Hearing aid device $750 every three calendar years