Bakery Drivers Local 734 | Welfare Schedule of Benefits – Retiree
15800
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Welfare Schedule of Benefits – Retiree

Retiree 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.

RETIREE DEATH BENEFIT
(For Retirees only)
 
Death Benefit Amount $1,000
 
COMPREHENSIVE MEDICAL 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
Out-of-network hospital penalty
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.
$250
Out-of-pocket limit per person
Only in-network covered medical expenses apply toward your out-of-pocket limit. The calendar year deductible also applies toward the out-of-pocket limit.
$2,500
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%
Applied Behavior Analysis (ABA) Therapy
Maximum number of allowable visits per calendar year
Must be pre-certified by Med-Care.
50 visits
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 requirements
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
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
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% 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.
Surgical TMJ is payable at 80%, subject to the deductible, and must be pre-certified by Med-Care.
$2,000
Travel Abroad
Maximum amount paid per participant per occurrence for medical ex-penses 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.  
Prescription Drug Out-of-Pocket Limit per person calendar year
If the total amount you paid in co-pay percentages reach $3,000 for a calendar year, the Plan will pay 100% for your covered prescription drug expenses during the remainder of that calendar year.
$3,000
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 equiva-lent, 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.
 
* PPIs and NSAHs are only covered if Med-Care pre-authorizes your use of a prescription version.