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

Retiree Comprehensive 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.

RETIREE COMPREHENSIVE PLAN
RETIREE DEATH BENEFIT
(For Retirees only)
Death benefit amount $1,000
WELLNESS BENEFIT
Maximum benefit per person per calendar year for all exams and tests: $300
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 per person $300
   Out-of-network hospital deductible $300
(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*
*$2,300 including deductible. This could be less if all or 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%
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) 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 $500 lifetime
Hospice care* – lifetime maximum benefit per person $10,000
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
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
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 (retiree and spouse) for all inpatient, intensive outpatient and outpatient treatment combined
$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
* Must be precertified by Med-Care. Calendar year deductible does not apply. 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
If your co-pay percentages reach $3,000 during calendar year, the Plan will pay 100% for your covered prescription drug expenses during the remainder of that calendar year.
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.
Maximum for Retirees and Their Spouses – Maximum benefit per person for ALL prescription drugs (applies to card, mail and walk-in programs) $4,000 per calendar year

Schedule of Benefits
Basic 65 Plan For Qualifying Retirees and their Spouses

(Payable when retiree reaches age 65)

(The benefits shown on this Schedule apply only to persons who are eligible for the applicable benefits and are subject to all applicable Plan limitations and exclusions.)
Death Benefit (for retirees only) $1,000
Basic 65 Medical Benefits (for retirees and their spouses)Basic 65 medical benefits are payable for medically necessary services provided for sickness or injury. No benefits are payable for pregnancy
Inpatient hospital benefits:
Room and board – Maximum benefit payable while confined as a hospital inpatient $14 per day, for up to 31 days per period of confinement
Ancillary hospital services – Maximum benefit payable per period of confinement $140
Surgery Benefits:
Amount payable for each surgical procedure See Schedule of Surgery Benefits
Maximum benefit payable per disability $250