Bakery Drivers Local 734 - Health and Welfare Fund | Welfare Schedule of Benefits
15797
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Welfare Schedule of Benefits

Active Employee Benefit Plan

The benefits shown on this schedule apply only to persons who are eligible for the applicable benefits and are subject to all limitations and exclusions.

INSURED BENEFITS
(For Employees only)
Life Insurance Benefit Amount $15,000
Accidental Death & Dismembership Insurance (full amount) $10,000
DEATH & DISMEMBERMENT BENEFITS
(For Dependents of Employees)
Death Benefit for spouse and children age 14 days but less than 19 years $1,000
Accidental Death & Dismemberment Benefit (full amount) $2,000
WEEKLY DISABILITY BENEFIT
(For Employees Only)
Amount of Weekly Benefit $250
Maximum period that benefits are payable Up to 26 weeks
When disability benefits start 8th day after first day of treatment
NEWBORN CARE BENEFIT
Maximum benefit for hospital and physician expenses for routine newborn care (in-hospital or follow-up office visits) during the first 7 days of life for a well newborn $2,500
Plan payment percentage 100%
(Covered medical expenses for hospital and physician care of a sick newborn are covered under the Comprehensive Benefit)
WELLNESS BENEFIT
Maximum benefit for exams and tests per person per calendar year:
Employees, retirees, spouses, and children from birth through age 5 $300
Routine childhood immunizations (birth through age 5)
(Plan benefits for immunizations do not apply toward the $300 maximum.)
100%
Children age 6-22 $100
Plan payment percentage $100
(Wellness Benefits are for routine examinations and tests. No Wellness Benefits are payable when the treatment is for a sickness or injury, or when the person has symptoms of a sickness or injury.)
COMPREHENSIVE BENEFIT
Benefit Reductions and Exclusions
Certain benefit reductions and exclusions apply when the precertification is not obtained.
Lifetime maximum benefit per person $1,000,000
Deductibles:
Calendar year deductibles:
Individual deductible $500
Family deductible (can be satisfied by 3 or more family members) $1,000
Out-of-network hospital deductible $250
(The out-of-network hospital deductible applies to each non-emergency hospital confinement and each occurrence of non-emergency outpatient treatment in an out-of-network hospital (some exceptions apply). Any such deductibles are in addition to the calendar year deductibles.)
Out-of-pocket limit per person per calendar year after the calendar year deductible is met $2,000*
*$2,250 including deductible. This could be less if all or part of your deductible is waived due to meeting the family deductible limit, or if part of your deductible was carried over from the prior year.
(Only PPO covered medical expenses apply toward your out-of-pocket limit. See the “Medical Benefits” section for a list of other expenses that do not apply to the out-of-pocket limit, and a list of expenses that will not be paid at 100% even if your out-of-pocket limit was previously met.)
Plan co-pay/payment percentages payable per person for covered medical expenses incurred during a calendar year:
Second or third surgical opinions recommended by Med-Care (ONLY when recommended by Med-Care) 100%
Hearing Aids 50%
All other covered medical expenses (unless an exception is given in the “Special Benefits and Limitations” section below)
UNTIL out-of-pocket limit is reached 80%
AFTER out-of-pocket limit is reached 100%
Special Benefits and Limitations
Out-of-network (non BCBSIL PPO) surgical center charges Excluded
Chiropractic care* – calendar year maximum benefit per person (includes x-rays, lab and all chiropractic-related physical therapy) $750
Podiatry*
Calendar year maximum benefit per person for all professional podiatry fees, surgical and non-surgical treatment combined $750
Calendar year maximum benefit for all surgical facility feesUse of surgical facility must be precertified by Med-Care $3,000
TMJ* – calendar year maximum benefit per person:
Non-surgical treatment $750
Surgical treatmentMaximums do not apply to covered hospital expenses. $3,000
Speech therapy* – maximum benefits per person (does not apply if therapy is required due to an organic cuase):
Per calendar year $1,500
Per lifetime $3,000
Hearing aids:
Maximum benefit payable per person in a 5-year calendar period $2,500
Plan co-payment percentage 50%
Retiree Comprehensive Plan – Maximum benefit payable per person $500 (lifetime)
Calendar year deductible does not apply. Out-of-pocket expenses do not apply to the out-of-pocket limit, and will not be paid at 100% if the person’s out-of-pocket limit was previously met.
* Must be precertified by Med-Care. Calendar year deductible does not apply. Out-of-pocket expenses do not apply to the out-of-pocket limit, and will not be paid at 100% if the person’s out-of-pocket limit was previously met.
Smoking cessation – lifetime maximum benefit per personCalendar year deductible does not apply. Pharmacy products are not covered through the Prescription Drug Program. You must file a claim with the Fund Office. $500
Chemical dependency and mental/nervous disorders:*
Maximum allowable number of outpatient/office treatments per person per calendar year (for mental/nervous disorders and chemical dependency combined) 60
Mental/nervous disorders only:
Lifetime maximum allowable number of days of hospital inpatient and/or intensive outpatient treatment
30 days
Chemical dependency only:
Lifetime maximum benefit payable per family for all inpatient and outpatient treatment
$50,000
(Amounts applied to this maximum, plus benefits paid for outpatient professional treatment, also apply to the Comprehensive Benefit lifetime maximum benefit.)
Maximum allowable course of inpatient and/or intensive outpatient treatment:
During a 24-month period 2
During a person’s lifetime 4
Maximum benefits payable for outpatient/office professional treatment:
During a calendar year $1,250
During a person’s lifetime $5,000
Transplant Donor – maximum benefit for all living donor expenses, per transplant $15,000
Chair Lift – lifetime maximum benefit for purchase and installation of a chair lift that meets the requirements stated in No. 27-l in the “Medical Benefits” section. $10,000
Hospice care* – lifetime maximum benefit per person $10,000
* Must be precertified by Med-Care. Out-of-pocket expenses for chemical dependency and outpatient treatment of mental/nervous disorders do not apply to the out-of-pocket limit, and will not be paid at 100% if the person’s out-of-pocket limit was previously met. The out-of-network hospital deductible does not apply to inpatient confinements for these conditions.
PRESCRIPTION DRUG PROGRAMS
Your co-pay under the Sav-Rx drug card program for up to a 30-day supply of a covered prescription drug obtained from a participating pharmacy, and under the Sav-Rx mail service and Walgreens walk-in programs, are based on a percentage of the negotiated price for the drug.
Your Co-Pay
Generic drugs 10%
Formulary brand-name drugs 20%
Non-formulary brands 30%
Lifestyle drugs 40%
Proton pump inhibitors (such as Nexium, Prevacid and Prilosec) excluded*
Non-sedating antihistamines (such as prescription Claritin and Allegra) excluded*
There is a $5 minimum and $200 maximum on each co-pay.
If the total amount paid in co-pay percentages reach the following amounts during a calendar year, the Plan will pay 100% for the person’s (or family’s) covered prescription drug expenses during the remainder of that calendar year:
Rx Out-of-Pocket Limit
Per person $3,000
Per family $5,000
The following refill limits apply to the drug card program:
Retail Refill Limits
Short-term or acute drugs 2 refills
Maintenance or long-term drugs no refills
Generic/Brand Differential (Card, Mail and Walk-in) – If you chose a brand name drug when a generic equivalent is available, you will be resonsible for the difference in cost between the brand and the generic equivalent, in addition to your percentage co-pay.
VISION BENEFIT
Maximum payable per person per calendar year:
Complete vision examination $40
Frame $50
Eyeglass lenses (per pair):
Single vision ($20 each) $40
Bifocal ($30 each) $60
Trifocal ($35 each) $70
Contact lenses in lieu of eyeglasses (per pair, or for all sets of disposable contacts purchased during a calendar year) $90
DENTAL BENEFIT
Dental HMO Plan (BlueCare Dental HMO)
Deductible None
Diagnostic and preventive sevices (check-ups and cleanings) and x-rays Provided at no charge
All other covered dental procedures Provided in full after patient co-payment
Calendar year maximum benefit No maximum
(When you enroll in the BlueCare Dental HMO, you will be sent a certificate of coverage with the schedule of dental services and patient co-payments.)
Dental PPO Plan (Dental Network of America, a BCBSIL Subsidiary)
Calendar year deductible per person (does not apply to diagnostic and preventive care) $50
Plan co-pay percentages of R&C allowances:
   Diagnostic and preventive
In-Network: 90%
Out-of-Network: 80%
   Restorative (minor and major)
In-Network: 90%
Out-of-Network: 80%
Calendar year maximum benefit payable per person $1,500
Lifetime maximum benefit payable per person for orthodontia $2,000