HEALTH SUMMARY

June 2016

$12,000

All services provided by or referred by a chiropractor or done in conjunction with a chiropractic course of treatment are payable under the Chiropractic Benefit.

Visits: 100% up to $75 per visit for 26 visits per calendar year

Deductible: None

X-Rays: (Requested by Chiropractor) – No Annual Maximum

$12,000

Deductible per Person $25 Deductible per Family $75

Maximum Calendar Year Benefit participant, spouse, and children over 19 $2,000

Maximum Calendar Year Benefit children under 19 No Annual Maximum

Routine Oral Exam-Exam and Prophyhylaxis (cleaning) every six months 100%

Covered Dental Services by a Delta Dental Network Provider 85%

Covered Dental Services by a Non-Network Provider 70%

Orthodontics Maximum Lifetime Benefit children over 19 $2,000

Orthodontics Maximum Lifetime Benefit children under 19 Unlimited

$2000 every 5 years

$300/week for 19 weeks

Deductible: $300/Individual; $600/Family

Co-Insurance (after deductible):

PPO Providers and Hospitals – 90%/10%

Non-PPO Providers and Hospitals – 60%/40%

Hospital Emergency Room:

Additional Deductible per visit - $100.00

(Charges are then payable at 90% PPO or 60% Non-PPO after annual $300 deductible)

is satisfied (Waived if admitted as an inpatient within the first 3 consecutive days.

PPO Physicians Only:

Office Visit $15 co-pay

(Does not apply to chiropractic, dental, vision, hearing aid, mental/nervous or chemical dependency.)

Out-of-Pocket Maximum:

PPO Providers - $4500 per person (plus deductible)

Non-PPO Providers - $10,000 per person (plus deductible)

Hospice Care:

100% After Major Medical deductible satisfied

Prescription Drugs: (30 day supply at local pharmacy)

SAV-RX Drug Card – Generic Drug Co-Pay – $8

SAV-RX Drug Card – Formulary Brand Drug Co-Pay - $25

SAV-RX Drug Card-Non-Formulary Brand Drug Co-Pay $40

SAV-RX Mail Order

Generic Drug Co-Pay - $16

Formulary Brand Drug Co-Pay - $50

Non-Formulary Brand Drug Co-Pay-$80

(Mail Order Program must be used to fill all prescriptions

 for long-term maintenance prescriptions up to 90 day supply)

Drug exclusions: growth hormones, Rogaine, Retin-A,

Nicorette, anorectics, non-legend Rx, immunosuppressants,

drugs covered by worker's comp., RX for sexual dysfunction.

For Active & Retiree Participants

Outpatient: 100% Inpatient: 90%

For Bare Bone Plan Participants

Outpatient: 100% Inpatient: 75%

For Active & Retiree Participants

Outpatient: 90% covered/10% copay

Inpatient: 1st Treatment Occurrence - 100%

2nd Treatment Occurrence - 90%

For Bare Bone Plan Participants

Outpatient: 75% covered/25% copay

Inpatient: 1st Treatment Occurrence - 100%

2nd Treatment Occurrence - 75%

Deductible -None

Benefit payable every 2 years:

Adult Exam, Lenses, Frames, and Contact Lenses - $500

Child under 19 Lenses, Frames, Contact Lenses, Lasik Surgery-$500

Exam for Child under 19 – No Maximum

Preventive annual well-person, well child, well-baby exams, selected tests and selected immunizations and tests covered at

100% - PPO Providers and Hospitals or

60% - Non PPO Providers and Hospitals

Initial - 600 Hours of Covered Work within a 12 Month Period. Insurance takes effect the first of the month after you reach 600 hours. Continued Insurance- 345 Hours in the previous 3 Month Period. Reinstatement – 345 Hours in 12 Month Period.

For more information, contact Wisconsin Laborers' Health Fund, 4633 LIUNA Way, Ste. 201, DeForest, WI 53532 608-846-1742 or 1-800-397-3373 – Fax: 608-846-3192