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Mid-America Carpenters Regional Council Benefit Funds
Comprehensive Medical Coverage is available for you and your family provided you are not yet eligible for Medicare. This coverage includes hospital & physician services, urgent care services, and even emergency room visits if needed. The Plan also provides for imaging, lab tests, durable medical equipment, skilled nursing, chiropractic care, physical therapy, maternity benefits, coverage for behavioral health, and substance use disorders and more.
What do I pay for medical coverage?
You are responsible for paying for a portion of the expense until you reach the maximum out of pocket. After that, the Plan pays 100% of covered expenses:
- Deductibles: the amount you must pay every calendar year before any benefits are paid by the Plan.
- Coinsurance: your share of the cost of the medical expenses after you meet the deductible.
|
PPO Provider |
Out-of-Network Provider |
| Coinsurance |
80% paid by Plan |
60% paid by Plan |
| Deductible per Calendar Year |
$300 per covered individual
$600 per family |
$600 per covered individual |
Are there limits on the amounts I pay out of pocket?
Yes. If you or a family member has a serious illness, you may incur a large number of medical expenses. If that happens, you may meet the out-of-pocket maximum, and then the Plan pays 100% of most covered expenses.
|
PPO Provider |
Out-of-Network Provider |
| Out-of-Pocket Maximum per Calendar Year |
$2,000 per covered individual
$4,000 per family
(includes calendar year deductible)
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$6,000 per covered individual
(does not include calendar year deductible)
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After a covered individual satisfies the deductible and out-of-pocket maximum, the Plan will pay 100% of most eligible covered services for the remainder of the calendar year. PPO and Non-PPO deductibles and out-of-pocket maximums are separate and cannot be combined.
What if I choose an Out-of-Network Provider?
It is much more cost effective to use an In-Network PPO Provider. In addition to higher out of pocket expenses, if you choose an Out-of-Network Provider, payment by the Plan is limited to the coinsurance amount and the total claim expense is subject to a reasonable and customary allowance. This means that if the provider charges amounts in excess of reasonable & customary rates, the provider can pursue additional payment from you. Here is an example of how In-Network and Out-of-Network costs compare:
EXAMPLE: Knee replacement surgery
The Reasonable and Customary (R & C) Allowance for a single knee replacement is $54,000
|
In-Network BCBS Provider |
Out-of-Network Provider |
| Total Amount of the Claim |
$70,000 |
$70,000 |
| In-Network Discount |
($30,000) |
$0 |
| Total After Discounts |
$40,000 |
$70,000 |
| YOU PAY... |
|
|
| Deductible |
$0 |
$600 |
| Coinsurance (out of pocket max) |
$2,000 |
$6,000 |
| Amount Over R & C Allowance |
$0 |
$16,600* |
| Total You Pay Out of Pocket |
$2,000 |
$22,600 |
*Amounts charged for covered out-of-network medical expenses are subject to the reasonable & customary allowances. In this example, the amount over R & C is $16,000 ($70,000-$54,000), which becomes your responsibility.
What is not covered by the Plan?
There are certain medical expenses that are not covered by the Plan; the comprehensive list of exclusions is outlined in the General Plan Limitations and Exclusions.
BCBSIL administers the PPO network of medical and behavioral health providers. BCBSIL also processes all retiree medical claims. Keep in mind that your coverage and out of pocket costs vary depending on if you choose a BCBSIL In-Network PPO Provider or an Out-of-Network Provider. The BlueCross BlueShield of Illinois website can help you find a physician, hospital, or surgi-center in the BCBSIL PPO Network.
The Carpenters Center for Health
Your coverage includes access to the Carpenters Center for Health, a comprehensive health and wellness-focused facility built by carpenters for carpenters. All services provided at the Carpenters Center for Health are FREE. The Health Center website provides additional information on this facility and the team of dedicated professionals waiting to provide you with a better level of care. This site is also your link to the MyPremise member portal. You can schedule appointments at the Health Center, see your test/lab results, send a message to your provider and more!
Pre-Medicare Prescription Drug Coverage
The Retiree Health Plan offers comprehensive prescription drug coverage and partners with Express Scripts to provide you with a national retail pharmacy network, a home delivery program, and access to critical specialty medications used to treat chronic and rare conditions. The Schedule of Benefits outlines the prescription coverage available to you.
Coverage includes 4 categories of prescription drugs. Each prescription you fill is in one of these categories. The type of medication determines your co-payment amount.
- Generic Drug: a non-brand name substitute for a brand-name medication; be sure to ask your doctor to approve a generic if available on your prescription.
- Single-Source Brand-Name Drug: currently no generic drug available as a substitute.
- Multi-Source Brand-Name Drug: one or more generic drugs available.
- Specialty Medication: one that is used to treat complex, chronic or rare medical conditions.
You have 2 options for filling your (non-specialty) prescription with Express Scripts:
For long-term medications taken on a regular basis, the Plan requires that you increase your prescription to a 90-day supply after your 3rd refill. This saves you and the Plan money.
Fill your 90-day prescription through the Express Scripts Home Delivery Program or at a Walgreen's retail pharmacy.
Accredo, affiliated with Express Scripts, is our contracted provider for specialty medications used to treat chronic and rare conditions, which often require special handling. Visit www.accredo.com to order specialty medication refills online, check your order status, track shipments, learn about your condition, and much more.
Download the Express Scripts App to your smartphone or tablet to order refills, make payments, and even set up reminders to take your medications.
Pre-Medicare Dental, Hearing Coverage
Delta Dental of Illinois
1-800-323-1743
MON – THU: 7 a.m. to 7 p.m.
FRI: 7 a.m. to 6 p.m.
EPIC Hearing Healthcare
(866) 956-5400
MON – FRI: 8 a.m. to 8 p.m.
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