| RETIREE COMPREHENSIVE PLAN |
RETIREE DEATH BENEFIT
(For Retirees only) |
| Death benefit amount |
$1,000 |
|
WELLNESS BENEFIT
|
| Maximum benefit per person per calendar year for all exams and tests: |
$300 |
| Plan payment percentage |
100% |
| (Wellness Benefits are for routine examinations and tests. No Wellness Benefits are payable when the treatment is for a sickness or injury, or when the person has symptoms of a sickness or injury.) |
|
| COMPREHENSIVE BENEFIT |
Benefit Reductions and Exclusions
Certain benefit reductions and exclusions apply when the precertification is not obtained. |
| Lifetime maximum benefit per person |
$1,000,000 |
| Deductibles |
| Calendar year deductibles per person |
$300 |
| Out-of-network hospital deductible |
$300 |
| (The out-of-network hospital deductible applies to each non-emergency hospital confinement and each occurrence of non-emergency outpatient treatment in an out-of-network hospital (some exceptions apply). Any such deductibles are in addition to the calendar year deductibles.) |
| Out-of-pocket limit per person per calendar year after the calendar year deductible is met |
$2,000* |
| *$2,300 including deductible. This could be less if all or part of your deductible was carried over from the prior year. |
| (Only PPO covered medical expenses apply toward your out-of-pocket limit. See the “Medical Benefits” section for a list of other expenses that do not apply to the out-of-pocket limit, and a list of expenses that will not be paid at 100% even if your out-of-pocket limit was previously met.) |
| Plan co-pay/payment percentages payable per person for covered medical expenses incurred during a calendar year: |
| Second or third surgical opinions recommended by Med-Care (ONLY when recommended by Med-Care) |
100% |
| All other covered medical expenses (unless an exception is given in the “Special Benefits and Limitations” section below) |
| UNTIL out-of-pocket limit is reached |
80% |
| AFTER out-of-pocket limit is reached |
100% |
| Special Benefits and Limitations |
| Out-of-network (non BCBSIL) surgical center charges |
Excluded |
| Chiropractic care* – calendar year maximum benefit per person (includes x-rays, lab and all chiropractic-related physical therapy) |
$750 |
| Podiatry* |
| Calendar year maximum benefit per person for all professional podiatry fees, surgical and non-surgical treatment combined |
$750 |
| Calendar year maximum benefit for all surgical facility feesUse of surgical facility must be precertified by Med-Care |
$3,000 |
| TMJ* – calendar year maximum benefit per person: |
| Non-surgical treatment |
$750 |
| Surgical treatmentMaximums do not apply to covered hospital expenses. |
$3,000 |
| Speech therapy* – maximum benefits per person (does not apply if therapy is required due to an organic cuase): |
| Per calendar year |
$1,500 |
| Per lifetime |
$3,000 |
| Hearing aids |
| Maximum benefit payable per person |
$500 lifetime |
| Hospice care* – lifetime maximum benefit per person |
$10,000 |
| Smoking cessation – lifetime maximum benefit per personCalendar year deductible does not apply. Pharmacy products are not covered through the Prescription Drug Program. You must file a claim with the Fund Office. |
$500 |
| Transplant Donor – maximum benefit for all living donor expenses, per transplant |
$15,000 |
| Chair Lift – lifetime maximum benefit for purchase and installation of a chair lift that meets the requirements stated in No. 27-l in the “Medical Benefits” section. |
$10,000 |
| Chemical dependency and mental/nervous disorders:* |
| Maximum allowable number of outpatient/office treatments per person per calendar year (for mental/nervous disorders and chemical dependency combined) |
60 |
Mental/nervous disorders only:
Lifetime maximum allowable number of days of hospital inpatient and/or intensive outpatient treatment |
30 days |
Chemical dependency only:
Lifetime maximum benefit payable per family (retiree and spouse) for all inpatient, intensive outpatient and outpatient treatment combined |
$50,000 |
| (Amounts applied to this maximum, plus benefits paid for outpatient professional treatment, also apply to the Comprehensive Benefit lifetime maximum benefit.) |
| Maximum allowable course of inpatient and/or intensive outpatient treatment: |
| During a 24-month period |
2 |
| During a person’s lifetime |
4 |
| Maximum benefits payable for outpatient/office professional treatment: |
| During a calendar year |
$1,250 |
| During a person’s lifetime |
$5,000 |
| * Must be precertified by Med-Care. Calendar year deductible does not apply. Out-of-pocket expenses for chemical dependency and outpatient treatment of mental/nervous disorders do not apply to the out-of-pocket limit, and will not be paid at 100% if the person’s out-of-pocket limit was previously met. The out-of-network hospital deductible does not apply to inpatient confinements for these conditions. |
|
| PRESCRIPTION DRUG PROGRAMS |
| Your co-pay under the Sav-Rx drug card program for up to a 30-day supply of a covered prescription drug obtained from a participating pharmacy, and under the Sav-Rx mail service and Walgreens walk-in programs, are based on a percentage of the negotiated price for the drug. |
| Your Co-Pay |
| Generic drugs |
10% |
| Formulary brand-name drugs |
20% |
| Non-formulary brands |
30% |
| Lifestyle drugs |
40% |
| Proton pump inhibitors (such as Nexium, Prevacid and Prilosec) |
excluded* |
| Non-sedating antihistamines (such as prescription Claritin and Allegra) |
excluded* |
| There is a $5 minimum and $200 maximum on each co-pay. |
| If the total amount paid in co-pay percentages reach the following amounts during a calendar year, the Plan will pay 100% for the person’s (or family’s) covered prescription drug expenses during the remainder of that calendar year: |
| Rx Out-of-Pocket Limit |
| Per person |
$3,000 |
| If your co-pay percentages reach $3,000 during calendar year, the Plan will pay 100% for your covered prescription drug expenses during the remainder of that calendar year. |
| The following refill limits apply to the drug card program: |
| Retail Refill Limits |
| Short-term or acute drugs |
2 refills |
| Maintenance or long-term drugs |
no refills |
| Generic/Brand Differential (Card, Mail and Walk-in) – If you chose a brand name drug when a generic equivalent is available, you will be resonsible for the difference in cost between the brand and the generic equivalent, in addition to your percentage co-pay. |
| Maximum for Retirees and Their Spouses – Maximum benefit per person for ALL prescription drugs (applies to card, mail and walk-in programs) |
$4,000 per calendar year |
|
