These benefits are provided by the Trust through Blue Cross. To see a side-by-side comparison of all medical plans, please click here.
This is only a guide. For more information, please see your Summary Plan Description. Information about the Self-Funded Medical Plan is on page 16.
| Maximums & Deductibles | |
|---|---|
| Maximum Lifetime Benefit | $2 million per eligible person |
| Maximum Lifetime Benefit for Chemical Dependency | $25,000 |
| Deductible | $250 for all accidents and sickness applied once each calendar year for each eligible person. Maximum per family is $750. |
| Supplemental Accidental Benefit | $500 |
| Medical Benefits | |
| Hospital - Medical - Surgical Benefits | 80% of such Usual, Customary, and Reasonable charges each calendar year in excess of the $250 deductible amount for each eligible person. |
| Private room limit | The average semi-private room charge made in the hospital where the eligible person is confined. |
| Blue Cross PPO Contract Hospitals | 80% of such Usual, Customary, and Reasonable charges each calendar year in excess of the $250 deductible amount for each eligible person. |
| Convalescent Care | One-half of the average semi-private room allowance for 120 days in a convalescent period. |
| Mental Health Benefits | |
| Outpatient Services | 80% of covered charges in excess of the $100 deductible, up to a maximum of 16 visits in a 12-month period, except for emergency services, which require prior authorization by Blue Cross. Without prior authorization, benefits will not be paid. |
| Inpatient services | Covered up to a maximum of 45 days in a 12-month period, if approved by Blue Cross. Regular plan benefits are payable for services at contracting facilities, except for emergency services at non-contracting facilities, which are limited to 50% of normal benefits. Without prior authorization, benefits will not be paid. |
| Residential care confinements | 80% of covered charges up to a maximum of 270 days in a 12-month period at a pre-approved inpatient residential care facility for eligible Dependent children with an AXIS I diagnosis (as defined in the Diagnostic and Statistical Manual of Mental Disorders). Without prior authorization from Blue Cross, benefits will nto be paid. |
| Prescription Drug Program | |
| Retail pharmacy (with prescription drug card); 30-day supply | The greater of 20% or $10 per prescription |
Mail Order Program; up to 90-day supply: -generic -brandname |
$10 |
To receive the highest coinsurance percentage for all medical services, utilize an Anthem Blue Cross PPO Network provider. For Out-of-Network services - the coinsurance is 60% in 2009.