Program $3.24
Contribution Rate of $3.24 & Above | Effective 1/1/09
Schedule of Benefits| Death Benefits — Employees | |||||||||||
| Classification: Hours Worked Weekly |
Employee Death Benefit |
Employee AD&D | Dependent Death Benefit |
Employee Weekly A&S¹ |
Survivor Death Benefit | ||||||
| Monthly | Mos. | ||||||||||
| I. Less than 12 hours per week | $4,000 | $4,000 | $3,000 | $70 | $200 | 12 | |||||
| II. 12 through 19 hours per week | $5,000 | $5,000 | $4,000 | $90 | $300 | 12 | |||||
| III. 20 through 29 hours per week | $7,000 | $7,000 | $5,000 | $150 | $300 | 24 | |||||
| IV. 30 hours or more per week | $8,000 | $8,000 | $6,000 | $200 | $400 | 24 | |||||
| NOTE: Single Employees will have an additional $1,000 death benefit. Children age 10 days to 6 months: $1,000 death benefit. |
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| Employees & Family Member's Medical Benefits | ||||||||
| Description | Employee Classification | |||||||
| I | II | III | IV | |||||
| Physician Visits2 | ||||||||
| Primary Care Physician3 | $20 | $20 | $20 | $20 | ||||
| Specialist Physician | $35 | $35 | $35 | $35 | ||||
| Calendar Year Deductible4 | $200 | $200 | $200 | $200 | ||||
| After the calendar year deductible: | ||||||||
| Fund Pays In-Network (PPO) | 75% | 75% | 75% | 75% | ||||
| Participant Pays In-Network (PPO) | 25% | 25% | 25% | 25% | ||||
| Fund Pays (Out of PPO Network) | 65% | 65% | 65% | 65% | ||||
| Participant Pays (Out of PPO Network) | 35% | 35% | 35% | 35% | ||||
| TO: (In & Out of Network, Plus Deductible) 5 | $2,000 | $2,000 | $2,000 | $2,000 | ||||
| Fund Maximum Payment Per Calendar Year | $140,000 | $200,000 | $250,000 | $300,000 | ||||
| Family Prescription Benefit - Calendar Year Max 6 | $7,000 | $7,000 | $10,000 | $10,000 | ||||
| Birth Control Prescriptions and Devices 7 | $300 | $300 | $300 | $300 | ||||
| Dental Benefit - Employee (Calendar Year Max) 8 | $2,000 | $2,000 | $2,000 | $2,000 | ||||
| Dental Benefit - Dependent (Calendar Year Max) | $1,000 | $1,000 | $1,000 | $1,000 | ||||
| Family Prescription Benefit - Yearly | 7,000 | 7,000 | 10,000 | 10,000 | ||||
| Vision Care Benefits 9 | ||||||||
| Examination | $60 | $60 | $60 | $60 | ||||
| Single Vision Lenses | $100 | $100 | $100 | $100 | ||||
| Bifocal or Higher Vision Lenses | $150 | $150 | $150 | $150 | ||||
| Contact Lenses | $100 | $100 | $100 | $100 | ||||
| Frames | $100 | $100 | $100 | $100 | ||||
| Maternity is treated as any other illness for female employees and dependent wives. Eligibility Period: Employees become eligible for the benefits outlined above after completion of 90 days employment. 1 Weekly Accident and Sickness (A&S) Benefit: Payments are made to employees when they are disabled by a non-occupational accident or sickness. Payments begin 1st day for accident, 4th day for sickness, for a maximum of 26 weeks. 2 Physician Visits: Any services performed in the Physician's office are covered at 100% after the copayment. Services performed outside of the Physician's Office are subject to the Calendar Year Deductible and then paid at 75% in-network or 65% out of network. 3 Primary Care Physician: Primary Care Physician means: General Practitioner, Internist, Family Practice Physician, and Pediatrician. 4 Medical Benefits: Any combination of deductible payment for families of three or more shall be no more than $600 in a calendar year, combined in and out of network. 5 Medical Benefits: Families of three or more shall have maximum out of pocket expenses of no more than three times $2,000 in a calendar year, combined in & out of network, plus deductibles, up to the Fund maximum per calendar year. 6 Prescription Drug Benefit: The Fund pays 75% of the eligible charge up to the family calendar year maximum. 7 Birth Control Prescriptions and Devices: Employees and spouses, $300 per calendar year paid at !00% (excludes dependent children) 8 Dental Benefits: Participant pays the first $25 calendar year deductible. The Fund then pays 75% of covered charges up to the calendar year maximum. Prosthetic devices and services have a 12-month waiting period and are paid at 50% of covered charges up to the annual maximum. Orthodontic services and supplies are not covered. 9 Vision Benefits: Only (3) vision benefits payable in a 24 month period. Examination - $60, Single Vision Lenses - $100, Bifocal or higher Vision Lenses - $150, Contact Lenses - $100, Frames - $100 | ||||||||
