Benefit Summary - Active Plan 4

Comprehensive Medical Benefits

Benefit Amount/Special Limitations

Annual Deductible

$200 per person per calendar year
$400 per family per calendar year

Coinsurance

After you pay your annual deductible, the Plan pays the applicable Coinsurance rate of the next $7,500 per person of eligible expenses each calendar year; the Plan then pays 100% of additional expenses up to the lifetime maximum

Medical Coinsurance
Network Provider
Non-Network Provider

Plan pays:
90% of covered expenses
80% of covered expenses

Plan Year Maximum

Unlimited

Chiropractic and Spinal Manipulation Annual Maximum

$2,000 per person per calendar year

Home Health Care Services and Skilled Nursing Facility Services Annual Maximum

180 days per calendar year

Infertility Treatment Lifetime Maximum

$12,500 per person (Member and Spouse Only)

Prosthetic Devices
Member, Spouse, & Children age 12 or older

Children under the age of 12
Initial or replacement device

Subject to deductible and co-insurance:
Plan pays covered expenses up to $25,000 once every 5 years per limb
Plan pays covered expenses up to $25,000 once every 2 years per limb

Hospice

Subject to deductible and co-insurance:
365 days per lifetime

Mental or Nervous Treament
Inpatient and Outpatient

Plan pays covered expenses subject to any applicable deductible and co-insurance

Speech Therapy for Dependents

Plan pays covered expenses subject to any applicable deductible and co-insurance

Suicide Attempt Expenses Maximum

One-time only benefit

Transplants

Contact Fund Office to determine coverage

Additional Medical Coverage

The following Additional Medical Coverages are not subject to the Annual Deductible or Coinsurance provisions, except as noted.

Diabetes Education

Plan pays 100% of covered expenses up to $400 per calendar year

Hearing Aids

Plan pays 100% of covered expenses up to $1,500 every three calendar years

Contraceptives (Member and Spouse Only)

$500 per calendar year

Wellness Benefits for Dependent Children

Plan pays 100% of covered expenses

Wellness Benefits for Members and Spouses

Plan pays 100% of covered expenses

Smoking Cessation Lifetime Benefit

Plan pays 100% of covered expenses up to $1,000 (Member and Spouse Only)

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 Prescription Drug Benefits (Caremark Inc.)

Benefit Amount/Special Limits

Basic Prescription Drug Benefit

$5,000 per person per calendar year (100% covered for eligible expenses) after you pay the copay3 for each prescription filled. Copays vary depending on the number of days supply the prescription covers.

                                                   30-day      90-day
Generic Drug                                $5.00        $12.50
Preferred Brand Name Drug           $10.00      $25.00
Non-Preferred Brand Name Drug    $25.00      $62.50

Annual Deductible1

After the Plan pays the first $5,000 of prescription drug expenses, you must pay:
$200 per person per calendar year
$400 per family per calendar year

Coinsurance2

After you pay your annual deductible, the Plan pays 80% of eligible expenses for the remainder of the calendar year up to the lifetime maximum

1 The Prescription Drug Benefit annual deductible is separate from the Comprehensive Major Medical Benefit annual deductible.

2 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. This amount does not count toward your basic Prescription Drug Benefit or your Prescription Drug Benefit annual deductible.

3 You can submit a claim to the Fund Office to have your copay reimbursed to you. When the first $5,000 of annual prescription expenses payable at 100% has been reached, your copays are no longer eligible for reimbursement.

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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.

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Routine Vision Benefits (VSP)

Benefit Amount/Special Limits

Eye exams (includes refraction, limited to one exam per calendar year)
Standard eye exam
Contact lens exam



100%; one visit per year
100%; one visit per year

Lenses1
Single vision
Bifocal
Trifocal
No line Bifocal
No line Trifocal
Contact Lenses (for correction of vision)
Contact Lenses (after cataract Surgery)
Disposable Lenses2

One pair per calendar year
100%
100%
100%
100%
100%
100% up to $250
100%
100% up to $250

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.

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Weekly Income Benefits

Members Only

Weekly Income Benefit Maximum
Non-Occupational Injury or Illness
Occupational Injury or Illness


$260 per week
$25 per week

Benefits Begin

On the first day you are unable to work due to an injury;
On the eighth day after you are unable to work due to an illness; or
On the eighth day after your Physician’s first treatment for an illness

Weekly Income Benefit Maximum Period

26 weeks

Extended Weekly Income Benefit
(Non-Occupational Only)

Up to 26 additional weeks per person per lifetime (certain restrictions apply)

Death Benefits

Benefit Amount

Your Death

$50,000 (payable to your beneficiary)

Death of Your Spouse or Child (6 months old or older)

$10,000 (payable to you)

Death of Your Child (less than 6 months old)

$200 (payable to you)

Accidental Dismemberment Benefits

Member

Dependent

For one hand, one foot, or sight of one eye

$5,500

$1,875

For one hand and one foot, one hand and sight in one eye, or one foot and sight in one eye

$11,000

$3,750

For both hands, both feet, or sight in both eyes

$11,000

$3,750

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