SPD Table of Contents

Plan A - Schedule of Benefits

FOR ELIGIBLE ACTIVE AND RETIRED PARTICIPANTS, AND THEIR DEPENDENTS (CLASSES 1, 3, 6, 7 AND 13)

INSURANCE

Life Insurance
Active participant	$20,000
Retiree (does not apply to Class 3)	$2,500
Dependent(s) of eligible active participant (actives only)	$5,000
Accidental Death and Dismemberment Insurance
Active participant under age 70	$20,000

WEEKLY LOSS OF TIME BENEFIT
(Active Employees Only)

Beneﬁt amount
Non-occupational disabilities	2.5% of last 12 months' earnings up to a maximum of $400 per week
Occupational disabilities	$45 for ﬁrst week $15 for subsequent weeks
Maximum weeks payable	26 weeks
When beneﬁts start	Accidents - 1st day Illnesses - 8th day if occupational, 4th day if non-occupational

PREVENTIVE BENEFIT

	In-Network	Out-of-Network
Plan payment percentage for covered preventive services (See list of preventive services starting on page 56.)	100%	70% after deductible

MAJOR MEDICAL BENEFIT

Deductible per calendar year
Per person	$400
Per family	$800
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	90%	70%
Out-of-pocket limits
Per person	$2,500	$5,000
Per family	$5,000	$10,000
(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%	90%	70%
	no deductible	after deductible
Infertility treatment - Maximum beneﬁt for participant and spouse (only)	$10,000 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 are subject to deductible and coinsurance.)	100% after $25 copay
Obesity (non-surgical treatment) - participant & spouse (only)	$1,000 per lifetime
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 for all related conditions
Physical/occupational therapy Additional visits may be covered if pre-certiﬁed by the review organization. Physical therapy performed at Union Wellness Centers is not subject to visit limits or copays.	12 visits for all related conditions and $50 per visit copay
Refractive surgery such as Lasik	$750 per eye per lifetime
Residential treatment facility	45 days for all related conﬁnements Annually
Skilled nursing facility	45 days for all related conﬁnements Annually
Speech therapy for children under the age of 12	40 visits per calendar year

PRESCRIPTION DRUG BENEFIT

Retirees and dependents enrolled in this Plan's Medicare Part D plan generally have the same beneﬁts as active participants (as shown below) — refer to page 64 for more information.

	Participant Pays
30-day retail
Generic drugs	$5
Preferred brands	20% with a min. of $20, to a max. $30
Non-preferred brands	20% with a min. of $25, to a max. $45
90-day retail
Generic drugs	$15
Preferred brands	$55
Non-preferred brands	$85
Mail-order
Generic drugs	$10
Preferred brands	$40
Non-preferred brands	$55
For Retail, Mail Order & Specialty 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 reﬁlls. Patients will pay the diﬀerence in cost plus non-preferred brand co-pay if generic substitution is declined. Additional requirements apply — see "Clinical Management Programs" starting on page 61.

DENTAL BENEFIT

Maximum beneﬁt
Per person	$5,000 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	$2,500 per lifetime

VISION BENEFIT

	NVA Network	Out-of-Network
Eye exam, one per calendar year	Provided in full	$50
Eyeglass lenses, one pair per year	Provided in full (plastic lenses)
Single vision, per pair		$65
Bifocal, trifocal or progressive lenses, per pair		$75
Frame, one every two calendar years	$50 wholesale allowance	$125
Contact lenses in lieu of eyeglasses, per calendar year	$100 allowance	$100
Safety glasses for active participants only, one per year	$100 allowance	$100

HEARING BENEFIT

Exam	$75 every two calendar years
Hearing aid device (per ear)	$1,500 every three calendar years