Welfare Summary Plan Description

MEDICAL PLAN BENEFIT – See SECTIONS 5.1 THROUGH 5.18

Benefit Funded by the Trust

Lifetime Maximum Benefit

For Eligible Employee and their Dependents - $1,000,000
For Retired Participants and their Dependents - $500,000
Lifetime Maximum for Treatment of Substance Abuse - $50,000
Maximum Restoration of Benefits Paid in Calendar Year - $10,000

Calendar Year Deductible

For Eligible Employees and their Dependents

Per Participant - $200
Per Family - $400

For Retired Participant and their Dependents

Each Participant WITH Medicare - $200
Each Participant WITHOUT Medicare - $2,000

Annual Out-of-Pocket Limit

For Eligible Employees and their Dependents

Per Participant - $3,000
Per Family - $6,000

For Retired Participant and their Dependents

Each Participant WITH Medicare - $1,500
Each Participant WITHOUT Medicare - $6,000

Hospital Services (inpatient and outpatient)

Preferred Providers
% of Covered Expenses

Non-Preferred Provider
% of contract rates
Hospitals in Alaska, in Anchorage
80%
70% of rate negotiated
with Preferred Provider;
after additional $1,000
inpatient deductible
Hospitals in Alaska, outside Anchorage
80%
70%
Hospitals outside of Alaska
80%
70%
Preadmission Testing
100%
100%
Professional Services and Supplies
Physician visits (home, office, or hospital visits)
80%
70%
Surgeon and assistant surgeon
80%
70%
Diagnostic x-rays, laboratory testing
80%
70%
Chiropractic office visits
(up to 10 visits per year)
80%
70%
Physical or occupational therapy
(up to 20 visits per year)
80%
70%
Speech therapy or cardiac rehabilitation
(up to 20 visits per year)
80%
70%
Medical equipment and prosthetics
80%
70%
Home Health Care Benefit
80%
70%

All Hospital confinements are subject to Precertification Review.

  % of Covered Expense
Skilled Nursing Facility 80%; up to 365 days
Hospice Care
 80%

Surgeries performed at a non-Preferred Provider facility in the Anchorage area may be payable at 70% of the rate negotiated with a Preferred Provider. In addition, certain Surgical procedures may be covered at 50% if performed on an inpatient basis.
Refer to the COVERED EXPENSES section of this Booklet.

 

% of Covered Expense

Preventive Health Care (Refer to Section 5.14)

Routine Physical Examination
Well Child Care
Immunizations

100%; up to $300 per calendar year; subject to UCR
100%; up to $300 per calendar year
100%; up to $500 per calendar year
Ambulance Service 70%
Hearing Loss Benefit 70%; up to $800 per ear during any
3 consecutive years

Treatment for Mental Illness/Substance Abuse
Inpatient facility charge Paid as Hospital Service
Inpatient provider treatment 50% of Covered Expenses, not subject to the annual deductible and balance does not apply to the annual out-of-pocket limit
Outpatient treatment 50% of Covered Expenses, not subject to the annual deductible and balance does not apply to the annual out-of-pocket limit
Inpatient detoxification limitation 3 days per confinement;
lifetime limit of 2 confinements
Inpatient treatment limitation 30 days per calendar year
Outpatient treatment limitation 26 visits per calendar year
Maximum Lifetime Benefit for Substance Abuse $50,000 per Participant