The following schedule shows the percentage of the “allowance” the Plan will pay for covered expenses. Your allowance is the Plan’s pre-determined amount for a particular service. For most medical services, the Plan pays 80% of expenses after you’ve met your Annual Deductible. You are responsible for the other 20% (the Patient’s Responsibility)..
Effective January 1, 2022, the Patient’s Responsibility for No Surprises Services will be determined based on the lesser of the Qualifying Payment Amount payable for such Services or the amount billed by the provider. Further, your Patient Responsibility payment for No Surprises Services will be counted towards your Deductible and Out-of-Pocket Maximum..
If you visit a provider in the UnitedHealthcare (UHC) network, the Allowance is accepted as payment in full for a particular service. In those cases, you will generally owe only the Patient’s Responsibility to the participating provider. If your provider is not in the UHC network, you are responsible for paying any amount your provider charges above the allowance in addition to the Patient’s Responsibility, unless the non-UHC provider’s services are No Surprises Services.
| MEDICAL DEDUCTIBLES, OUT-OF-POCKET MAXIMUM, IN/OUT OF NETWORK, & LIFETIME BENEFIT COVERAGE Both Standard (full) and “H” Plan Members (limited) |
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|---|---|
| Annual Deductible | $150 per individual |
| $300 per family | |
| Annual Out-of-Pocket Maximum | All Standard Plan Members--$8,000 per family, after meeting the annual deductible “H” Plan Members—No Annual Out-of-Pocket Maximum |
| Network Access | All Standard Plan Members—In and Out of Network Coverage; “H” Plan Members—Only In-Network Coverage |
| Lifetime Benefit Coverage | All Standard Plan Members--$1,000,000 (essential and non-essential health benefits) then coverage level reduces from 80% of allowance to 50% of allowance for essential health benefits and non-essential health benefits are no longer covered “H” Plan Members--$100,000 (essential and non-essential health benefits) then coverage level reduces from 80% of allowance to 50% of allowance for essential health benefits and non-essential health benefits are no longer covered |
| MEDICAL BENEFITS Both Standard and “H” Plan Members |
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|---|---|
| Covered Service | Plan Pays |
| Doctor’s Office Visits | 80% of allowance, after annual deductible |
| Chiropractic Care | 80% of allowance, after annual deductible prior authorization required after first 20 visits) |
| Emergency Medical Care | 80% of allowance, after annual deductible |
| Diagnostic Laboratory Pathology Tests and X-Ray Examination (Outpatient) | 80% of allowance, after annual deductible |
| Emergency Room Treatment, if Not Hospitalized | 80% of allowance, after annual deductible |
| Charges by Physicians and Surgeons (Inpatient or Outpatient) | 80% of allowance, after annual deductible |
| Durable Medical Equipment | 80% of allowance, after annual deductible |
| Hospitalization | |
| Expenses up to $7,000 for each spell of illness | 100% of allowance, no deductible applies |
| Expenses in excess of $7,000 | 80% of allowance, no deductible applies |
| Home Health Care | Prior Authorization Required |
| Covered home health care visits by a registered or licensed practical nurse | 80% of allowance, no deductible applies |
| Covered home health care visits by a home health care aide | 100% of allowance, after annual deductible |
| Convalescent Nursing Home Care |
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| Semi-private accommodations rate charged by discharging hospital | 50% of allowance, no deductible applies |
| Maximum days per spell of illness | 60 days |
| Maximum benefit when combined with covered charges made by discharging hospital | $7,000 |
| Covered charges that exceed the maximum | 80% of allowance, no deductible applies |
| Hospice Care (Approved Facility) | 100% of allowance, no deductible applies |
| Surgery (Including Organ Transplants) | |
| Charges by physicians and surgeons in or out of the hospital | 80% of allowance, after annual deductible |
| Assistant or co-surgeon | 25% of allowance for surgeon, at 80%, after annual deductible |
| Anesthesiologist’s charges | 80% of allowance |
| Second Surgical Opinion | 100% of allowance, no deductible applies |
| Facility fee charged by an approved facility for outpatient surgery (up to first $7,000 per spell of illness) | 100% of allowance, no deductible applies |
| Expenses after $7,000 | 80% of allowance, no deductible applies |
| Wellness |
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| Child Wellness Visits and Examinations of eligible dependent children by a physician including required immunizations according to the following maximum number of visits: Birth through age 23 months; maximum of ten visits 80% of allowance, after annual deductible |
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| Birth through age 23 months; maximum of ten visits | 80% of allowance, after annual deductible |
| Age 2 through age 26; one visit per year | 80% of allowance, after annual deductible |
| Physical Exams for participants and spouses | 80% of allowance, after annual deductible (including tests and immunizations) |
| Well-woman office visit | 80% of allowance, after annual deductible |
| Bariatric surgery — Only one surgical procedure is covered and prior authorization is required by Bariatric Resource Services. | 80% of allowance up to maximum lifetime benefit of $100,000. After maximum reached, eligible expenses covered at 50%. |
| Mammogram | One per year for women age 35 or over |
| Zostavax - Physical Examination includes coverage (including administration) for Zostavax, a vaccine for the prevention of herpes zoster (shingles). NOTE: The Zostavax vaccine benefit is also available to Medicare-eligible retirees and their spouses, provided such retirees or spouses are not enrolled in a separate Medicare Part “D” prescription plan. | 80% of allowance, no deductible applies |
| Gardasil – for all eligible members through age 26 and dependents through the end of the month they reach age 26 | 80% of allowance, subject to deductible |
| Gynecological Care and Maternity Expenses |
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| Hospital bills, including maternity and nursery expenses up to $7,000 per spell of illness. | 100% of allowance, no deductible applies |
| Expenses in excess of $7,000 | 80% of allowance, no deductible applies |
| Maternity and Gynecological Care expenses including charges by physicians and surgeons in or out of the hospital | 80% of allowance, after annual deductible |
| Initial routine physical examination for newborn | 100% of allowance, no deductible applies |
| Assistant or co-surgeon | 25% of allowance for surgeon, at 80% after annual deductible |
| Pap Test | One routine exam per year |
| MENTAL HEALTH BENEFITS Both Standard (full) and “H” Plan Members (limited) Substance Use Disorder and Mental Health Treatment Coverage for Standard Plan Members Only; NO Coverage for “H” Plan Members |
|
|---|---|
| Covered Service | Plan Pays |
| Outpatient treatment | 80% of allowance, after annual deductible |
| Inpatient treatment for the first $7,000 of expenses for each spell of illness | 100% of allowance, no deductible applies |
| Inpatient expenses in excess of $7,000 for each spell of illness | 80% of allowance, no deductible applies |
| Employee Assistance Program (EAP) —Both Standard and “H” Plan Members | |
| Counseling Sessions | 8 Free Sessions per Year |
| PRESCRIPTION DRUG BENEFITS— Coverage for Standard Plan Members Only; NO Coverage for “H” Plan Members |
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|---|---|---|
| Prescription Drug | Participating Pharmacy Participant Pays | Non-Participating Pharmacy Participant Pays |
| Retail (34-Day Supply) |
||
| Generic Drugs | $10 copayment | $10 copayment plus difference between the allowance and retail price |
| Preferred Brand Name Drugs | $25 copayment | $25 copayment plus difference between the allowance and retail price |
| Non-Preferred Brand Name Drugs | $35 copayment | $35 copayment plus difference between the allowance and retail price |
| Mail Order or CVS (90-Day Supply) |
||
| Generic Drugs | $20 copayment | Not covered |
| Preferred Brand Name Drugs | $50 copayment | Not covered |
| Non-Preferred Brand Name Drugs | $70 copayment | Not covered |
| DENTAL BENEFITS Coverage for Standard Plan Members Only; NO Coverage for “H” Plan Members |
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|---|---|---|
| Dental Services | PPO Provider Plan Pays | Non-PPO Provider Plan Pays |
| Dental Care (Preventive Services) |
||
| Visits and Examinations | 100% of the allowance | 80% of the allowance |
| Examinations (limited to once every six months) | 100% of the allowance | 80% of the allowance |
| Prophylaxis, including scaling and polishing (limited to once every six months) | 100% of the allowance | 80% of the allowance |
| Topical applications of fluorides limited to one course of treatment per 12-month period | 100% of the allowance | 80% of the allowance |
| X-Rays and Pathology | ||
| Single films (up to 13) | 100% of the allowance | 80% of the allowance |
| Panorex (limited to once every year) | 100% of the allowance | 80% of the allowance |
| Entire denture series (14 or more films; limited to once every year) | 100% of the allowance | 80% of the allowance |
| Bitewings | 100% of the allowance | 80% of the allowance |
| Biopsy and examination of oral tissue | 100% of the allowance | 80% of the allowance |
| Dental Care (Basic Services) | ||
| Problem visits | 80% of the allowance | 80% of the allowance |
| Consultation by specialist when diagnosis has been made by a general dentist | 80% of the allowance | 80% of the allowance |
| Restoration (fillings) | 80% of the allowance | 80% of the allowance |
| Oral Surgery (Including Local Anesthesia) | 80% of the allowance | 80% of the allowance |
| Extractions | 80% of the allowance | 80% of the allowance |
| Incision and drainage of abscess | 80% of the allowance | 80% of the allowance |
| Removal of cyst or tumor | 80% of the allowance | 80% of the allowance |
| Alveoplasty with ridge extension | 80% of the allowance | 80% of the allowance |
| Suture, soft tissue injury | 80% of the allowance | 80% of the allowance |
| Periodontics | 80% of the allowance | 80% of the allowance |
| Subgingival curettage | 80% of the allowance | 80% of the allowance |
| Root planning | 80% of the allowance | 80% of the allowance |
| Provisional splinting | 80% of the allowance | 80% of the allowance |
| Gingivectomy | 80% of the allowance | 80% of the allowance |
| Endodontics | 80% of the allowance | 80% of the allowance |
| Pulp capping | 80% of the allowance | 80% of the allowance |
| Root canals | 80% of the allowance | 80% of the allowance |
| Apicoectomy | 80% of the allowance | 80% of the allowance |
| Denture repairs | 80% of the allowance | 80% of the allowance |
| Space maintainer, fixed (bank type) and removable | 80% of the allowance | 80% of the allowance |
| Dental Care (Major Services) |
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| Inlays and Crowns (not covered if teeth can be restored with a filling material) | 80% of the allowance | 50% of the allowance |
| Pontics (artificial teeth) | 80% of the allowance | 50% of the allowance |
| Removable bridge (one piece casting clasp attachment) | 80% of the allowance | 50% of the allowance |
| Dentures (complete upper or lower; specialized techniques not eligible) | 80% of the allowance | 50% of the allowance |
| Orthodontia | 50% of the allowance | 50% of the allowance |
| Maximum for Orthodontia Dental Services | $3,000 per lifetime per participant | $3,000 per lifetime per participant |
| Maximum For All Covered, non-Orthodontia Dental Services | Children Under Age 18: No Limit Members, Spouses and Children Age 18 and Older: $3,000 per calendar year |
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| VISION BENEFITS Coverage for Standard Plan Members Only; NO Coverage for “H” Plan Members |
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|---|---|---|
| Vision Services | VSP Provider Plan Pays | Non- VSP Provider Plan Pays |
| Vision survey once every calendar year, unless prescription changes and meets specified criteria | 100% of allowance | You pay the difference between the actual charge and the allowance |
| Vision analysis, if indicated, once every calendar year, unless prescription changes and meets specified criteria | 100% of allowance | You pay the difference between the actual charge and the allowance |
| Eyeglass lenses, if necessary, once per every two calendar years, unless prescription changes and meets specified criteria | 100% of allowance | You pay the difference between the actual charge and the allowance |
| Frames, once every two calendar years, unless prescription changes and meets specified criteria | 100% of allowance, up to $150 per person | You pay the difference between the actual charge and the allowance |
| Contact lenses once every two calendar years, unless prescription changes and meets specified criteria | 100% of allowance, up to $100 per person | You pay the difference between the actual charge and the allowance |
| Safety Glasses (actively working eligible members only) once per calendar year | 100% of allowance for lenses. Safety frames at 100% of allowance up to $65 plus 20% of out of pocket costs | You pay the difference between the actual charge and the allowance |
| Computer Glasses (actively working eligible members only) once every two calendar years | 100% of allowance for lenses. Frames at 100% of allowance up to $40 plus 20% of out of pocket costs | You pay the difference between the actual charge and the allowance |
| HEARING BENEFITS Coverage for Standard Plan Members Only; NO Coverage for “H” Plan Members |
|
|---|---|
| Audiologist Exam | 80% of allowance, up to $100 maximum |
| First Hearing Aid | $3,000 |
| Second Hearing Aid | $1,000 |
| ACCIDENTAL DISMEMBERMENT AND LOSS OF SIGHT BENEFITS Coverage for Standard Plan Members Only; NO Coverage for “H” Plan Members |
|
|---|---|
| Loss of One Hand | $5,000 |
| Loss of One Foot | $5,000 |
| Loss of Sight of One Eye | $5,000 |
| Loss of Two or more of the above | $10,000 |
| WEEKLY ACCIDENT AND SICKNESS BENEFITS Coverage for Standard Plan Members Only; NO Coverage for “H” Plan Members |
|
|---|---|
| Benefit based on a percentage of regular gross compensation and a normally scheduled work week of 40 hours or less |
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| First 13 weeks of disability | 50%; $700 per week maximum |
| Next 13-weeks of disability (after Trustee approval) | 40%; $420 maximum per week |
| DEATH BENEFITS Coverage for Standard Plan Members Only; NO Coverage for “H” Plan Members |
|
|---|---|
| Eligible Active Electrical Worker or Non-Bargaining Unit Employee | $50,000 |
| Eligible Retired Employee | $12,000 |
| SUPPLEMENTAL OCCUPATIONAL ACCIDENT BENEFITS Coverage for Standard Plan Members Only; NO Coverage for “H” Plan Members |
|
|---|---|
| Loss of life | $100,000 maximum benefit payable |
| Loss of one hand | $50,000 maximum benefit payable |
| Loss of one foot | $50,000 maximum benefit payable |
| Loss of sight in one eye | $50,000 maximum benefit payable |
| Loss of hearing in one ear | $50,000 maximum benefit payable |
| Two or more of the above | $100,000 maximum benefit payable |
| Loss of speech | $100,000 maximum benefit payable |
| Thumb and index finger of same hand | $25,000 maximum benefit payable |
| First 52 weeks of disability | $150 per week maximum |
| Next 52 weeks of disability | $150 per week maximum |
| The maximum amount payable for Supplemental Occupational Accident Benefits is $100,000 including $50,000 for disability. |
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