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| Medical Benefits
Organization Description
The Plan's medical benefits cover a large part of your expenses for treatment of non-work related illnesses (including pregnancy) or accidental injuries, and protect you and your family in the event of
catastrophic illnesses.
Active Summary of Benefits as of June 1, 2007
Comprehensive Medical Benefit
|
Calendar Year Deductible |
$250 per person; $500 per family |
|
Non-PPO Hospital Deductible |
$500 per person for each non-emergency admission to a non-PPO hospital |
|
Calendar Year Out-of-Pocket Maximum |
|
|
Combined PPO and Non-PPO Maximum |
$2,500 per person; $5,000 per family |
|
Additional Non-PPO Maximum |
$1,000 per person; $2,000 per family |
Lifetime Maximum
|
$1,000,000 per person |
|
Well Baby Care |
$1,000 per dependent child up to age two |
|
Chiropractic/Spinal Care |
$5,000 per person |
|
Substance Abuse Treatment |
$25,000 per person |
|
Inpatient Treatment |
One 21-day course of treatment per person |
|
Infertility Treatment |
$10,000 |
Calendar Year Maximums
|
|
|
Chiropractic/Spinal Care |
$1,000 per person |
|
Substance Abuse Treatment |
$10,000 per person |
|
Mental Health Treatment |
|
|
Inpatient Maximum |
15 days per person with up to 15 physician visits |
|
Outpatient Maximum |
30 visits per person |
|
Speech Therapy |
30 visits per person |
|
Outpatient Physical, Speech, and Occupational Therapy |
$5,000 per dependent child (diagnosed with congenital, neurological disease) (Speech therapy limited to 30 visits per year) |
|
Specific Benefit Maximums |
|
|
Routine Physical Exam |
$600 per person every two years for Member and Spouse |
|
Hospital Daily Room And Board |
Semi-private room rate |
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Hospital Intensive Care |
Three times semi-private room rate |
|
Hearing Aid Program |
$600 per person every three years |
|
Type of Service |
PPO Provider |
Non-PPO Provider |
|
Outpatient Pre-Admission Tests |
Plan pays 100%; no deductible |
Plan pays 100%; no deductible |
|
Hospital Benefits |
Plan pays 90% |
Plan pays 70% |
|
Well Baby Care |
Plan pays 80%; no deductible |
Plan pays 70%; no deductible |
|
Routine Physical Exam (for employees and dependent spouses) |
Plan pays 100%; no deductible |
Plan pays 100%; no deductible |
|
Mammograms |
Plan pays 100%; no deductible |
Plan pays 100%; no deductible4 |
|
Colon Cancer Screenings |
Plan pays 100%; no deductible |
Plan pays 100%; no deductible |
|
Chiropractic/Spinal Care |
Plan pays 80% |
Plan pays 70% |
|
Substance Abuse Treatment |
|
|
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Inpatient Treatment |
Plan pays 90% |
Plan pays 70% |
|
Outpatient Treatment |
Plan pays 90% of first $5,000 in a year; 50% thereafter |
Plan pays 50% |
|
Mental Health Treatment |
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|
|
Inpatient Treatment |
Plan pays 90% |
Plan pays 50% |
|
Outpatient Treatment |
Plan pays 50% |
Plan pays 50% |
|
Hearing Aid Program |
Plan pays 100% |
Plan pays 100% |
|
Ambulatory Surgical Center |
Plan pays 90% |
NOT COVERED |
|
For All Other Covered Medical Expenses |
Plan pays 80% |
Plan pays 70% |
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| Welfare Fund Active Member Summary Plan Description (SPD) |
This is a plan description. Not a guarantee of benefits.
Benefits depend on eligibility, date of service and Fund Plan limitations.
In the event of a conflict between the Summary Plan Description,
this web site and the Plan's legal documents, the legal documents will govern.
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