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HEALTH & WELFARE FUND
Schedule of Benefits IV
Back to Schedule of Benefits Main Page
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Schedule
of Benefits IV |
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PREFERRED
PROVIDERS |
NON-PREFERRED
PROVIDERS |
|
MAXIMUM LIFETIME BENEFIT
AMOUNT |
$2,000,000
per person |
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DEDUCTIBLE, PER CALENDAR
YEAR |
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Per
Person |
$750 |
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Per
Family Unit |
$2,250 |
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MAXIMUM OUT-OF-POCKET
AMOUNT, PER CALENDAR YEAR |
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Per
Person (including deductible) |
$7,500 |
Not
covered |
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The
Plan will pay the designated percentage of covered charges until
out-of-pocket amounts are reached, at which time the Plan will pay 100%
of the remainder of covered charges for the rest of the calendar year.
There is no out-of-pocket limit for the following: -
Mental
Illness Outpatient Treatment -
Substance
Abuse Outpatient Treatment -
Plan
Exclusions |
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COVERED
SERVICES |
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Hospital
Services |
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Room and Board |
80% |
Not
covered |
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Intensive Care Unit |
80% |
Not covered |
|
Other Inpatient |
80% |
Not covered |
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Outpatient Surgery &
Diagnostic |
80% |
Not
covered |
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Outpatient Pre-Admission
Testing |
80% |
Not covered |
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Outpatient Urgent Care Room |
80% |
Not covered |
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Outpatient Emergency Room |
80%
after $100 copay (waived if admitted) |
Not
covered
|
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Inpatient Rehabilitation
Facility |
80% |
Not covered |
|
Skilled
Nursing Facility |
80% 90
days lifetime maximum |
Not
covered
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Schedule
of Benefits IV (continued)
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PREFERRED
PROVIDERS |
NON-PREFERRED
PROVIDERS |
Physician
Services
|
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Inpatient visits |
80% |
|
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Office visits, labs and x-rays |
80% |
Not
covered |
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Surgery |
80% |
Not
covered |
|
Second Surgical Opinions |
80% |
Not
covered |
Home Health Care |
80% 104
visits per calendar year maximum |
Not covered |
Private Duty Nursing
|
80% |
Not covered |
Hospice Care
|
80% |
Not covered |
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Ambulance
Service |
80% |
|
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Occupational
Therapy |
80%/$2,500 maximum |
Not covered |
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Speech
Therapy (due to accident or illness) |
80% |
Not covered |
|
Physical
Therapy |
80% 15
visits per calendar year maximum |
Not covered |
|
Chiropractic
Services |
80% |
Not covered
|
|
Durable
Medical Equipment |
80% |
Not covered |
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Prosthetics |
80% |
Not covered |
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Orthotics |
80% $3,000
maximum benefit per calendar year |
Not covered |
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Medical
Supplies |
80% |
|
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Hearing
Aids |
80%
1,500 maximum benefit each 5 - year period |
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Corrective
Vision Eye Surgery (correction of nearsightedness or farsightedness
only) |
80% $1,600
maximum benefit per eye per lifetime |
Not covered
|
|
Infertility Testing (excluding treatment) |
80% |
Not covered |
|
Birthing
Center |
80% |
Not covered |
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Voluntary
Sterilization |
80% |
Not covered |
Schedule
of Benefits IV (continued)
|
PREFERRED
PROVIDERS |
NON-PREFERRED
PROVIDERS |
|
Mental Illness |
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|
Inpatient |
80% limited
to 30 days per calendar year and 60 days per lifetime (combined with
Partial Hospitalization limits) |
Not covered
|
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Outpatient Treatment |
80% limited
to 30 visits per calendar year |
Not covered
|
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Partial Hospitalization (2
days of partial hospitalization equals one day of inpatient treatment) |
80% limited
to 30 days per calendar year and 60 days per lifetime (combined with
Inpatient care limits) |
Not covered
|
|
Substance Abuse |
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Inpatient |
80% limited
to 30 days per calendar year and 60 days per lifetime (combined with
Partial Hospitalization limits) |
Not covered
|
|
Outpatient Treatment |
80% limited
to 30 visits per calendar year |
Not covered
|
|
Partial Hospitalization (2
days of partial hospitalization equals one day of inpatient treatment) |
80% limited
to 30 days per calendar year and
60 days per lifetime (combined with Inpatient care limits) |
Not covered
|
|
Wellness
Benefit (Medical
Services Only) |
100%
(not subject to deductible) $300
calendar year maximum per person Now includes HPV Vaccine |
Not covered
|
|
Organ
Transplants (Refer
to Page 36) |
80%
up to $35,000 per lifetime for all transplants combined $10,000
per year and $30,000 per lifetime for follow-up care for all transplants
combined |
Not covered
|
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All
Other Covered Services |
80% |
Not covered |
|
Prescription
Drug Benefit (Schedule of Benefits IV) |
Benefit
|
|
Retail:
(30 day supply
Generic Drugs/Tier 1
Formulary Drugs/Tier 2
Non Formulary Drugs/Tier 3 Mail
Order Program(90 day supply)
Generic Drugs
Brand Drug |
Plan
Pays after $100 calendar year deductible 80% 60% 50% $15 $45 |
