East Central Illinois Pipe Trades Health & Welfare Fund Retiree Benefits

East Central Illinois Pipe Trades Health & Welfare Fund Retiree Benefits Retiree Benefits

Benefit Summary
Hartford Plans I & II

MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD*

* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

SERVICES	MEDICARE PAYS	PLAN I PAYS	PLAN II PAYS
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies:
First 60 days	All but $992	$0	$992 (Part A Deductible)
61st thru 90th day	All but $248 a day	$248 a day	$248 a day
91st day and after:
While using 60 lifetime reserve days	All but $496 a day	$496 a day	$496 a day
Once lifetime reserve days are used:
Additional 365 days	$0	100% of Medicare Eligible Expenses	100% of Medicare Eligible Expenses
Beyond the Additional 365 days	$0	$0	$0
SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital:
First 20 days	All approved amounts	$0	$0
21st thru 100th day	All but $124 a day	$0	Up to $124 a day
101st day thru 365th day	$0	$0	$0
366th day and after	$0	$0	$0
BLOOD
First 3 pints	$0	3 pints	3 pints
Additional amounts	100%	$0	$0

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR*

SERVICES	MEDICARE PAYS	PLAN I PAYS	PLAN II PAYS
MEDICAL EXPENSES - In or Out of the Hospital and Outpatient Hospital Treatment, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment:
First $131 of Medicare Approved Amounts**	$0	$0	$0
Remainder of Medicare Approved Amounts	80%	20%	20%
Part B Excess Charges (Above Medicare Approved Amounts)	$0	$0	$0
BLOOD
First 3 pints	$0	All costs	All costs
Next $131 of Medicare Approved Amounts**	$0	$0	$0
Remainder of Medicare Approved Amounts	80%	20%	20%
CLINICAL LABORATORY SERVICES
Blood tests for Diagnostic Services	100%	$0	$0

MEDICARE PARTS A & B

SERVICES	MEDICARE PAYS	PLAN I PAYS	PLAN II PAYS
HOME HEALTH CARE
Medicare Approved Services:
Medically necessary skilled care services and medical supplies	100%	$0	$0
Durable medical equipment:
First $131 of Medicare Approved Amounts**	$0	$0	$0
Remainder of Medicare Approved Amounts	80%	20%	20%

OTHER BENEFITS - NOT COVERED BY MEDICARE

SERVICES	MEDICARE PAYS	PLAN I PAYS	PLAN II PAYS
FOREIGN TRAVEL Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA:
First $250 each calendar year	$0	$0	$0
Remainder of charges	$0	80% to a lifetime maximum of $50,000	80% to a lifetime maximum of $50,000

OUTPATIENT PRESCRIPTION DRUGS ***

COST OF PRESCRIPTIONS	PLAN PAYS	YOU PAY
Medicare Part D with Supplement
First $265	$0	$265
$266 to $14,605	75%	25%
$14,605 and up	95%	5%

** Once you have been billed $131 of Medicare approved amounts for covered services, your Medicare Part B Deductible will have been met for the calendar year.

*** Prescription drugs are a stand-alone benefit issued through Sterling Retiree Rx/IdealScripts. Benefits are paid only when using one of the approximately 42,000 Sterling Retiree Rx/IdealScripts Participating Pharmacies.

The summary of program benefits described herein is for illustrative purposes only. In case of differences or errors, the Group Policy governs.