• SPD Table of Contents
  1. Introduction
  2. Plan A - Schedule of Benefits
  3. Plan B - Schedule of Benefits
  4. Plan C - Schedule of Benefits
  5. Plan 11 - Schedule of Benefits
  6. Plan 11-C - Schedule of Benefits
  7. Plan 14 - Schedule of Benefits
  8. Eligibility for Active Participants
  9. Eligibility for Retiree Coverage
  10. Insurance Coverage
  11. Medical Benefits
  12. Prescription Drug Program
  13. Weekly Time Loss
  14. Medicare Part D Prescription Drug Plan (PDP) for Retirees
  15. Member Assistance Program (MAP)
  16. Dental Benefit
  17. Vision Benefit
  18. Hearing Benefit
  19. Special Fund Program
  20. Union Wellness Centers
  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 B - Schedule of Benefits

LOW-OPTION SELF-PAY PLAN
(CLASS 1, CLASS 6 AND CLASS 13 PARTICIPANTS ONLY)

PREVENTIVE BENEFIT

	In-Network		Out-of-Network
Plan payment percentage for covered preventive services (See list of preventive services starting on page 56.)	100%		50% after deductible

MAJOR MEDICAL BENEFIT

Deductible per calendar year
Per person	$900
Per family	$1,800
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	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
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
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

	Participant Pays
30-day retail
Generic drugs	$5
Preferred brands	20%; with a min. of $30, to a max. of $55
Non-preferred brands	20%; with a min. of $35, to a max. $85
90-day retail
Generic drugs	$15
Preferred brands	$105
Non-preferred brands	$165
Mail-order
Generic drugs	$10
Preferred brands	$75
Non-preferred brands	$105
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	$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	50%
Major restorative	50%

HEARING BENEFIT

Exam	$75 every two calendar years
Hearing aid device	$1,500 every three calendar years

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