Welfare Summary Plan Description

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 10 visits per year) 80% 60%
    Acupuncture (up to 10 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