Alaska Teamster-Employer Welfare and Pension Trusts

Medical Plan Benefit

See SECTIONS 5.1 THROUGH 5.20

Benefit Funded by the Trust

• Annual/Lifetime Maximum Benefit – No Dollar Limit (Visit or Procedure Limits May Apply)
  Medicare Eligible Retired Participant – See TEAMStar Retiree Booklet
• Calendar Year Deductible
  

  For Eligible Employees and their Dependents
  Per Participant	$1,000
  Per Family	$3,000
  For Retired Participants and their Dependents
  Each Participant WITH Medicare See TEAMStar Retiree Booklet

• Annual Out-of-Pocket Limit (includes Calendar Year Deductible)
  

  For Eligible Employees and their Dependents
  Per Participant – PPO	$3,800
  Per Family	$7,600
  Per Participant -non-PPO	$7,600
  Per Family – non-PPO	$15,200
  Per Participant for Prescriptions	$3,200
  Per Family for Prescriptions	$6,000
  For Retired Participant and their Dependents
  Each Participant WITH Medicare See TEAMStar Retiree Booklet

• 	Preferred Providers  % of Covered Expenses	Non-Preferred Provider % of contract rates
  Hospital Services (inpatient & outpatient)
  Hospitals in Alaska, within 75 miles of a Preferred Provider facility	80%	60% of rate negotiated with Preferred Provider; after additional $1,000 inpatient deductible
  Hospitals in Alaska; not within 75 miles of a Preferred Provider facility	80%	60%
  Hospitals outside of Alaska	80%	60%
  Preadmission Testing	100%	100%

• 	Preferred Providers  % of Covered Expenses	Non-Preferred Provider % of contract rates
  Professional Services and Supplies
  Physician visits (home, office, or hospital visits)	80%	60%
  Surgeon and assistant surgeon	80%	60%
  Diagnostic x-rays, laboratory testing	80%	60%
  Chiropractic office visits (up to 15 visits per year)	80%	60%
  Acupuncture (up to 15 visits per year)	80%	60%
  Naturopathic Services (some exclusions apply)	80%	60%
  Physical, occupational or massage therapy (up to a combined limit of 20 visits per year)	80%	60%
  Speech therapy (up to 20 visits per year)	80%	60%
  Cardiac rehabilitation	80%	60%

• 	Preferred Providers  % of Covered Expenses	Non-Preferred Provider % of contract rates
  Medical equipment and prosthetics	80%	60%
  Home Health Care Benefit	80%	60%

  All Hospital confinements are subject to Precertification Review.

• 	% of Covered Expense
  Skilled Nursing Facility	80%; up to 100 days
  Hospice Care	80%

  Surgeries performed at a non-Preferred Provider facility within 75 miles of a Preferred Provider facility may be payable at 60% of the rate negotiated with a Preferred Provider. In addition, certain Surgical procedures may be covered at 50% if performed on an inpatient basis. Also, expenses for non-emergency orthopedic surgery are covered only if provided through BridgeHealth or a Preferred Provider. No other non-emergency orthopedic surgery expenses are covered by this Plan.

  Refer to the COVERED EXPENSES section of this Booklet.

• 	% of Covered Expense
  Teladoc Services	100%
  Preventive Health Care (Refer to Section 5.13)
  Routine Physical Examination	100%; subject to UCR and Schedule of Routine Examination Benefits.
  Well Child Care	100%; subject to UCR and Schedule of Well Child Benefits
  Immunizations	100%; subject to UCR and Schedule of Immunizations

• 	% of Covered Expense
  Services at the Coalition Health Center	No copay for the first visit each year. Subject to a $20 copay per visit thereafter Deductible waived

• 	% of Covered Expense
  Ambulance Service	70%; limited to 70% of preferred provider charges for non-Emergency air ambulance services

• 	% of Covered Expense
  Hearing Loss Benefit	70%; up to $800 per hearing device, per ear during any 3 consecutive years; not subject to deductible or out-of-pocket limitations