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