MEDICAL

Plan A (Current Plan) Plan B (New Plan)
PPO Provider Non-PPO Provider PPO Provider Non-PPO Provider 
Annual deductible $250 per individual; $500 per family per calendar year $750 per individual; $1,500 per family per calendar year $500 per individual $1,000 per family per calendar year $1,000 per individual; $2,000 per family per calendar year
Hospital – Inpatient Per admission: Fund pays 100% of the first $50,000 plus 85% of the excess charges with an out-of-pocket maximum of $2,000 (after deductible) Per admission: Fund pays 90% of the first $50,000 plus 75% of the excess charges with an out-of-pocket maximum of $7,000 (after deductible) Per admission: Fund pays 100% of the first $7,500 plus 85% of the excess charges with an out-of-pocket maximum of $5,000 (after deductible) Per admission: Fund pays 90% of the first $7,500 plus 75% of the excess charges with an out-of-pocket maximum of $7,000 (after deductible)
Hospital – Outpatient Fund pays 100% after $20
co-payment
Fund pays 80%
of R & C fees for most procedures
Fund pays 90%
after $20 co-payment
Fund pays 75% of R & C fees for most procedures
 Physician Fund pays 100% after $20
co-payment
In most cases,
Fund pays 80% of R & C fees
Fund pays 90%
after $20
co-payment
In most cases,
Fund pays 75% of R & C fees
Annual physical exam
(must be at least one year old)
Fund pays 100% in network after $20 co-payment
(no deductible)
Fund pays 100% in network after $20 co-payment
(no deductible)
Well baby care Paid same as other Plan A medical treatment Paid same as other Plan B medical treatment
Emergency treatment Fund pays 100%
after $75 penalty for each emergency
medical treatment
(waived if admitted
to the hospital),
plus $20 
co-payment
 Fund pays 80% of R&C fees,
after $75 penalty for each
emergency medical 
treatment (waived if 
admitted to the
hospital)
Fund pays 100% 
after $75 penalty 
for each emergency
medical treatment
(waived if admitted
to the hospital),
plus $20 
co-payment
 Fund pays 75% of R&C fees,
after $75 penalty for each
emergency medical 
treatment (waived if 
admitted to the
hospital)

MENTAL HEALTH CARE BENEFITS: Subject to deductible and applicable copayments

Plan A (Current Plan) Plan B (New Plan)
PPO Provider Non-PPO Provider PPO Provider Non-PPO Provider
Inpatient Fund pays 100% of the first $50,000 plus 85% of the excess charges with an out-of-pocket maximum of $2,000 Fund pays 90% of the first $50,000 plus 75% of the excess charges with an out-of-pocket maximum of $7,000 Fund pays 100% of the first $7,500 plus 85% of the excess charges with an out-of-pocket maximum of $5,000 Fund pays 100% of the first $7,500 plus 75% of the excess charges with an out-of-pocket maximum of $7,000
Outpatient Fund pays 100% after $20 copayment Fund pays 80% of reasonable and customary fees Fund pays 100% after $20 copayment Fund pays 75% of reasonable and customary fees

SUBSTANCE ABUSE BENEFITS: Subject to deductible 

Plan A (Current Plan) Plan B (New Plan)
PPO Provider Non-PPO Provider  PPO Provider Non-PPO Provider
Inpatient Paid the same as inpatient mental health care
Outpatient Fund pays 100% of covered charges Fund pays 80% of reasonable and customary fees Fund pays 100% of first $500 in covered charges, then 90% Fund pays 80% of reasonable and customary fees

DENTAL BENEFITS

Plan A (Current Plan) Plan B (New Plan)
PPO Provider Non-PPO Provider  PPO ProvideR Non-PPO Provider
Type I (Diagnostic and Preventive
Benefits: exams, cleanings, etc.)
100% 100% of usual and
customary charges
100% 100% of usual and
customary charges
Type II (Restorative and Other
Basic Services: fillings and crowns,
etc.)
80% 80% of usual and
customary charges
None
Type III (Major Restorative
Services: crowns, dentures and
bridges, etc.)
50% 50% of usual and customary charges None
Annual Maximum
None None
Orthodontia Lifetime Maximum of $2,500, available to age 19 None

PRESCRIPTION DRUG BENEFITS

Plan A (Current Plan) Plan B (New Plan)
PPO Provider Non-PPO Provider PPO Provider Non-PPO Provider 
Retail Pharmacy You pay the following co-payment per prescription for up to a 30-day supply:

  • Generic drug: $5
  • Preferred brand-name: $15
  • Non-preferred brand-name: $25
Same as Plan A
Prescription filled at a retail pharmacy You pay the following copayment per prescription for up to a 30-day supply:

  • Generic drug: $5
  • Preferred brand-name: $15
  • Non-preferred brand-name: $25

The Fund covers the remaining cost.
Note: Your copayment for any refills at a retail pharmacy beynod the third fill will be 50% of the cost.

Same as Plan A
Prescription filled through the plan’s mail-order program You pay the following copayment per prescription for up to a 90-day supply:

  • Generic drug: $10
  • Preferred brand-name: $30
  • Non-preferred brand-name: $50

The Fund covers the remaining cost.

Same as Plan A