Death Benefit for Active Employees Only

$10,000

Accidental Death and Dismemberment Benefit for Active Employees Only

For loss of:

                Life

$10,000

                Both hands, both feet, or sight of both eyes

$10,000

                One hand, one foot, or sight of one eye

$5,000

Weekly Accident and Sickness Disability Benefit for Active Employees Only

                Weekly Benefit Amount

$350 up to Maximum of 26 weeks

Medical Expense Benefits for Active Employees and Dependents

Calendar Year Deductible

$300 per Person
Maximum 3 deductibles per Family

Maximum Benefit

                Maximum per Sickness or Accident

$1,000,000 per Person

                Spinal Manipulation Maximum
                (including diagnostic tests)

$1,000 per Calendar Year (for covered individuals age 16 and older)

up to the Usual and Customary Fees

PPO Charges

Non-PPO Charges

 
Physician, Hospital/Facility  (inpatient and outpatient)

85%

 
75%

Out-of-Pocket Maximum per Calendar Year

Out-of-Pocket Maximum Does Not Include:

·           Deductible Amount

·           Prescription Drug Copayments

·           Dental Expense Payments

·           Vision Care Expense Payments

·           Copayments for Outpatient Treatment of Mental and      Nervous Disorders, or Chemical Dependency

$1,000 per Person for PPO expenses

$2,500 per Person for Non-PPO expenses

Once you reach the Out-of-Pocket Maximum, the Plan pays 100% of allowable expenses for the calendar year up to the Maximum Benefit listed above. Expenses that apply towards the Non-PPO out-of-pocket limits apply towards the PPO out-of-pocket limits and vice versa.

Note:    Durable Medical Equipment and Local Ambulance Service for which PPO services are not available will be covered the same as PPO charges

Mental and Nervous Disorders

PPO Charges

Non-PPO Charges

Outpatient

50%

50%

Inpatient

85%

75%

 Chemical Dependency

PPO Charges

Non-PPO Charges

Outpatient

50%

50%

Inpatient Maximum

$6,000 per Course of Treatment
Limited to Two Courses of Treatment per Lifetime

Dental Expense Benefit for Active Employees and Dependents

                Dental Benefits Other than Orthodontia Care

                                Maximum Benefit

$1,000 per Person per Calendar Year

                                Copayment Paid by the Plan

80%

                Orthodontia Treatment

$1,000 per Person per Lifetime

             TMJ Treatment

$2,000 per Person per Lifetime

Vision Benefits for Active Employees and Dependents

                Maximum Benefit

$150 per Person per Calendar Year

Employee Assistance Plan (EAP) for Active Employees and Dependents

                Initial Counseling with EAP Staff

Up to Three Sessions Covered at No Charge

Hearing Aid Benefit for Active Employees and Dependents

                Hearing Aid and Exam

100% Up to $900 per ear

                Frequency Limit

One per ear for any 36 consecutive month period

Hospice Benefits for Active Employees and Dependents

                Coverage

100% up to the $10,000 per lifetime

Home Birth Benefits for Active Employees and Dependents

                Coverage

100% up to the $3,500 per pregnancy

Prescription Drug Benefits Co-Pay Percentage
 (if greater than minimum co-pay amounts)                                                                                        20%

Minimum Co-Pay Amount

Retail  (34 day supply)

Mail  (90 day supply)

Generic

$5

$10

Brand Preferred

$15

$30

Brand Non-Preferred

$30

$60

  
Specialty Drug Co-Pay Percentage                                                                                                        20%

 Out-of-Pocket Maximum per year for Specialty and
Prescription Drugs Excluding
Prescription Narcotics (narcotic agonists)                                                                                             $5,000

The Participant co-payment for prescription narcotics (narcotic agonists) is always 20% and is not subject to any Out-of-Pocket Maximum