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Schedule of Benefits
Updated On: May 07, 2013

 Contact the Benefits Office

As always, the Plan Documents and Amendments supercede any other documents or any of the information listed above and can be changed by the Board of Trustees at any time without any prior notice.

Benefits for Employees Only Benefits For Retirees Only

Life Insurance 

Benefits For Employees, Retirees, and Their Dependents
Schedule of Dental Benefits
Vision Care Expense Benefit
Benefits for Employees Only
Life Insurance
 
$20,000
Accidental Death And Dismemberment (AD&D) Insurance
 

$20,000

Maximum period that benefits are payable per sickness/injury
26 weeks
Day of disability that benefits start:
Disabilities due to Accidental injury 1st day
Disabilities due to sickness:
Outpatient surgery 1st day
Not hospital confined 8th day
Hospital Confined 1st day of confinement before 8th day
Benefits For Retirees Only
Retiree Life Insurance
$5,000
Benefits For Employees, Retirees, and Their Dependents
Maximum benefit payable per person per accident for covered expenses incurred within 90 days of the accident
$250
Plan co-pay percentage (no deductible applies)
100%
(Excess covered expenses are considered for payment under the Comprehensive Benefit, subject to the deductibles, co-pay percentage, out-of--pocket limits, etc.)
Maximum benefit payable per person per employee, retiree or dependent spouse for covered expenses incurred for routine examinations and preventative services $300
Plan co-pay percentage (no deductible applies)
100%
Well-Child Care for Dependent Children--the Plan will pay 100% (no deductible) up to the following maximums:
  • $1,000 first year of life - child's birth through day before child's 1st birthday.
  • $300 second year of life - child's 1st birthday through day before child's 2nd birthday.
  • $300 third year of life - child's 2nd birthday through day before child's 3rd birthday.
  • $300 fourth year of life - child's 3rd birthday through day before child's 4th birthday.
  • $300 fifth year of life - child's 4th birthday through day before child's 5th birthday.
  • $600 for the period from the child's fifth birthday through day before child's 13th birthday.
  • $600 for the period from the child's 13th birthday through day before child's 19th birthday.
  • $600 for the period from the child's 19th birthday through day before child's 26th birthday.
These maximum benefits will apply to all covered well-child care expenses - exams, immunizations and inoculations.  Amounts paid under the prior well-child care benefits will apply to the new maximums shown above.
Excess charges will carry over to major medical - Covered expenses incurred on and after January 1, 2008 that are in excess of the maximums listed above WILL carry over to the major medical benefit (the "Comprehensive Benefit") and be paid subject to the deductible and co-payment provisions.  As with other covered expenses, the Plan pays higher benefits when you use physicians in the Blue Cross PPO Network.
Only charges incurred on and after January 1, 2008 are eligible for the increased benefits.  No additional benefits are payable for claims incurred prior to that date.
Maximum benefit payable per person for covered expenses incurred for hearing care  $1,500 each ear
every 5 years
Plan co-pay percentage (no deductible applies)
80%
(Excess charges do not carry over to the Comprehensive Benefit)
Calendar year maximum benefit payable per person for diagnostic x-rays $100
Calendar year maximum benefit payable per person for all chiropractic treatment, including up to $100 for  x-rays $750
Maximum benefit payable per visit $35
Plan co-pay percentage (no deductible applies)
100%
(Excess charges do not carry over to the Comprehensive Benefit)
  • Only the  "covered medical expenses" listed on pages 63-66 will be considered for payment under the Comprehensive Benefit. Only covered medical expenses can be used to satisfy deductibles. Only a person's out-of-pocket payments for his co-pay percentage share of  covered medical expenses count toward out-of-pocket limits. You are responsible for paying all amounts of charges incurred by you and your dependents that are not considered medical expenses.
  • If non-emergency care is received from a non-PPO provider (hospital or doctor) and there is no equivalent (same medical specialty) PPO provider within 10 miles of the non-PPO provider, benefits will be paid for the non-PPO covered medical expenses as though a PPO provider had been used.
  • Only excess covered expenses incurred under the Supplemental Accident Expense Benefit and the Routine Physical Examination Expense Benefit (except well child care) carry over for consideration for payment under the Comprehensive Benefit. Excess charges incurred under any of the other health care benefits do not carry over for payment under the Comprehensive Benefit.
  • Payments under this benefit are based only on the amounts of charges that are considered to be reasonable and customary (R&C) charges (see page 23).
Calendar Year  Maximum Benefit Payable per Person $2,000,000
Deductibles
Calendar year deductibles (amounts of covered medical expenses applied to PPO deductibles also apply to non-PPO deductibles and vice versa)
PPO deductibles (applied  to covered medical expenses incurred from PPO providers):
Individual deductible $200
Family deductible (satisfied by 2 or more family members) $600
(These deductibles apply to covered medical expenses incurred for prescription drugs, whether or not prescribed by a PPO doctor)
Non- PPO deductibles (applied to covered medical expenses incurred from non-PPO providers and other non-doctor and non-hospital providers):
Individual deductible $300
Family deductible (satisfied by 2 or more family members) $900
Plan Co-Pay/Payment Percentages subject to all maximum benefits and other stated limitations (see "Special Limitations" starting on page 15 for exceptions and additional limitations).
  • The 80% co-payment shown below does not apply to chemical dependency or mental/nervous disorders expenses ("Special Limitations"), and the Plan will not at any time pay 100% for those types of expenses.
  • Amounts of out-of-pocket payments applied toward meeting PPO out-of-pocket limits will also apply toward meeting the non-PPO out-of-pocket limits and vice versa.
Payments for PPO covered medical expenses during a calendar year:
Plan co-pay percentage per person per family for covered medical expenses incurred during a year from PPO providers and for prescription drugs after satisfaction of the PPO individual/family incentive deductible UNTIL the person/family has met the PPO individual/family out-of-pocket limit. 80%
Plan payment percentage per person per family for covered medical expenses incurred during a year from PPO providers and for prescription drugs after satisfaction of the PPO individual/family incentive deductible AFTER  the person/family has met the PPO individual/family out-of-pocket limit. 100%
Payments for non-PPO covered medical expenses during a calendar year:
Plan co-pay percentage per person per family for covered medical expenses incurred during a year from non-PPO providers and other non-doctor/non-hospital service providers after satisfaction of the non-PPO individual/family incentive deductible UNTIL the person/family has met the non-PPO individual/family out-of-pocket limit. 60%
Plan payment  percentage per person per family for covered medical expenses incurred during a year from non-PPO providers and other non-doctor/non-hospital service providers after satisfaction of the non-PPO individual/family incentive deductible AFTER  the person/family has met the non-PPO individual/family out-of-pocket limit. 100%
Out-Of Pocket Limits per Calendar Year after satisfaction of applicable deductibles.
  • Out-of-pocket limits do not include out-of-pocket payments made to satisfy deductibles or made as a person's co-pay share of covered medical expenses incurred for chemical dependency or mental/nervous disorders. (See pages 59-61 for more details).
  • Amounts of out-of-pocket payments applied toward meeting PPO out-of-pocket limits will also apply to the non-PPO out-of-pocket limits and vice versa.
PPO out-of-pocket limits:
Individual out-of-pocket limit $1,500
Family out-of-pocket limit (met by 3 or more family members) $3,000
Non-PPO out-of-pocket limits:
Individual out-of-pocket limit $3,000
Family out-of-pocket limit (met by 3 or more family members) $4,000
Special Limitations
Hospital Room and Board allowable covered medical expenses:
Semi-private or private room
Semi-private room rate
Intensive Care Units, Cardiac Care Units, etc. Hospital's R&C charge
Treatment of Mental or Nervous Disorders:
Lifetime maximum allowable number of days pf inpatient hospital treatment per person, including days of partial hospitalization and day care (intensive outpatient treatment)

Effective January 1, 2010

No limit

Calendar year maximum allowable number of regular outpatient visits per person No limit
(Benefits which apply to these maximums also apply to the person's $2,000,000 Comprehensive Benefit lifetime maximum benefit.)
Plan co-payment percentages:
Inpatient treatment 80% PPO, 60% Non-PPO
Regular Outpatient visits 80% PPO, 60% Non-PPO
Treatment for Chemical Dependency*

Lifetime maximum benefit per person

 No limit   
                                           
Calendar year maximum allowable days of inpatient and outpatient treatment combined per person No limit
Plan co-pay percentage for all inpatient and outpatient treatment 80% PPO, 60% Non-PPO
Treatment of Learning or Behavior Disorders
Plan co-pay percentage 80% PPO, 60% Non-PPO
Orthotics -Lifetime maximum benefit payable per person for covered medical expenses incurred for foot orthotics Paid at 80%, 20%, deductible applied if not met up to maximum of $1,000
Transplant Maximums Removed:  Effective July 1, 2011, the specific dollar maximums for transplants will no longer apply.
Infertility
CHANGES TO INFERTILITY BENEFITS
$40,000 Lifetime Maximum -The scheduled limits on the numbers of infertility treatments of infertility treatments covered  by the Plan have been replaced by a $40,000 maximum. This is the most the Plan will pay for  all covered treatment  received by an eligible employee and his spouse combined during the employee's lifetime. It applies to all diagnostic procedures and all treatments, including prescription drugs and surgery. It will not be reinstated if you divorce and remarry.
How Benefits Will be Paid -Covered infertility expenses in excess of your calendar year deductible will be paid at 80% up to the $40,000 maximum. Your 20% co-payments will not apply to the out-of-pocket limit, and the Plan will not pay 100% for infertility expenses if your out-of-pocket limit has been met by other claims.
Covered Expenses -The types of covered infertility expenses are not changing. As before, the Plan covers reasonable and customary charges for:
  • Office visits and consultations
  • Hormone Treatments (prescription)
  • Surgery
  • Gamete intrafallopian transfer (GIFT)
  • Intracytoplasmic sperm injection (ICSI)
  • Diagnostic tests
  • Intrauterine insemination (IUI)
  • In Vitro fertilization (IVF)
  • Zygote intrafallopian transfer (ZIFT)
Exclusions -Except for the removal of the frequency limits and the $40,000 maximum, the same limitations, provisions and exclusions will continue to apply. As before, infertility benefits will be provided for active employees and their spouses ONLY. No benefits are payable for children, or retirees and their spouses.
Effective date of change – This change was made effective November 1, 2003, but it applies to charges incurred prior to November 1, 2003.
Plan payment percentage for up to a 90-day supply of a covered prescription drug:
Generic equivalent drugs per prescription or refill
100% after your
 $15 co-payment
Brand Name drugs per prescription or refill
100% after your
 $30 co-payment
How to use the Caremark Prescription Drug Program (Retail)
  • You will be required to pay $5 minimum / 10% of the contracted price to the participating pharmacy. Contracted prices are usually lower than the pharmacy's regular retail prices. The Plan will pay the rest.
  • For each purchase you make, you will be able to get up to a 30-day quantity, or the quantity prescribed by the doctor, whichever is less.
  • There are no claims to file
  • You can use your I.D. card to get the amount of medication prescribed by your doctor plus 2 refills. After you purchase the initial supply plus 2 refills if a maintenance drug, you must use the Mail Order Program or CVS Retail for all additional refills. If a doctor prescribes a drug that must be taken on a long-term basis, ask the doctor for two prescriptions- one for 30 day supply that you can have filled immediately at a local participating pharmacy under the Drug Card Program, and one for up to a 90-day supply (with refills) that you can obtain through the Mail Order Program.
  • Your $5 minimum / 10% co-pay amounts do not apply any Plan deductibles or out-of-pocket limits.
If you use a non-participating pharmacy- If you purchase a covered prescription drug at a pharmacy that is NOT in the Caremark network, you will need to file a claim with the Fund Office for partial reimbursement under the Comprehensive Benefit.
  • The amount you paid the non-participating pharmacy will be reduced by 50% and the remaining balance will be paid at 80% (provided your $200 calendar year deductible has been satisfied).
  • Neither the 50% reduction nor your 20% co-pay will apply to any Plan deductibles or out-of-pocket limits.
  • The 50% reduction will not apply if live more than 15 miles from a participating pharmacy- be sure to note this information on your claim.
Exclusions and Limitations - You cannot use the Prescription Drug Card Program for:
  1. any products, drugs or medications which can be obtained without a doctor's written prescription
  2. experimental or investigative drugs or medications
  3. drugs or medications which are used for or in connection with any type of treatment or condition for which benefits are excluded under the Plan, even though such drugs or medications are obtained with a doctor's prescription
  4. drugs or medications that are excluded from coverage under any other provision or rule of this Plan, including but not limited to the provisions of "What the Plan Does Not Cover" starting on page 78 of your SPD.
Schedule of Dental Benefits
Delta Preferred Network
Schedule
Delta Premier Network
Schedule
Out of Network Schedule
Calendar Year Maximum Benefit
$1,500
$1,250
$1,000
(The $1,500 maximum includes all payments made under the DeltaPreferred Network, DeltaPremier Network or Out-of-Network Schedules. The $1,250 maximum includes all payments made under the DeltaPremier Network or Out-of-Network Schedules.)
Deductible
None
None
None
Delta Co-Payment Percentage:
Diagnostics and Preventive
100%
100%
100%
Routine and Major Restorative and Prosthodontics
80%
80%
80%
Orthodontics
(Dependent Children to age 19)
Lifetime Maximum Benefit
$1,5000
$1,250
$1,000
(The $1,500 maximum includes all payments made under the DeltaPreferred Network, DeltaPremier Network or Out-of-Network Schedules. The $1,250 maximum includes all payments made under the DeltaPremier Network or Out-of-Network Schedules.)
IMPORTANT NOTES
You are not responsible for the difference between the billed charges and negotiated charges
You are not responsible for the difference between the billed charges and Delta's usual & customary fees
The dentist may bill you for charges exceeding Delta's usual and customary fees.
See No. 15 on page 72 for information about benefits for tooth implantation for the sole purpose of anchoring a denture
Please contact Delta Dental at 1-800-452-1987 to verify the Schedule of Benefits
VSP DOCTOR
SCHEDULE
NON-VSP DOCTOR
REIMBURSEMENT
SCHEDULE
Vision Examination
COVERED IN FULL
Up to $30.00
Frame
$120 allowance, 20% discount off the amount over the allowance.
Up to $45.00
Lenses
Single Vision
COVERED IN FULL
Up to $30.00
Lined Bifocal Lenses COVERED IN FULL
Up to $35.00
Lined Trifocal Lenses COVERED IN FULL
Up to $45.00
Lined Lenticular Lenses COVERED IN FULL
Up to $60.00
Polycarbonate Lenses (dependent children) COVERED IN FULL N/A
Tints / Photochromics COVERED IN FULL
Up to $ 5.00
Contacts (in lieu of frame and eyeglass lenses), per pair:
Visually Necessary* COVERED IN FULL
Up to $210.00
Elective $120.00
$120

-Services and allowances are available every 12 months.

-When the schedule shows a dollar allowance, VSP will pay the lesser of the reasonable and customary charge, or the allowance for that service or supply.

* Contacts are visually necessary when a patient's vision cannot be corrected with glasses, as determined by VSP.

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August 18, 2018
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