Schedule of Benefits

The following schedule shows the percentage of the “allowance” the Plan will pay for covered expenses. Your allowance is the Plan’s pre-determined amount for a particular service. For most medical services, the Plan pays 80% of expenses after you’ve met your annual deductible. You are responsible for the other 20% (the Patient’s Responsibility).

If you visit a provider in the UnitedHealthcare (UHC) network, the allowance is accepted as payment in full for a particular service. In those cases, you will generally owe only the Patient’s Responsibility to the participating provider. If your provider is not in the UHC network, you are responsible for paying any amount your provider charges above the allowance in addition to the Patient’s Responsibility.

MEDICAL DEDUCTIBLES, OUT-OF-POCKET MAXIMUM,
IN/OUT OF NETWORK, & LIFETIME BENEFIT COVERAGE
Both Standard (full) and “H” Plan Members (limited)
Annual Deductible$150 per individual

$300 per family
Annual Out-of-Pocket Maximum


All Standard Plan Members--$8,000 per family, after meeting the annual deductible
“H” Plan Members—No Annual Out-of-Pocket Maximum
Network AccessAll Standard Plan Members—In and Out of Network Coverage;
“H” Plan Members—Only In-Network Coverage
Lifetime Benefit CoverageAll Standard Plan Members--$1,000,000 (essential and non-essential health benefits) then coverage level reduces from 80% of allowance to 50% of allowance for essential health benefits and non-essential health benefits are no longer covered
“H” Plan Members--$100,000 (essential and non-essential health benefits) then coverage level reduces from 80% of allowance to 50% of allowance for essential health benefits and non-essential health benefits are no longer covered
MEDICAL BENEFITS
Both Standard and “H” Plan Members
Covered Service
Plan Pays
Doctor’s Office Visits 80% of allowance, after annual deductible
Chiropractic Care80% of allowance, after annual deductible prior authorization required after first 20 visits)
Emergency Medical Care
80% of allowance, after annual deductible
Diagnostic Laboratory Pathology Tests and X-Ray Examination (Outpatient)
80% of allowance, after annual deductible
Emergency Room Treatment, if Not Hospitalized


80% of allowance, after annual deductible
Charges by Physicians and Surgeons (Inpatient or Outpatient)80% of allowance, after annual deductible
Durable Medical Equipment80% of allowance, after annual deductible
Hospitalization
Prior Authorization Required
Expenses up to $7,000 for each spell of illness 100% of allowance, no deductible applies
Expenses in excess of $7,000
80% of allowance, no deductible applies
Home Health Care
Prior Authorization Required
Covered home health care visits by a registered or licensed practical nurse
80% of allowance, no deductible applies
Covered home health care visits by a home health care aide
100% of allowance, after annual deductible
Convalescent Nursing Home Care
Semi-private accommodations rate charged by discharging hospital 50% of allowance, no deductible applies
Maximum days per spell of illness
60 days
Maximum benefit when combined with covered charges made by discharging hospital
$7,000
Covered charges that exceed the maximum 80% of allowance, no deductible applies
Hospice Care (Approved Facility) 100% of allowance, no deductible applies
Surgery (Including Organ Transplants)
Charges by physicians and surgeons in or out of the hospital 80% of allowance, after annual deductible
Assistant or co-surgeon 25% of allowance for surgeon, at 80%, after annual deductible
Anesthesiologist’s charges 80% of allowance
Second Surgical Opinion 100% of allowance, no deductible applies
Facility fee charged by an approved facility for outpatient surgery (up to first $7,000 per spell of illness) 100% of allowance, no deductible applies

Expenses after $7,000 80% of allowance, no deductible applies
Wellness
Child Wellness Visits and Examinations of eligible dependent children by a physician including required immunizations according to the following maximum number of visits:
Birth through age 23 months; maximum of seven visits 80% of allowance, after annual deductible
Birth through age 23 months; maximum of seven visits 80% of allowance, after annual deductible
Age 2 through age 26; one visit per year 80% of allowance, after annual deductible
Physical Exams for participants and spouses 80% of allowance, after annual deductible (including tests and immunizations)
Well-woman office visit 80% of allowance, after annual deductible
Bariatric surgery — Only one surgical procedure is covered and prior authorization is required by Bariatric Resource Services. 80% of allowance up to maximum lifetime benefit of $100,000. After maximum reached, eligible expenses covered at 50%.
Mammogram One per year for women age 35 or over
Zostavax - Physical Examination includes coverage (including administration) for Zostavax, a vaccine for the prevention of herpes zoster (shingles). NOTE: The Zostavax vaccine benefit is also available to Medicare-eligible retirees and their spouses, provided such retirees or spouses are not enrolled in a separate Medicare Part “D” prescription plan.
80% of allowance, no deductible applies
Gardasil – for all eligible members through age 26 and dependents through the end of the month they reach age 26 80% of allowance, subject to deductible
Gynecological Care and Maternity Expenses
Hospital bills, including maternity and nursery expenses up to $7,000 per spell of illness. 100% of allowance, no deductible applies
Expenses in excess of $7,000 80% of allowance, no deductible applies
Maternity and Gynecological Care expenses including charges by physicians and surgeons in or out of the hospital 80% of allowance, after annual deductible
Initial routine physical examination for newborn
100% of allowance, no deductible applies
Assistant or co-surgeon 25% of allowance for surgeon, at 80% after annual deductible
Pap Test One routine exam per year
MENTAL HEALTH BENEFITS
Both Standard (full) and “H” Plan Members (limited)
Substance Misuse and Mental Health Treatment
Coverage for Standard Plan Members Only; NO Coverage for “H” Plan Members
Covered Service
Plan Pays
Outpatient treatment 80% of allowance, after annual deductible
Inpatient treatment for the first $7,000 of expenses for each spell of illness 100% of allowance, no deductible applies
Inpatient expenses in excess of $7,000 for each spell of illness 80% of allowance, no deductible applies
Employee Assistance Program (EAP) —Both Standard and “H” Plan Members
Counseling Sessions
8 Free Sessions per Year
PRESCRIPTION DRUG BENEFITS—
Coverage for Standard Plan Members Only; NO Coverage for “H” Plan Members
Prescription Drug Participating Pharmacy
Participant Pays
Non-Participating Pharmacy
Participant Pays
Retail (34-Day Supply)
Generic Drugs $10 copayment $10 copayment plus difference between the allowance and retail price
Preferred Brand Name Drugs $25 copayment $25 copayment plus difference between the allowance and retail price
Non-Preferred Brand Name Drugs $35 copayment $35 copayment plus difference between the allowance and retail price
Mail Order or CVS (90-Day Supply)
Generic Drugs

$20 copayment


Not covered
Preferred Brand Name Drugs$50 copaymentNot covered
Non-Preferred Brand Name Drugs
$70 copaymentNot covered
DENTAL BENEFITS
Coverage for Standard Plan Members Only; NO Coverage for “H” Plan Members
Dental Services PPO Provider
Plan Pays
Non-PPO Provider
Plan Pays
Dental Care (Preventive Services)
Visits and Examinations
100% of the allowance80% of the allowance
Examinations (limited to once every six months)
100% of the allowance80% of the allowance
Prophylaxis, including scaling and polishing (limited to once every six months)
100% of the allowance80% of the allowance
Topical applications of fluorides limited to one course of treatment per 12-month period
100% of the allowance80% of the allowance
X-Rays and Pathology
Single films (up to 13)
100% of the allowance80% of the allowance
Panorex (limited to once every year)
100% of the allowance80% of the allowance
Entire denture series (14 or more films; limited to once every year)

100% of the allowance80% of the allowance
Bitewings100% of the allowance80% of the allowance
Biopsy and examination of oral tissue
100% of the allowance80% of the allowance
Dental Care (Basic Services)
Problem visits
80% of the allowance80% of the allowance
Consultation by specialist when diagnosis has been made by a general dentist
80% of the allowance80% of the allowance
Restoration (fillings)80% of the allowance80% of the allowance
Oral Surgery (Including Local Anesthesia)80% of the allowance80% of the allowance
Extractions80% of the allowance80% of the allowance
Incision and drainage of abscess80% of the allowance80% of the allowance
Removal of cyst or tumor80% of the allowance80% of the allowance
Alveoplasty with ridge extension
80% of the allowance80% of the allowance
Suture, soft tissue injury80% of the allowance80% of the allowance
Periodontics
80% of the allowance80% of the allowance
Subgingival curettage

80% of the allowance80% of the allowance
Root planning80% of the allowance80% of the allowance
Provisional splinting


80% of the allowance80% of the allowance
Gingivectomy80% of the allowance80% of the allowance
Endodontics80% of the allowance80% of the allowance
Pulp capping



80% of the allowance80% of the allowance
Root canals80% of the allowance80% of the allowance
Apicoectomy80% of the allowance80% of the allowance
Denture repairs80% of the allowance80% of the allowance
Space maintainer, fixed (bank type) and removable
80% of the allowance80% of the allowance
Dental Care (Major Services)
Inlays and Crowns (not covered if teeth can be restored with a filling material)

80% of the allowance50% of the allowance
Pontics (artificial teeth)80% of the allowance50% of the allowance
Removable bridge (one piece casting clasp attachment)
80% of the allowance50% of the allowance
Dentures (complete upper or lower; specialized techniques not eligible)
80% of the allowance50% of the allowance
Orthodontia (Dependent Children Only)
Orthodontia
50% of the allowance50% of the allowance
Maximum Coverage
Maximum For All Covered, non-Orthodontia Dental Services
Children Under Age 18: No Limit
Members, Spouses and Children Age 18 and Older: $3,000 per calendar year
Maximum For Orthodontia
Dental Services (Dependent
Children Only)
$3,000 per lifetime
VISION BENEFITS
Coverage for Standard Plan Members Only; NO Coverage for “H” Plan Members
Vision Services VSP Provider
Plan Pays
Non-
VSP Provider
Plan Pays
Vision survey once per every two calendar years, unless prescription changes and meets specified criteria 100% of allowanceYou pay the difference between the actual charge and the allowance
Vision analysis, if indicated, once per every two calendar years, unless prescription changes and meets specified criteria100% of allowanceYou pay the difference between the actual charge and the allowance
Eyeglass lenses, if necessary, once per every two calendar years, unless prescription changes and meets specified criteria 100% of allowanceYou pay the difference between the actual charge and the allowance
Frames, once every two calendar years, unless prescription changes and meets specified criteria 100% of allowance, up to $150 per person
You pay the difference between the actual charge and the allowance
Contact lenses once every two calendar years, unless prescription changes and meets specified criteria 100% of allowance, up to $100 per person
You pay the difference between the actual charge and the allowance
Safety Glasses (actively working eligible members only) once per calendar year 100% of allowance for lenses. Safety frames at 100% of allowance up to $65 plus 20% of out of pocket costs
You pay the difference between the actual charge and the allowance
Computer Glasses (actively working eligible members only) once every two calendar years 100% of allowance for lenses. Frames at 100% of allowance up to $40 plus 20% of out of pocket costs
You pay the difference between the actual charge and the allowance
HEARING BENEFITS
Coverage for Standard Plan Members Only; NO Coverage for “H” Plan Members
Audiologist Exam


80% of allowance, up to $100 maximum


First Hearing Aid $3,000
Second Hearing Aid $1,000
ACCIDENTAL DISMEMBERMENT AND LOSS OF SIGHT BENEFITS
Coverage for Standard Plan Members Only; NO Coverage for “H” Plan Members
Loss of One Hand

$5,000
Loss of One Foot$5,000
Loss of Sight of One Eye

$5,000
Loss of Two or more of the above$10,000
WEEKLY ACCIDENT AND SICKNESS BENEFITS
Coverage for Standard Plan Members Only; NO Coverage for “H” Plan Members
Benefit based on a percentage of regular gross compensation and a normally scheduled work week of 40 hours or less
First 13 weeks of disability

50%; $350 per week maximum
Next 13-weeks of disability (after Trustee approval)40%; $210 maximum per week
DEATH BENEFITS
Coverage for Standard Plan Members Only; NO Coverage for “H” Plan Members
Eligible Active Electrical Worker or Non-Bargaining Unit Employee
$25,000
Eligible Retired Employee
$6,000
SUPPLEMENTAL OCCUPATIONAL ACCIDENT BENEFITS
Coverage for Standard Plan Members Only; NO Coverage for “H” Plan Members
Loss of life
$100,000 maximum benefit payable
Loss of one hand
$50,000 maximum benefit payable
Loss of one foot
$50,000 maximum benefit payable
Loss of sight in one eye$50,000 maximum benefit payable
Loss of hearing in one ear $50,000 maximum benefit payable
Two or more of the above $100,000 maximum benefit payable
Loss of speech
$100,000 maximum benefit payable
Thumb and index finger of same hand $25,000 maximum benefit payable
First 52 weeks of disability $150 per week maximum
Next 52 weeks of disability $150 per week maximum
The maximum amount payable for Supplemental Occupational Accident Benefits is $100,000
including $50,000 for disability.