Schedule of Benefits for Retired Employees and Dependents
Not Yet Eligible for Medicare.
Benefit Benefit Amount or Limitation
Medical Expense Benefits for Retired Employees Not Yet Eligible for Medicare and Dependents
  Calendar Year Deductible

$500 per person
 
  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)
Confinement in a Skilled Nursing Care Facility

60 Days per Confinement
 
  Covered Expenses Payable by the Fund
  up to the Usual and Customary Fees		 PPO Charges Non-PPO Charges

Physician, Hospital/Facility (inpatient and outpatient)

 85% 75%

Skilled Nursing Care

60 days per confinement; See Sec. 7.08 (A) (11)
 
  Out-of-Pocket Maximum per Calendar Year

$1,000 per Person for PPO expenses
   Out-of-Pocket Maximum Does Not Include:
  

·         Deductible Amount

·         Prescription Drug Co-payments

·         Dental Expense Payments

·         Vision Care Expense Payments

·         Co-payments for Outpatient Treatment of Mental and Nervous Disorders or Chemical Dependency

$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
Benefit Benefit Amount or Limitation
  Mental and Nervous Disorders PPO Charges Non-PPO Charges
Outpatient 50% 50%
Inpatient 85% 75%
Benefit Benefit Amount or Limitation
  Chemical Dependency PPO Charges Non-PPO Charges
Outpatient 50% 50%
Inpatient 85% 75%

Inpatient Maximum

$6,000 per Course of Treatment
Limited to Two Courses of Treatment per Lifetime
 
  Employee Assistance Plan (EAP)
Initial Counseling with EAP Staff Up to Three Sessions Covered at No Charge
 
  Hearing Aid Benefit  
Hearing Aid and Exam 100% Up to $900 per Ear
Frequency Limit One per ear for any 36 consecutive month period
 
  Hospice Benefits  
Coverage 100% up to the $10,000 per Lifetime
 
  Home Birth Benefits
Coverage 100% up to $3,500 per Pregnancy