Bakery Drivers Local 734 | 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.

DEATH AND DISMEMBERMENT BENEFITS
 
For employees (insured benefits):
Life Insurance Benefit Amount $15,000
Accidental Death & Dismembership Insurance (full amount) $10,000
For dependents of employees (self-funded benefits):
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
 
COMPREHENSIVE BENEFIT
 
Benefit Reductions and Exclusions
Certain benefit reductions and exclusions apply when the precertification is not obtained. All benefits and provisions are per person unless specifically stated otherwise.
Calendar year deductible:
Per person $500
Per family (can be satisfied by two or more family members) $1,000
Out-of-network hospital penalty $250
The out-of-network hospital penalty 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 $2,500
Per family (can be satisfied by two or more family members) $5,000
Only in-network covered medical expenses apply toward your out-of-pocket limit; prescription drug expenses are subject to a separate out-of-pocket limit. The calendar year deductible also applies toward the out-of-pocket limit.
Plan co-pay/payment percentages payable per person for covered medical expenses incurred during a calendar year, until out-of-pocket limit is met.
 
Exceptions may apply. Those exceptions are noted in the “Special Benefits and Limitations” section below.
80%

Special Benefits and Limitations

Applied Behavior Analysis (ABA) Therapy
Maximum number of allowable visits per calendar year
Must be pre-certified by Med-Care
50 Visits per calendar year
Acupuncture
Must be pre-certified by Med-Care. Calendar year deductible does not apply.
12 Visits per calendar year
Aqua Therapy
(subject to the medical necessity criteria)
Must be pre-certified by Med-Care
No limit per calendar year
Chair Lift
Lifetime maximum benefit for purchase and installation of a chair lift that meets the re-quirements in No. 15-i
Must be pre-certified by Med-Care
$10,000
Chiropractic Care
Calendar year maximum benefit per person (includes adjustments and manipulations). Physical therapy, acupuncture and massage therapy have separate limitations.
Must be pre-certified by Med-Care. Calendar year deductible does not apply.
$2,500
Hearing aids:
Maximum benefit payable per person
$3,000 in a two-calendar year period
Plan co-payment percentage
Calendar year deductible does not apply
50%
Massage Therapy
subject to the medical necessity criteria explained below
Must be pre-certified by Med-Care. Calendar year deductible does not apply.
12 visits per calendar year
Nutrition Counseling
subject to the medical necessity criteria explained in section below
Must be pre-certified by Med-Care. Calendar year deductible does not apply.
12 visits per calendar year
Occupational Therapy
Maximum number of allowable visits per calendar year
Must be pre-certified by Med-Care
50 visits
Out-of-network surgical facility charges Excluded
Physical Therapy
Maximum number of allowable visits per calendar year
Must be pre-certified by Med-Care
50 visits
Podiatry
Calendar year maximum benefit per person for all non-surgical podiatry fees
(professional fees only) Calendar year deductible does not apply
$750
Preventive care
When provided by in-network providers
100% deductible does not apply
When provided by out-of-network providers 80% of the allowable charge after deductible
Second or third surgical opinions recommended by Med-Care 100%
Speech Therapy
Maximum number of allowable visits per calendar year
Must be pre-certified by Med-Care
50 visits
TMJ
Lifetime maximum benefit for non-surgical treatment (professional fees only)
Must be pre-certified by Med-Care. Calendar year deductible does not apply
$2,000
Travel Abroad
Maximum amount paid per participant per occurrence for medical expenses incurred while traveling abroad.
Calendar year deductible does not apply
$250
 
PRESCRIPTION DRUGS
 
Your co-pays 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-order 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
* PPIs and NSAHs are only covered if Med-Care pre-authorizes your use of a prescription version.
 
Generic/Brand Differential (Card, Mail and Walk-In) – If you chose a brand name drug when a generic equiva-lent is available, you will be responsible for the difference in cost between the brand and the generic equivalent, in addition to your percentage co-pay. The cost difference that you pay does not apply to the Rx out-of-pocket limit.
 
Prior Authorization and Clinical Review – Specialty drugs and other high-cost medications may require prior authorization by clinical personnel at Sav-Rx and/or Med-Care Management. The Plan has the right to exclude a high-cost drug if there are less expensive but clinically appropriate alternatives available.
 
Out-of-network prescriptions drugs are not covered.
 
VISION BENEFIT
 
Plan payment percentage:
 
Employees and spouses
80%
Children (under age 26) 100%
Maximum benefit payable per calendar year for all covered vision services and supplies $500
 
DENTAL BENEFIT
 
Dental HMO Plan (BlueCare Dental HMO)  
Deductible None
Diagnostic and preventive services (check-ups and cleanings) and x-rays Provided at no charge
All other covered dental procedures Provided in full after patient co-payment shown in the DHMO Plan brochure
Calendar year maximum benefit
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
No maximum
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:  
In-Network  
Diagnostic and preventive 100%
Restorative (minor and major) 90%
Out-of-Network  
Diagnostic and preventive 100%
Restorative (minor and major) 80%
Calendar year maximum benefit payable per person
 
Calendar year maximum does not apply to diagnostic and preventive services received by persons under age 19
$1,500
Lifetime maximum benefit payable per person for orthodontia $2,000