LOCAL UNION 82 IBEW HEALTH & WELFARE FUND
BENEFITS AT A GLANCE
COMPREHENSIVE MAJOR MEDICAL BENEFITS
All benefits will be based upon Reasonable & Customary allowances.
Network (PPO Providers)
Calendar Year Deductible
| Per Individual | Per Family |
|---|---|
| $ 500.00 | $1,000.00 |
Most eligible charges will generally be paid at 80% until the maximum out-of-pocket amount has been satisfied. After the maximum out-of-pocket amount has been satisfied, 100% payment on eligible charges thereafter for that individual for the remainder of that Calendar Year.
Maximum Out-of-Pocket Expense per Calendar Year (including the deductible)
| Per Individual | Per Family |
|---|---|
| $2,500.00 | $5,000.00 |
Non-Network (Non-PPO Providers)
Calendar Year Deductible
| Per Individual | Per Family |
|---|---|
| $1,000.00 | $2,000.00 |
Most eligible charges will generally be paid at 60% of the Reasonable and Customary until the maximum out-of-pocket amount has been satisfied. After the maximum out-of-pocket amount has been satisfied, 100% payment on eligible charges thereafter for that individual for the remainder of that Calendar Year.
Maximum Out-of-Pocket Expense per Calendar Year (including the deductible)
| Per Individual | Per Family |
|---|---|
| $ 5,000.00 | $10,000.00 |
Once a person or family reaches the Out-of-Pocket maximum for Non-Network benefits, all future Out-of-Network benefits will be paid at 80% of the Reasonable and Customary charges for the remainder of the Calendar Year. In Network and Non-Network Deductibles and Out-of-Pocket amounts will cross-apply. This means that Non-Network expenses apply toward your Network deductible and Network Out-of-Pocket maximum.
PRESCRIPTION DRUG BENEFITS
| Calendar Year Deductible per Individual | $25.00 |
| Maximum Out-of-Pocket Expense per Calendar Year | $2,500.00 |
| Retail Copay at a Sav-Rx Pharmacy, up to a 34-day supply | You pay 20% |
$5.00 minimum on generic
$20.00 minimum on brand
| Retail Copay at a Non- Sav-Rx Pharmacy, up to a 34-day supply | You pay 50% |
| Sav-Rx Mail Order Copay, up to 90-day supply | You pay 20% |
$5.00 minimum on generic
$20.00 minimum on brand
DENTAL BENEFITS
| Calendar Year Maximum (per individual, Class I, II and III) | $2,500.00* |
| Deductible (per individual, Class II, III and IV) | $100.00 | Orthodontic Lifetime Maximum | $2,500.00 per Participant |
Percentages Payable:
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