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 B Schedule of Benefits

LOW-OPTION SELF-PAY PLAN (CLASS 1 PARTICIPANTS ONLY)

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

 $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 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.)

 12 visits for all related conditions
Refractive surgery such as Lasik $750 per eye per lifetime
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 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
  • 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.
DENTAL BENEFIT
Maximum benefit

Per person

 $750 per calendar year

Per family

 $2,500 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