Appendix C SCHEDULE OF BENEFITS FOR THE LOW COST MEDICAL PLAN OF BENEFITS

Transcription

1 Appendix C SCHEDULE OF BENEFITS FOR THE LOW COST MEDICAL PLAN OF BENEFITS The schedule n the fllwing pages highlights key features f the Lw Cst Medical Plan f Benefits fr Cvered Individuals. These benefits are described in greater detail in the Plan Dcument. The amunts charged fr Cvered Medical Expenses prvided by Netwrk prviders are subject t the PPO allwed cntractual amunts. A Cvered Individual will nt be balance billed fr amunts ver the allwed cntractual amunt. The amunts charged fr Cvered Medical Expenses prvided by Out-f-Netwrk prviders are subject t the Reasnable and Custmary Allwance (R&C Allwance). R& C Allwances are determined by the Trustees (r their designee) in their sle discretin, and are amended frm time t time. Out-f-Netwrk charges are paid at 285% f the Medicare Physician Fee Schedule Natinal Payment Amunt Schedule. A Cvered Individual is respnsible t pay fr amunts ver the R&C Allwance. COMPREHENSIVE MEDICAL BENEFITS PPO Prvider Out-f-Netwrk Prvider Cinsurance Deductible per Calendar Year Out-f-Pcket Maximum per Calendar Year $600 per Cvered Individual / $1,800 per family $4,600 per Cvered Individual / $9,200 per family (includes Deductible) After a Cvered Individual satisfies the Deductible and Out-f-Pcket Maximum, the Plan will pay 100% f mst eligible cvered services fr the remainder f the Calendar Year. MEDICAL BENEFITS Cntracted Netwrk Prvider: BlueCrss BlueShield f Illinis (BCBS) BCBS PPO Prvider Out-f-Netwrk Prvider Acupuncture Maximum visit limit per Emplyee: 45 visits per Calendar Year Maximum visit limit per spuse: 15 visits per Calendar Year Cmbined with chirpractic and naprapathy visits fr Dependent children Ambulance Service subject t the PPO Deductible Anesthesia r Sedatin Bariatric Surgery (nly fr the diagnsis and treatment f mrbid besity) Prir t surgery, a Cvered Individual is required t cntact the Fund Office t enrll in and successfully cmplete CmPsych s Bariatric Supprt Service Prgram (BSSP). Participatin in the BSSP is mandatry fr cverage. Behaviral Health Care See page App. C-5 App. C-1

2 Breast Feeding Supprt and Equipment t the extent required under the Affrdable Care Act Lactatin supprt and cunseling Breast pump rental up t the purchase price and initial supplies (tubing and shields). Limited t ne nn-retail purchase per pregnancy. BCBS PPO Prvider Deductible des nt apply Out-f-Netwrk Prvider Hspital-grade breast pump must be Medically Necessary. Chirpractic Care Clinical Trials t the extent required by the Affrdable Care Act Cntraceptives, including related ffice visits, t the extent required under the Affrdable Care Act fr FDA apprved methds fr females with reprductive capacity: Cntraceptive supprt and cunseling Diaphragms, spnges, cervical caps, female cndms & spermicide Vaginal rings Emergency cntraceptives (mrning after pill nly), generic nly Implants & implantable rds Oral cntraceptives, generic nly Patch Injectables IUD Csmetic Surgery slely t imprve appearance Dental Service fr a Nn-Occupatinal Injury t Teeth Diagnstic Imaging Benefit MRI, CAT/CT and PET Scans Maximum visit limit per Emplyee: 45 visits per Calendar Year Maximum visit limit per spuse: 15 visits per Calendar Year Cmbined with acupuncture and naprapathy visits fr Dependent children See Plan Sectins 5.04(G) 100% paid by the Plan Deductible des nt apply Diagnstic X-Rays and Lab Tests Durable Medical Equipment Emergency Rm Facility Physician fees Emergency Rm C-payment $300 per Emergency Rm visit Waived if admitted t the Hspital as an in-patient within 72 hurs r held in the bservatin unit fr mre than 24 hurs Emergency Rm C-payment n lnger applicable after Cvered Individual meets the Calendar Year Out-f-Pcket Maximum Extended Care/Skilled Nursing Facility Maximum f 120 days per cnvalescent perid App. C-2

3 Genetic Testing Benefit BCBS PPO Prvider Out-f-Netwrk Prvider Genetic testing t the extent required under the Affrdable Care Act Deductible des nt apply 50% paid by Plan Subject t Deductible, Out-f- Pcket Maximum and the cmbined annual maximum benefit f $7,500 Diagnstic genetic testing Cmbined annual maximum benefit f $7,500 Nn-diagnstic genetic testing Hearing Benefit, except as required by the Affrdable Care Act under the Wellness and Preventive Care benefit Hme Health Care Maximum f 120 visits per year Hspice Care Lifetime maximum f 180 days per Individual Hspital Care Infertility Services including Hspital, Physician, prescriptin drugs & treatments, except diagnstic genetic testing which is cvered abve Infusin Therapy fr the administratin f an intravenus prescriptin drug Cnfinement maximum: 180 days per Calendar Year fr n-patient care Cmbined lifetime maximum f $10,000 fr services prvided t the Emplyee and spuse Member Assistance Prgram See page App. C-5 Naprapathy Nutritinal Cunseling t the extent required under the Affrdable Care Act fr chrnic disease management Maximum visit limit per Emplyee: 45 visits per Calendar Year Maximum visit limit per spuse: 15 visits per Calendar Year Cmbined with acupuncture and chirpractic visits fr Dependent children Deductible des nt apply Oral and Maxillfacial Surgery Organ Transplant Physical, Occupatinal and Speech Outpatient Therapy fr Restrative/ Rehabilitative Therapy Physical, Occupatinal and Speech Outpatient Therapy fr Develpmental Disabilities (Habilitative r t teach; fr cvered individuals thrugh age 18) Physician Services Pregnancy Care, except t the extent required under the Affrdable Care Act. Services cvered under the Affrdable Care Act are paid at 100% by the Plan and the Deductible des nt apply. 50% paid by Plan App. C-3

4 BCBS PPO Prvider Out-f-Netwrk Prvider Prsthetics Artificial limbs and eyes Wigs and hairpieces fr hair lss as a result f treatment fr a cancer diagnsis Recnstructive Breast Surgery Sterilizatin Females t the extent required under the Affrdable Care Act Males Sterilizatin reversals (female/male), Deductible des nt apply N Cverage Substance Use Disrder See page App. C-5 N Cverage N Cverage N Cverage Surgi-Center Facility Hspital Affiliated N Hspital Affiliatin Surgical Assistant r Assistant Surgen, limited t 20% f surgical prcedure s R&C Allwance Surgical Cnsultatins Temprmandibular Jint Care (TMJ) Physician and therapy services Appliances, and their adjustments, fr TMJ and bruxism (cclusal) Urgent/Immediate Care Facilities and Retail Clinics Visin Surgery (excluding csmetic r refractive crrectins) Wellness and Preventive Care Wellness and Preventive Care t the extent required under the Affrdable Care Act and interpretive guidance including rutine screenings, immunizatins and ther services (see fr list f services) nce every 3 cnsecutive years. Maximum f tw (2) appliances per lifetime.. Deductibles and Cinsurance d nt apply Cmprehensive Health Evaluatin and Physical Exam (bld, glucse and chlesterl analysis, strength and flexibility testing, mammgram r prstate screening and mre) Preferred Cntracted Prvider: Health Dynamics fr Participant and spuse nce every Calendar Year. fr Dependent children Health Center Services HEALTH CENTER Fr Eligible Cvered Individuals Only. Deductibles and Cinsurance d nt apply. Member Assistance Prgram (MAP) MEMBER ASSISTANCE PROGRAM Cntracted Netwrk Prvider: CmPsych, Guidance Resurces CmPsych In-Netwrk Prvider fr 5 shrt-term cunseling sessins per issue App. C-4 Out f Netwrk Prvider

5 BEHAVIORAL HEALTH & SUBSTANCE USE DISORDER BENEFITS Emergency Rm Facility Physician fees Emergency Rm C-payment Cntracted Netwrk Prvider: CmPsych, Guidance Resurces Hspital Care and Residential Treatment Facilities CmPsych In-Netwrk Prvider Out f Netwrk Prvider $300 per Emergency Rm visit Waived if admitted t the Hspital as an in-patient within 72 hurs r held in the bservatin unit fr mre than 24 hurs Emergency Rm C-payment n lnger applicable after Cvered Individual meets the Calendar Year Out-f-Pcket Maximum 50% Paid by Plan Cnfinement maximum: 180 days per calendar year cmbined fr Hspital and Residential Treatment in-patient care) Hspital Outpatient Diagnstic Tests Outpatient Therapy (Including Partial Hspitalizatin) Custdial r Grup Hmes PRESCRIPTION BENEFITS Cntracted Netwrk Prvider: Express Scripts, Inc. and Diplmat Specialty Pharmacy Prescriptin drug benefits are nt available t an apprentice except as described in Sectins 3.02(C) and 3.11(C) f the Plan Dcument. Out-f-Pcket Maximum per Calendar Year ESI Netwrk Retail Pharmacy (Lesser f 100 units r a 30-day supply) ESI By Mail (Up t a 90-day supply thrugh mail rder) $2,000 per individual / $4,000 per family Diplmat Specialty Pharmacy (Fr specialty drugs) Generic C-payment Des nt apply Single-Surce Brand C-payment (A generic is nt available) Des nt apply Multi-Surce Brand C-payment (A generic is available) Specialty Medicatin C-payment (Used t treat cmplex cnditins such as cancer, hemphilia, immune deficiency, rheumatid arthritis, etc. and require a higher level f care) Des nt apply Des nt apply LIFE INSURANCE BENEFITS Cntracted Prvider: Self-Funded Eligible Participant Spuse Child Plicy amunt $5,000 $1,000 $1,000 EXCLUDED BENEFITS Visin Benefits Dental Benefits Shrt Term Disability Benefits Accidental Death and Dismemberment Insurance Benefits App. C-5