September 9, 2010   TABLE OF CONTENTS   C. BENEFITS APPLICABLE TO MEDICARE RETIREES   1. OPEN ACCESS MEDICARE MEDICAL BENEFITS Benefits payable for Participants and Dependents covered by Medicare are subject to the plan’s “carve-out” provision. “Carve-Out" means that the Fund computes its regular benefits under the Open Access III PPO benefit schedule. Any applicable deductibles and co-pays are applied and then benefits will be calculated at the reimbursement rate of 90% of the Medicare allowed amount. Medicare’s payment amount will then be deducted from the Plan’s payment amount and the difference, if any, will be paid to the provider. Any difference between Medicare’s allowed amount and the combined amount paid by Medicare and the Fund is your responsibility. Medicare retirees are not required to use HealthLink providers. Medical Deductible Amounts   Individual Family Inpatient $300 $600 Outpatient $400 $800 In addition to the deductible amounts shown above, you are responsible for any applicable Co-Pays (see Section 4.1, beginning on page 59) for each Physician’s office visit. The Inpatient and Outpatient Deductibles are applied once per calendar year. Out of Pocket Maximum Per Calendar Year Individual $2,000 (including deductibles and co-pays) Family $4,000 (including deductibles and co-pays) 2. PRESCRIPTION SOLUTIONS PRESCRIPTION DRUG BENEFITS Prescription drug benefits for Medicare retirees are insured by PacifiCare and provided through their Prescription Solutions plan. The following is a summary of those benefits, which are subject to the terms of the insurance contract documents. Each Generic prescription or refill Co-pay 20% Minimum Co-pay $5 for up to and including a 30-day supply; $15 for over a 30-day supply Each Brand Name prescription or refill Co-pay 35% Maximum Co-pay $50 for up to and including a 30-day supply; $150 for over a 30-day supply of certain catastrophic single source brand name drugs Prescription Drug Out-of-Pocket Maximum per Calendar Year Per individual $1,500 Per family $2,500 3. MEDICARE RETIREE HEALTH MAINTENANCE ORGANIZATION (HMO) As an alternative to Open Access Medicare coverage through the Fund, Medicare retirees have the option of electing coverage under Medicare Complete, a “Medicare Advantage” plan which takes the place of Medicare, a Medicare supplement and Medicare prescription drug benefit. All benefits payable under the Medicare Complete plan are insured by United Healthcare and are described in the Medicare Complete Evidence of Coverage. Medicare retirees who wish to join Medicare Complete may do so during semi-annual open enrollment. If the spouse of a Medicare retiree is not yet eligible for Medicare, he or she will remain eligible for the Value Plan until eligible for Medicare.   TABLE OF CONTENTS   St. Louis Graphic Arts Joint Health & Welfare Fund 14323 South Outer Forty Rd. - Suite S106 Chesterfield, Missouri 63017 Fund Office: (314) 878-1579 twesthues@slgahw.org Fax: (314) 275-2640   If you have any comments about this web site, please contact us at twesthues@slgahw.org.   Site Concept and Design ©2002 jWeb. Maintenance and Hosting provided by jWeb.