Common use of Profit Sharing Plan Clause in Contracts

Profit Sharing Plan. For profit-sharing for covered employees effective for 2013 profit sharing paid in 2014 and subsequent years of this agreement, the profit sharing plan for IAM represented employees shall be funded with five percent (5%) of pre-tax profit up to a pre-tax margin of six and nine-tenths percent (6.9%) plus ten percent (10%) of pre-tax profit in excess of a pre-tax margin of six and nine-tenths percent (6.9%). Special and unusual items shall be excluded from pre-tax profit when making these calculations. APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-Network Out-of- Network In-Network In-Network Out-of- Network Annual Deductibles $300 single/ $600 family $600 single/ $1200 family $200 single/ $400 family $2500 single only $5000 true family deductible* $5000 single only $10,000 true family deductible* HSA Seed Amount (pro- rated per paycheck) NA NA $750 single / $1500 family Annual Out-of- Pocket (OOP) Limits $2000 single/ $4000 family (includes medical coinsurance and deductible, but not copays) $4000 single/ $8000 family (includes medical coinsurance and deductible, but not copays) $1,500/$3,000 (includes medical coinsurance and deductible, but not copays) $3000 single only $6000 true family maximum* (includes deductible and coinsurance) $6000 single only $12000 true family maximum* (includes deductible and coinsurance) Cross Application Out-of-Network Deductibles and OOP to In- Network Yes NA Yes Office Visit PCP $25 co-pay Covered at 60% after deductible $25 co-pay Covered at 95% after deductible Covered at 60% after deductible Office Visit Specialist $40 co-pay $40 co-pay Preventive Services (comprehensive array; See Appendix C) 100% preventive 100% preventive 100% preventive APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-Network Out-of- Network In-Network In-Network Out-of- Network Laboratory, x-ray and diagnostic testing Covered at 80% after deductible Covered at 60% after deductible Included w/office visit Covered at 95% after deductible Covered at 60% after deductible Hospital/Inpatient Covered at 90% after deductible Outpatient Facilities/Surgical Covered at 90% after deductible Urgent Care Center $50 $50 co-pay Emergency Room $200 flat copay, waived if admitted $200 co-pay, waived if admitted Retail Generic Drugs $10 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs* (Workaround for lower costs Rx at Target/Costco) $10 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs (Workaround for lower costs Rx at Target/Costco) Covered at 100% after deductible Retail Brand Preferred Drugs $30 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs- only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) $30 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs- only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) Covered at 95% after deductible APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-Network Out-of- Network In-Network In-Network Out-of- Network Retail Brand Non-Preferred Drugs $50 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs - only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) $50 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs - only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) Covered at 95% after deductible Retail Drug Supply Limit 30 day supply 30 day supply 30 day supply Mail Order Generic Drugs $25 co-pay $25 co-pay Covered at 100% after deductible (plan provides coverage for drugs that are allowed to be covered pre- deductible) Mail Order Brand Preferred Drugs $75 co-pay $75 co-pay Covered at 95% after deductible Mail Order Brand Non- preferred $125 co-pay $125 co-pay Covered at 95% after deductible Mail Order Drug Supply Limit 90 day supply 90 day supply 90 day supply Covered Services and Excluded Services will be the same for employees under this Agreement as for all other employee groups participating in such plans. APPENDIX B – PLAN DESIGN FOR CORE DENTAL OPTION Benefit Features Traditional PPO Dental Benefits In-network: Out-of-network: Annual Deductibles Individual $50 $50 Family (2 members of family must each satisfy individual deductible) $100 $100 Annual Benefit Maximum $2,000 $2,000 Orthodontics Lifetime Maximum $2,000 $2,000 Office Visit Copay $0 $0

Appears in 2 contracts

Samples: Storekeeper Employees, Passenger Service Employees

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Profit Sharing Plan. For profit-sharing for covered employees effective for 2013 2014 profit sharing paid in 2014 2015 and subsequent years of this agreement, the profit sharing plan for IAM represented employees shall be funded with five percent (5%) of pre-tax profit up to a pre-tax margin of six and nine-tenths percent (6.9%) plus ten percent (10%) of pre-tax profit in excess of a pre-tax margin of six and nine-tenths percent (6.9%). Special and unusual items shall be excluded from pre-tax profit when making these calculations. APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-Network Out-of- Network In-Network In-Network Out-of- Network Annual Deductibles $300 single/ $600 family $600 single/ $1200 family $200 single/ $400 family $2500 single only $5000 true family deductible* $5000 single only $10,000 true family deductible* HSA Seed Amount (pro- rated per paycheck) NA NA $750 single / $1500 family Annual Out-of- Pocket (OOP) Limits $2000 single/ $4000 family (includes medical coinsurance and deductible, but not copays) $4000 single/ $8000 family (includes medical coinsurance and deductible, but not copays) $1,500/$3,000 (includes medical coinsurance and deductible, but not copays) $3000 single only $6000 true family maximum* (includes deductible and coinsurance) $6000 single only $12000 true family maximum* (includes deductible and coinsurance) Cross Application Out-of-Network Deductibles and OOP to In- Network Yes NA Yes Office Visit PCP $25 co-pay Covered at 60% after deductible $25 co-pay Covered at 95% after deductible Covered at 60% after deductible Office Visit Specialist $40 co-pay $40 co-pay Preventive Services (comprehensive array; See Appendix C) 100% preventive 100% preventive 100% preventive APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-Network Out-of- Network In-Network In-Network Out-of- Network Laboratory, x-ray and diagnostic testing Covered at 80% after deductible Covered at 60% after deductible Included w/office visit Covered at 95% after deductible Covered at 60% after deductible Hospital/Inpatient Covered at 90% after deductible Outpatient Facilities/Surgical Covered at 90% after deductible Urgent Care Center $50 $50 co-pay Emergency Room $200 flat copay, waived if admitted $200 co-pay, waived if admitted Retail Generic Drugs $10 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs* (Workaround for lower costs Rx at Target/Costco) $10 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs (Workaround for lower costs Rx at Target/Costco) Covered at 100% after deductible Retail Brand Preferred Drugs $30 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs- only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) $30 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs- only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) Covered at 95% after deductible APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-Network Out-of- Network In-Network In-Network Out-of- Network Retail Brand Non-Preferred Drugs $50 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs - only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) $50 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs - only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) Covered at 95% after deductible Retail Drug Supply Limit 30 day supply 30 day supply 30 day supply Mail Order Generic Drugs $25 co-pay $25 co-pay Covered at 100% after deductible (plan provides coverage for drugs that are allowed to be covered pre- deductible) Mail Order Brand Preferred Drugs $75 co-pay $75 co-pay Covered at 95% after deductible Mail Order Brand Non- preferred $125 co-pay $125 co-pay Covered at 95% after deductible Mail Order Drug Supply Limit 90 day supply 90 day supply 90 day supply Covered Services and Excluded Services will be the same for employees under this Agreement as for all other employee groups participating in such plans. APPENDIX B – PLAN DESIGN FOR CORE DENTAL OPTION Benefit Features Traditional PPO Dental Benefits In-network: Out-of-network: Annual Deductibles Individual $50 $50 Family (2 members of family must each satisfy individual deductible) $100 $100 Annual Benefit Maximum $2,000 $2,000 Orthodontics Lifetime Maximum $2,000 $2,000 Office Visit Copay $0 $0

Appears in 2 contracts

Samples: Maintenance Instructor Employees, iam141.org

Profit Sharing Plan. For profit-sharing for covered employees effective for 2013 2014 profit sharing paid in 2014 2015 and subsequent years of this agreement, the profit sharing plan for IAM represented employees shall be funded with five percent (5%) of pre-tax profit up to a pre-tax margin of six and nine-tenths percent (6.9%) plus ten percent (10%) of pre-tax profit in excess of a pre-tax margin of six and nine-tenths percent (6.9%). Special and unusual items shall be excluded from pre-tax profit when making these calculations. APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-In- Network Out-of- Network In-Network In-Network Out-of- Network Annual Deductibles $300 single/ $600 family $600 single/ $1200 family $200 single/ $400 family $2500 single only $5000 true family deductible* $5000 single only $10,000 true family deductible* HSA Seed Amount (pro- rated per paycheck) NA NA $750 single / $1500 family Annual Out-of- Pocket (OOP) Limits $2000 single/ $4000 family (includes medical coinsurance coinsuranc e and deductible, but not copays) $4000 single/ $8000 family (includes medical coinsurance coinsuranc e and deductible, but not copays) $1,500/$3,000 1,500/$3,00 0 (includes medical coinsurance and deductible, but not copays) $3000 single only $6000 true family maximum* (includes deductible and coinsurancecoinsurance ) $6000 single only $12000 true family maximum* (includes deductible and coinsurancecoinsurance ) Cross Application Out-Out- of-Network Deductibles and OOP to In- Network Yes NA Yes Office Visit PCP $25 co-pay Covered at 60% after deductible $25 co-pay Covered at 95% after deductible Covered at 60% after deductible Office Visit Specialist $40 co-pay $40 co-pay Preventive Services (comprehensive array; See Appendix C) 100% preventive 100% preventive 100% preventive APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-In- Network Out-of- Network In-Network In-Network Out-of- Network Laboratory, x-x- ray and diagnostic testing Covered at 80% after deductible Covered at 60% after deductible Included w/office visit Covered at 95% after deductible Covered at 60% after deductible Hospital/Inpatient Inpatien t Covered at 90% after deductible Outpatient Facilities/Surgical Surgica l Covered at 90% after deductible Urgent Care Center $50 $50 co-pay Emergency Room $200 flat copay, waived if admitted $200 co-pay, waived if admitted Retail Generic Drugs $10 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs* (Workaround for lower costs Rx at Target/Costco) $10 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs (Workaround for lower costs Rx at Target/CostcoCostco ) Covered at 100% after deductible Retail Brand Preferred Drugs $30 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs- only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) $30 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs- only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) Covered at 95% after deductible APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-In- Network Out-of- Network In-Network In-Network Out-of- Network Target/Costco ) Retail Brand Non-Preferred Drugs $50 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs - only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) $50 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs - only if less expensive than retail (Workaround for lower costs Rx at Target/CostcoCostco ) Covered at 95% after deductible Retail Drug Supply Limit 30 day supply 30 day supply 30 day supply Mail Order Generic Drugs $25 co-pay $25 co-pay Covered at 100% after deductible (plan provides coverage for drugs that are allowed to be covered pre- deductible) Mail Order Brand Preferred Drugs $75 co-pay $75 co-pay Covered at 95% after deductible Mail Order Brand Non- preferred $125 co-pay $125 co-pay Covered at 95% after deductible Mail Order Drug Supply Limit 90 day supply 90 day supply 90 day supply Covered Services and Excluded Services will be the same for employees under this Agreement as for all other employee groups participating in such plans. APPENDIX B – PLAN DESIGN FOR CORE DENTAL OPTION Benefit Features Traditional PPO Dental Benefits In-network: Out-of-network: Annual Deductibles Individual $50 $50 Family (2 members of family must each satisfy individual deductible) $100 $100 Annual Benefit Maximum $2,000 $2,000 Orthodontics Lifetime Maximum $2,000 $2,000 Office Visit Copay $0 $00 PREVENTIVE SERVICES and DIAGNOSTIC SERVICES Dental cleaning Topical Application of Fluoride, Sealants and Space Maintainers 100% Covered frequency and/or age limitations may apply to these services 100% Covered frequency and/or age limitations may apply to these services MINOR RESTORATIVE SERVICES Fillings, Endodontics, Periodontics, Oral Surgery Covered up to 80%; after deductible Covered up to 80%; after deductible; Subject to reasonable and customary limits MAJOR RESTORATIVE AND PROSTHODONTICS Initial placement of Dentures or Bridges to 1 or more natural teeth which are lost while covered by the Plan. Inlays and Crowns (Porcelain or Stainless Steel) Covered up to 50%; after deductible; frequency and/or age limitations may apply to these services Covered up to 50% after deductible; Subject to reasonable and customary limits; frequency and/or age limitations may apply to these services ORTHODONTICS APPENDIX B – PLAN DESIGN FOR CORE DENTAL OPTION Benefit Features Traditional PPO Dental Benefits Exams, X-Rays, Models, Appliances (Adult and Child) Covered up to 50%; after deductible; frequency and/or age limitations may apply to these services Covered up to 50% after deductible; Subject to reasonable and customary limits; frequency and/or age limitations may apply to these services Covered Services and Excluded Services will be the same for employees under this Agreement as for all other employee groups participating in such plan. Preventive Exams and Screenings – Adult Male Physical Exam 100% annually Prostate-Specific Antigen (PSA) 100% annually Lipid Panel 100% annually Glucose Testing 100% annually Colorectal Screening 100% annually Complete Blood Count (CBC) 100% annually Immunizations – Adult Male Tetanus Injections (with or without diphtheria) 100% as often as recommended by physician Meningitis 100% Herpes Zoster 100% Influenza Vaccine 100% annually Pneumococcal Vaccine 100% Travel Vaccinations 100% as often as recommended by physician Measles, Mumps, Rubella (MMR) for Adults 100% Preventive Exams and Screenings – Adult Female Physical Exam 100% annually, 1 general and 1 well-woman exam annually Lipid Panel 100% annually Glucose Testing 100% annually Colorectal Screening 100% annually Chlamydia Infection Screening 100% annually Mammogram 100% annually Bone Density 100% annually Pap Test 100% annually Complete Blood Count (CBC) 100% annually Immunizations – Adult Female Tetanus Injections (with or without diphtheria) 100% as often as recommended by physician Meningitis 100% Herpes Zoster 100% Influenza Vaccine 100% annually Human Papillomavirus (HPV) 100% Pneumococcal Vaccine 100% Travel Vaccinations 100% as often as recommended by physician Measles, Mumps, Rubella (MMR) for Adults 100% Preventive Exams and Screenings – Children Birth to 18 (Covered as Well-Child Care) Office Visits; Examinations Includes: ■ Physical and medical history ■ Height and weight ■ Head circumference (<1 year) ■ Ocular prophylaxis (at birth) ■ Hemoglobin (<1 year) 100%, as often as recommended by physician up to age 2, annually as of age 2 ■ Preventive health counseling, injury prevention and education ■ Dental health ■ Subjective assessment of vision and hearing (0–4 years) ■ Vision and hearing screen (4–18 years) ■ Developmental screening (up to 4 years) ■ Blood pressure (>1 year) ■ Administration of immunizations as indicated below Immunizations – Children Birth to 18 (Covered as Well-Child Care) Hepatitis B Series Hepatitis A Series Diptheria/Tetanus/Pertussis (DTaP) Adult Tetanus/Diphtheria (Td) Haemophilus Influenza (Hib) Series Xxxxxxxxx Xxxxxxx 100%, as often as recommended by physician Rotavirus Polio Series (IPV) Pneumococcal Conjugate (PCV) Measles/Mumps/Rubella (MMR) Chickenpox Vaccine (VZV) Travel Vaccinations

Appears in 1 contract

Samples: iam141.org

Profit Sharing Plan. 1. For profit-sharing for covered employees effective for 2013 profit sharing paid in 2014 and subsequent years of this agreement, the profit sharing plan for IAM represented employees shall be funded with five percent (5%) of pre-tax profit up to a pre-tax margin of six and nine-tenths percent (6.9%) plus ten percent (10%) of pre-pre- tax profit in excess of a pre-tax margin of six and nine-tenths percent (6.9%). Special and unusual items shall be excluded from pre-tax profit when making these calculations. APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-In- Network Out-of- Network In-Network In-Network Out-of- Network Annual Deductibles $300 single/ $600 family $600 single/ $1200 family $200 single/ $400 family $2500 single only $5000 true family deductible* $5000 single only $10,000 true family deductible* HSA Seed Amount (pro- rated per paycheck) NA NA $750 single / $1500 family Annual Out-of- Pocket (OOP) Limits $2000 single/ $4000 family (includes medical coinsurance coinsuranc e and deductible, but not copays) $4000 single/ $8000 family (includes medical coinsurance coinsuranc e and deductible, but not copays) $1,500/$3,000 1,500/$3,00 0 (includes medical coinsurance and deductible, but not copays) $3000 single only $6000 true family maximum* (includes deductible and coinsurancecoinsurance ) $6000 single only $12000 true family maximum* (includes deductible and coinsurancecoinsurance ) Cross Application Out-Out- of-Network Deductibles and OOP to In- Network Yes NA Yes Office Visit PCP $25 co-pay Covered at 60% after deductible $25 co-pay Covered at 95% after deductible Covered at 60% after deductible Office Visit Specialist $40 co-pay $40 co-pay Preventive Services (comprehensive array; See Appendix C) 100% preventive 100% preventive 100% preventive APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-In- Network Out-of- Network In-Network In-Network Out-of- Network Laboratory, x-x- ray and diagnostic testing Covered at 80% after deductible Covered at 60% after deductible Included w/office visit Covered at 95% after deductible Covered at 60% after deductible Hospital/Inpatient Inpatien t Covered at 90% after deductible Outpatient Facilities/Surgical Surgica l Covered at 90% after deductible Urgent Care Center $50 $50 co-pay Emergency Room $200 flat copay, waived if admitted $200 co-pay, waived if admitted Retail Generic Drugs $10 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs* (Workaround for lower costs Rx at Target/Costco) $10 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs (Workaround for lower costs Rx at Target/CostcoCostco ) Covered at 100% after deductible Retail Brand Preferred Drugs $30 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs- only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) $30 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs- only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) Covered at 95% after deductible APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-In- Network Out-of- Network In-Network In-Network Out-of- Network Target/Costco ) Retail Brand Non-Preferred Drugs $50 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs - only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) $50 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs - only if less expensive than retail (Workaround for lower costs Rx at Target/CostcoCostco ) Covered at 95% after deductible Retail Drug Supply Limit 30 day supply 30 day supply 30 day supply Mail Order Generic Drugs $25 co-pay $25 co-pay Covered at 100% after deductible (plan provides coverage for drugs that are allowed to be covered pre- deductible) Mail Order Brand Preferred Drugs $75 co-pay $75 co-pay Covered at 95% after deductible Mail Order Brand Non- preferred $125 co-pay $125 co-pay Covered at 95% after deductible Mail Order Drug Supply Limit 90 day supply 90 day supply 90 day supply Covered Services and Excluded Services will be the same for employees under this Agreement as for all other employee groups participating in such plans. APPENDIX B – PLAN DESIGN FOR CORE DENTAL OPTION Benefit Features Traditional PPO Dental Benefits In-network: Out-of-network: Annual Deductibles Individual $50 $50 Family (2 members of family must each satisfy individual deductible) $100 $100 Annual Benefit Maximum $2,000 $2,000 Orthodontics Lifetime Maximum $2,000 $2,000 Office Visit Copay $0 $0

Appears in 1 contract

Samples: Service Employees

Profit Sharing Plan. For profit-sharing for covered employees effective for 2013 2023 profit sharing paid in 2014 2024 and subsequent years of this agreement, the profit profit-sharing plan for IAM represented employees shall be funded with five percent (5%) of pre-tax profit up to a pre-tax margin of six and nine-tenths percent (6.9%) plus ten percent (10%) of pre-tax profit in excess of a pre-tax margin of six and nine-tenths percent (6.9%). Special and unusual items shall be excluded from pre-tax profit when making these calculations.IAM represented employees covered under this agreement will cease any future participation in the Company’s Profit Sharing Plan effective January 1, 2015. APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-Network Out-of- Network In-Network In-Network Out-of- Network Annual Deductibles $300 single/ $600 family $600 single/ $1200 family $200 single/ $400 family $2500 single only $5000 true family deductible* $5000 single only $10,000 true family deductible* HSA Seed Amount (pro- rated per paycheck) NA NA $750 single / $1500 family Annual Out-of- Pocket (OOP) Limits $2000 single/ $4000 family (includes medical coinsurance and deductible, but not copays) $4000 single/ $8000 family (includes medical coinsurance and deductible, but not copays) $1,500/$3,000 (includes medical coinsurance and deductible, but not copays) $3000 single only $6000 true family maximum* (includes deductible and coinsurance) $6000 single only $12000 true family maximum* (includes deductible and coinsurance) Cross Application Out-of-Network Deductibles and OOP to In- Network Yes NA Yes Office Visit PCP $25 co-pay Covered at 60% after deductible $25 co-pay Covered at 95% after deductible Covered at 60% after deductible Office Visit Specialist $40 co-pay $40 co-pay Preventive Services (comprehensive array; See Appendix C) 100% preventive 100% preventive 100% preventive APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-Network Out-of- Network In-Network In-Network Out-of- Network Laboratory, x-ray and diagnostic testing Covered at 80% after deductible Covered at 60% after deductible Included w/office visit Covered at 95% after deductible Covered at 60% after deductible Hospital/Inpatient Covered at 90% after deductible Outpatient Facilities/Surgical Covered at 90% after deductible Urgent Care Center $50 $50 co-pay Emergency Room $200 flat copay, waived if admitted $200 co-pay, waived if admitted Retail Generic Drugs $10 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs* (Workaround for lower costs Rx at Target/Costco) $10 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs (Workaround for lower costs Rx at Target/Costco) Covered at 100% after deductible Retail Brand Preferred Drugs $30 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs- only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) $30 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs- only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) Covered at 95% after deductible APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-Network Out-of- Network In-Network In-Network Out-of- Network Retail Brand Non-Preferred Drugs $50 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs - only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) $50 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs - only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) Covered at 95% after deductible Retail Drug Supply Limit 30 day supply 30 day supply 30 day supply Mail Order Generic Drugs $25 co-pay $25 co-pay Covered at 100% after deductible (plan provides coverage for drugs that are allowed to be covered pre- deductible) Mail Order Brand Preferred Drugs $75 co-pay $75 co-pay Covered at 95% after deductible Mail Order Brand Non- preferred $125 co-pay $125 co-pay Covered at 95% after deductible Mail Order Drug Supply Limit 90 day supply 90 day supply 90 day supply Covered Services and Excluded Services will shall be the same for employees under this Agreement as for all other employee groups participating in such plans. APPENDIX B – PLAN DESIGN FOR CORE DENTAL OPTION Benefit Features Traditional PPO Dental Benefits In-network: Out-of-network: Annual Deductibles Individual $50 $50 Family (2 members of family must each satisfy individual deductible) $100 $100 Annual Benefit Maximum $2,000 $2,000 Orthodontics Lifetime Maximum $2,000 $2,000 Office Visit Copay $0 $0

Appears in 1 contract

Samples: iam141.org

Profit Sharing Plan. For profit-sharing for covered employees effective for 2013 profit sharing paid in 2014 and subsequent years of this agreement, the profit sharing plan for IAM represented employees shall be funded with five percent (5%) of pre-tax profit up to a pre-tax margin of six and nine-tenths percent (6.9%) plus ten percent (10%) of pre-tax profit covered under this agreement will cease any future participation in excess of a pre-tax margin of six and nine-tenths percent (6.9%). Special and unusual items shall be excluded from pre-tax profit when making these calculationsthe Company’s Profit Sharing Plan effective January 1, 2015. APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-Network Out-of- Network In-Network In-Network Out-of- Network Annual Deductibles $300 single/ $600 family $600 single/ $1200 family $200 single/ $400 family $2500 single only $5000 true family deductible* $5000 single only $10,000 true family deductible* HSA Seed Amount (pro- rated per paycheck) NA NA $750 single / $1500 family Annual Out-of- Pocket (OOP) Limits $2000 single/ $4000 family (includes medical coinsurance and deductible, but not copays) $4000 single/ $8000 family (includes medical coinsurance and deductible, but not copays) $1,500/$3,000 (includes medical coinsurance and deductible, but not copays) $3000 single only $6000 true family maximum* (includes deductible and coinsurance) $6000 single only $12000 true family maximum* (includes deductible and coinsurance) Cross Application Out-of-Network Deductibles and OOP to In- Network Yes NA Yes Office Visit PCP $25 co-pay Covered at 60% after deductible $25 co-pay Covered at 95% after deductible Covered at 60% after deductible Office Visit Specialist $40 co-pay $40 co-pay Preventive Services (comprehensive array; See Appendix C) 100% preventive 100% preventive 100% preventive APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-Network Out-of- Network In-Network In-Network Out-of- Network Laboratory, x-ray and diagnostic testing Covered at 80% after deductible Covered at 60% after deductible Included w/office visit Covered at 95% after deductible Covered at 60% after deductible Hospital/Inpatient Covered at 90% after deductible Outpatient Facilities/Surgical Covered at 90% after deductible Urgent Care Center $50 $50 co-pay Emergency Room $200 flat copay, waived if admitted $200 co-pay, waived if admitted Retail Generic Drugs $10 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs* (Workaround for lower costs Rx at Target/Costco) $10 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs (Workaround for lower costs Rx at Target/Costco) Covered at 100% after deductible Retail Brand Preferred Drugs $30 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs- only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) $30 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs- only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) Covered at 95% after deductible APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-Network Out-of- Network In-Network In-Network Out-of- Network Retail Brand Non-Preferred Drugs $50 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs - only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) $50 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs - only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) Covered at 95% after deductible Retail Drug Supply Limit 30 day supply 30 day supply 30 day supply Mail Order Generic Drugs $25 co-pay $25 co-pay Covered at 100% after deductible (plan provides coverage for drugs that are allowed to be covered pre- deductible) Mail Order Brand Preferred Drugs $75 co-pay $75 co-pay Covered at 95% after deductible Mail Order Brand Non- preferred $125 co-pay $125 co-pay Covered at 95% after deductible Mail Order Drug Supply Limit 90 day supply 90 day supply 90 day supply Covered Services and Excluded Services will shall be the same for employees under this Agreement as for all other employee groups participating in such plans. APPENDIX B – PLAN DESIGN FOR CORE DENTAL OPTION Benefit Features Traditional PPO Dental Benefits In-network: Out-of-network: Annual Deductibles Individual $50 $50 Family (2 members of family must each satisfy individual deductible) $100 $100 Annual Benefit Maximum $2,000 $2,000 Orthodontics Lifetime Maximum $2,000 $2,000 Office Visit Copay $0 $0

Appears in 1 contract

Samples: iam141.org

Profit Sharing Plan. For profit-sharing for covered employees effective for 2013 profit sharing paid in 2014 and subsequent years of this agreement, the profit sharing plan for IAM represented employees shall be funded with five percent (5%) of pre-tax profit up to a pre-tax margin of six and nine-tenths percent (6.9%) plus ten percent (10%) of pre-tax profit in excess of a pre-tax margin of six and nine-tenths percent (6.9%). Special and unusual items shall be excluded from pre-tax profit when making these calculations. APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-Network Out-of- Network In-Network In-Network Out-of- Network Annual Deductibles $300 single/ $600 family $600 single/ $1200 family $200 single/ $400 family $2500 single only $5000 true family deductible* $5000 single only $10,000 true family deductible* HSA Seed Amount (pro- rated per paycheck) NA NA $750 single / $1500 family Annual Out-of- Pocket (OOP) Limits $2000 single/ $4000 family (includes medical coinsurance and deductible, but not copays) $4000 single/ $8000 family (includes medical coinsurance and deductible, but not copays) $1,500/$3,000 (includes medical coinsurance and deductible, but not copays) $3000 single only $6000 true family maximum* (includes deductible and coinsurance) $6000 single only $12000 true family maximum* (includes deductible and coinsurance) Cross Application Out-of-Network Deductibles and OOP to In- Network Yes NA Yes Office Visit PCP $25 co-pay Covered at 60% after deductible $25 co-pay Covered at 95% after deductible Covered at 60% after deductible Office Visit Specialist $40 co-pay $40 co-pay Preventive Services (comprehensive array; See Appendix C) 100% preventive 100% preventive 100% preventive APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-Network Out-of- Network In-Network In-Network Out-of- Network Laboratory, x-ray and diagnostic testing Covered at 80% after deductible Covered at 60% after deductible Included w/office visit Covered at 95% after deductible Covered at 60% after deductible Hospital/Inpatient Covered at 90% after deductible Outpatient Facilities/Surgical Covered at 90% after deductible Urgent Care Center $50 $50 co-pay Emergency Room $200 flat copay, waived if admitted $200 co-pay, waived if admitted Retail Generic Drugs $10 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs* (Workaround for lower costs Rx at Target/Costco) $10 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs (Workaround for lower costs Rx at Target/Costco) Covered at 100% after deductible Retail Brand Preferred Drugs $30 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs- only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) $30 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs- only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) Covered at 95% after deductible APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-Network Out-of- Network In-Network In-Network Out-of- Network Retail Brand Non-Preferred Drugs $50 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs - only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) $50 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs - only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) Covered at 95% after deductible Retail Drug Supply Limit 30 day supply 30 day supply 30 day supply Mail Order Generic Drugs $25 co-pay $25 co-pay Covered at 100% after deductible (plan provides coverage for drugs that are allowed to be covered pre- deductible) Mail Order Brand Preferred Drugs $75 co-pay $75 co-pay Covered at 95% after deductible Mail Order Brand Non- preferred $125 co-pay $125 co-pay Covered at 95% after deductible Mail Order Drug Supply Limit 90 day supply 90 day supply 90 day supply Covered Services and Excluded Services will be the same for employees under this Agreement as for all other employee groups participating in such plans. APPENDIX B – PLAN DESIGN FOR CORE DENTAL OPTION Benefit Features Traditional PPO Dental Benefits In-network: Out-of-network: Annual Deductibles Individual $50 $50 Family (2 members of family must each satisfy individual deductible) $100 $100 Annual Benefit Maximum $2,000 $2,000 Orthodontics Lifetime Maximum $2,000 $2,000 Office Visit Copay $0 $00 PREVENTIVE SERVICES and DIAGNOSTIC SERVICES Dental cleaning Topical Application of Fluoride, Sealants and Space Maintainers 100% Covered frequency and/or age limitations may apply to these services 100% Covered frequency and/or age limitations may apply to these services MINOR RESTORATIVE SERVICES Fillings, Endodontics, Periodontics, Oral Surgery Covered up to 80%; after deductible Covered up to 80%; after deductible; Subject to reasonable and customary limits MAJOR RESTORATIVE AND PROSTHODONTICS Initial placement of Dentures or Bridges to 1 or more natural teeth which are lost while covered by the Plan. Inlays and Crowns (Porcelain or Stainless Steel) Covered up to 50%; after deductible; frequency and/or age limitations may apply to these services Covered up to 50% after deductible; Subject to reasonable and customary limits; frequency and/or age limitations may apply to these services ORTHODONTICS Exams, X-Rays, Models, Appliances (Adult and Child) Covered up to 50%; after deductible; frequency and/or age limitations may apply to these services Covered up to 50% after deductible; Subject to reasonable and customary limits; frequency and/or age limitations may apply to these services Covered Services and Excluded Services will be the same for employees under this Agreement as for all other employee groups participating in such plan. Preventive Exams and Screenings – Adult Male Physical Exam 100% annually Prostate-Specific Antigen (PSA) 100% annually Lipid Panel 100% annually Glucose Testing 100% annually Colorectal Screening 100% annually Complete Blood Count (CBC) 100% annually Immunizations – Adult Male Tetanus Injections (with or without diphtheria) 100% as often as recommended by physician Meningitis 100% Herpes Zoster 100% Influenza Vaccine 100% annually Pneumococcal Vaccine 100% Travel Vaccinations 100% as often as recommended by physician Measles, Mumps, Rubella (MMR) for Adults 100% Preventive Exams and Screenings – Adult Female Physical Exam 100% annually, 1 general and 1 well-woman exam annually Lipid Panel 100% annually Glucose Testing 100% annually Colorectal Screening 100% annually Chlamydia Infection Screening 100% annually Mammogram 100% annually Bone Density 100% annually Pap Test 100% annually Complete Blood Count (CBC) 100% annually Immunizations – Adult Female Tetanus Injections (with or without diphtheria) 100% as often as recommended by physician Meningitis 100% Herpes Zoster 100% Influenza Vaccine 100% annually Human Papillomavirus (HPV) 100% Pneumococcal Vaccine 100% Travel Vaccinations 100% as often as recommended by physician Measles, Mumps, Rubella (MMR) for Adults 100% Preventive Exams and Screenings – Children Birth to 18 (Covered as Well-Child Care) Office Visits; Examinations Includes: ■ Physical and medical history ■ Height and weight ■ Head circumference (<1 year) ■ Ocular prophylaxis (at birth) 100%, as often as recommended by physician up to age 2, annually as of age 2 ■ Hemoglobin (<1 year) ■ Preventive health counseling, injury prevention and education ■ Dental health ■ Subjective assessment of vision and hearing (0–4 years) ■ Vision and hearing screen (4–18 years) ■ Developmental screening (up to 4 years) ■ Blood pressure (>1 year) ■ Administration of immunizations as indicated below Immunizations – Children Birth to 18 (Covered as Well-Child Care) Hepatitis B Series Hepatitis A Series Diptheria/Tetanus/Pertussis (DTaP) Adult Tetanus/Diphtheria (Td) Haemophilus Influenza (Hib) Series Xxxxxxxxx Xxxxxxx 100%, as often as recommended by physician Rotavirus Polio Series (IPV) Pneumococcal Conjugate (PCV) Measles/Mumps/Rubella (MMR) Chickenpox Vaccine (VZV) Travel Vaccinations

Appears in 1 contract

Samples: Fleet Service Employees

Profit Sharing Plan. For profit-sharing for covered employees effective for 2013 profit sharing paid in 2014 and subsequent years of this agreement, the profit sharing plan for IAM represented employees shall be funded with five percent (5%) of pre-tax profit up to a pre-tax margin of six and nine-tenths percent (6.9%) plus ten percent (10%) of pre-tax profit in excess of a pre-tax margin of six and nine-tenths percent (6.9%). Special and unusual items shall be excluded from pre-tax profit when making these calculations. APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-Network Out-of- Network In-Network In-Network Out-of- Network Annual Deductibles $300 single/ $600 family $600 single/ $1200 family $200 single/ $400 family $2500 single only $5000 true family deductible* $5000 single only $10,000 true family deductible* HSA Seed Amount (pro- rated per paycheck) NA NA $750 single / $1500 family Annual Out-of- Pocket (OOP) Limits $2000 single/ $4000 family (includes medical coinsurance and deductible, but not copays) $4000 single/ $8000 family (includes medical coinsurance and deductible, but not copays) $1,500/$3,000 (includes medical coinsurance and deductible, but not copays) $3000 single only $6000 true family maximum* (includes deductible and coinsurance) $6000 single only $12000 true family maximum* (includes deductible and coinsurance) Cross Application Out-of-Network Deductibles and OOP to In- Network Yes NA Yes Office Visit PCP $25 co-pay Covered at 60% after deductible $25 co-pay Covered at 95% after deductible Covered at 60% after deductible Office Visit Specialist $40 co-pay $40 co-pay Preventive Services (comprehensive array; See Appendix C) 100% preventive 100% preventive 100% preventive APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-Network Out-of- Network In-Network In-Network Out-of- Network Laboratory, x-ray and diagnostic testing Covered at 80% after deductible Covered at 60% after deductible Included w/office visit Covered at 95% after deductible Covered at 60% after deductible Hospital/Inpatient Covered at 90% after deductible Outpatient Facilities/Surgical Covered at 90% after deductible Urgent Care Center $50 $50 co-pay Emergency Room $200 flat copay, waived if admitted $200 co-pay, waived if admitted Retail Generic Drugs $10 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs* (Workaround for lower costs Rx at Target/Costco) $10 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs (Workaround for lower costs Rx at Target/Costco) Covered at 100% after deductible Retail Brand Preferred Drugs $30 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs- only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) $30 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs- only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) Covered at 95% after deductible APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-Network Out-of- Network In-Network In-Network Out-of- Network Retail Brand Non-Preferred Drugs $50 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs - only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) $50 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs - only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) Covered at 95% after deductible Retail Drug Supply Limit 30 day supply 30 day supply 30 day supply Mail Order Generic Drugs $25 co-pay $25 co-pay Covered at 100% after deductible (plan provides coverage for drugs that are allowed to be covered pre- deductible) Mail Order Brand Preferred Drugs $75 co-pay $75 co-pay Covered at 95% after deductible Mail Order Brand Non- preferred $125 co-pay $125 co-pay Covered at 95% after deductible Mail Order Drug Supply Limit 90 day supply 90 day supply 90 day supply Covered Services and Excluded Services will be the same for employees under this Agreement as for all other employee groups participating in such plans. APPENDIX B – PLAN DESIGN FOR CORE DENTAL OPTION Benefit Features Traditional PPO Dental Benefits In-network: Out-of-network: Annual Deductibles Individual $50 $50 Family (2 members of family must each satisfy individual deductible) $100 $100 Annual Benefit Maximum $2,000 $2,000 Orthodontics Lifetime Maximum $2,000 $2,000 Office Visit Copay $0 $00 PREVENTIVE SERVICES and DIAGNOSTIC SERVICES Dental cleaning Topical Application of Fluoride, Sealants and Space Maintainers 100% Covered frequency and/or age limitations may apply to these services 100% Covered frequency and/or age limitations may apply to these services MINOR RESTORATIVE SERVICES Fillings, Endodontics, Periodontics, Oral Surgery Covered up to 80%; after deductible Covered up to 80%; after deductible; Subject to reasonable and customary limits MAJOR RESTORATIVE AND PROSTHODONTICS Initial placement of Dentures or Bridges to 1 or more natural teeth which are lost while covered by the Plan. Inlays and Crowns (Porcelain or Stainless Steel) Covered up to 50%; after deductible; frequency and/or age limitations may apply to these services Covered up to 50% after deductible; Subject to reasonable and customary limits; frequency and/or age limitations may apply to these services ORTHODONTICS Exams, X-Rays, Models, Appliances (Adult and Child) Covered up to 50%; after deductible; frequency and/or age limitations may apply to these services Covered up to 50% after deductible; Subject to reasonable and customary limits; frequency and/or age limitations may apply to these services Covered Services and Excluded Services will be the same for employees under this Agreement as for all other employee groups participating in such plan. Preventive Exams and Screenings – Adult Male Physical Exam 100% annually Prostate-Specific Antigen (PSA) 100% annually Lipid Panel 100% annually Glucose Testing 100% annually Colorectal Screening 100% annually Complete Blood Count (CBC) 100% annually Immunizations – Adult Male Tetanus Injections (with or without diphtheria) 100% as often as recommended by physician Meningitis 100% Herpes Zoster 100% Influenza Vaccine 100% annually Pneumococcal Vaccine 100% Travel Vaccinations 100% as often as recommended by physician Measles, Mumps, Rubella (MMR) for Adults 100% Preventive Exams and Screenings – Adult Female Physical Exam 100% annually, 1 general and 1 well-woman exam annually Lipid Panel 100% annually Glucose Testing 100% annually Colorectal Screening 100% annually Chlamydia Infection Screening 100% annually Mammogram 100% annually Bone Density 100% annually Pap Test 100% annually Complete Blood Count (CBC) 100% annually Immunizations – Adult Female Tetanus Injections (with or without diphtheria) 100% as often as recommended by physician Meningitis 100% Herpes Zoster 100% Influenza Vaccine 100% annually Human Papillomavirus (HPV) 100% Pneumococcal Vaccine 100% Travel Vaccinations 100% as often as recommended by physician Measles, Mumps, Rubella (MMR) for Adults 100% Preventive Exams and Screenings – Children Birth to 18 (Covered as Well-Child Care) Office Visits; Examinations Includes: ■ Physical and medical history ■ Height and weight ■ Head circumference (<1 year) ■ Ocular prophylaxis (at birth) 100%, as often as recommended by physician up to age 2, annually as of age 2 ■ Hemoglobin (<1 year) ■ Preventive health counseling, injury prevention and education ■ Dental health ■ Subjective assessment of vision and hearing (0–4 years) ■ Vision and hearing screen (4–18 years) ■ Developmental screening (up to 4 years) ■ Blood pressure (>1 year) ■ Administration of immunizations as indicated below Immunizations – Children Birth to 18 (Covered as Well-Child Care) Hepatitis B Series Hepatitis A Series Diptheria/Tetanus/Pertussis (DTaP) Adult Tetanus/Diphtheria (Td) Haemophilus Influenza (Hib) Series Influenza Vaccine 100%, as often as recommended by physician Rotavirus Polio Series (IPV) Pneumococcal Conjugate (PCV) Measles/Mumps/Rubella (MMR) Chickenpox Vaccine (VZV) Travel Vaccinations

Appears in 1 contract

Samples: Fleet Service Employees

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Profit Sharing Plan. For profit-sharing for covered employees effective for 2013 2014 profit sharing paid in 2014 2015 and subsequent years of this agreement, the profit sharing plan for IAM represented employees shall be funded with five percent (5%) of pre-tax profit up to a pre-tax margin of six and nine-tenths percent (6.9%) plus ten percent (10%) of pre-tax profit in excess of a pre-tax margin of six and nine-tenths percent (6.9%). Special and unusual items shall be excluded from pre-tax profit when making these calculations. APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-In- Network Out-of- Network In-Network In-Network Out-of- Network Annual Deductibles $300 single/ $600 family $600 single/ $1200 family $200 single/ $400 family $2500 single only $5000 true family deductible* $5000 single only $10,000 true family deductible* HSA Seed Amount (pro- rated per paycheck) NA NA $750 single / $1500 family Annual Out-of- Pocket (OOP) Limits $2000 single/ $4000 family (includes medical coinsurance coinsuranc e and deductible, but not copays) $4000 single/ $8000 family (includes medical coinsurance coinsuranc e and deductible, but not copays) $1,500/$3,000 1,500/$3,00 0 (includes medical coinsurance and deductible, but not copays) $3000 single only $6000 true family maximum* (includes deductible and coinsurancecoinsurance ) $6000 single only $12000 true family maximum* (includes deductible and coinsurancecoinsurance ) Cross Application Out-Out- of-Network Deductibles and OOP to In- Network Yes NA Yes Office Visit PCP $25 co-pay Covered at 60% after deductible $25 co-pay Covered at 95% after deductible Covered at 60% after deductible Office Visit Specialist $40 co-pay $40 co-pay Preventive Services (comprehensive array; See Appendix C) 100% preventive 100% preventive 100% preventive APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-In- Network Out-of- Network In-Network In-Network Out-of- Network Laboratory, x-x- ray and diagnostic testing Covered at 80% after deductible Covered at 60% after deductible Included w/office visit Covered at 95% after deductible Covered at 60% after deductible Hospital/Inpatient Inpatien t Covered at 90% after deductible Outpatient Facilities/Surgical Surgica l Covered at 90% after deductible Urgent Care Center $50 $50 co-pay Emergency Room $200 flat copay, waived if admitted $200 co-pay, waived if admitted Retail Generic Drugs $10 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs* (Workaround for lower costs Rx at Target/Costco) $10 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs (Workaround for lower costs Rx at Target/CostcoCostco ) Covered at 100% after deductible Retail Brand Preferred Drugs $30 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs- only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) $30 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs- only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) Covered at 95% after deductible APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-In- Network Out-of- Network In-Network In-Network Out-of- Network Target/Costco ) Retail Brand Non-Preferred Drugs $50 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs - only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) $50 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs - only if less expensive than retail (Workaround for lower costs Rx at Target/CostcoCostco ) Covered at 95% after deductible Retail Drug Supply Limit 30 day supply 30 day supply 30 day supply Mail Order Generic Drugs $25 co-pay $25 co-pay Covered at 100% after deductible (plan provides coverage for drugs that are allowed to be covered pre- deductible) Mail Order Brand Preferred Drugs $75 co-pay $75 co-pay Covered at 95% after deductible Mail Order Brand Non- preferred $125 co-pay $125 co-pay Covered at 95% after deductible Mail Order Drug Supply Limit 90 day supply 90 day supply 90 day supply Covered Services and Excluded Services will be the same for employees under this Agreement as for all other employee groups participating in such plans. APPENDIX B – PLAN DESIGN FOR CORE DENTAL OPTION Benefit Features Traditional PPO Dental Benefits In-network: Out-of-network: Annual Deductibles Individual $50 $50 Family (2 members of family must each satisfy individual deductible) $100 $100 Annual Benefit Maximum $2,000 $2,000 Orthodontics Lifetime Maximum $2,000 $2,000 Office Visit Copay $0 $0

Appears in 1 contract

Samples: iam141.org

Profit Sharing Plan. For profit-sharing for covered employees effective for 2013 profit sharing paid in 2014 and subsequent years of this agreement, the profit sharing plan for IAM represented employees shall be funded with five percent (5%) of pre-tax profit up to a pre-tax margin of six and nine-tenths percent (6.9%) plus ten percent (10%) of pre-tax profit in excess of a pre-tax margin of six and nine-nine- tenths percent (6.9%). Special and unusual items shall be excluded from pre-tax profit when making these calculations. APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-Network Out-of- of-Network In-Network In-Network Out-of- of-Network Annual Deductibles $300 single/ $600 family $600 single/ $1200 family $200 single/ $400 family $2500 single only $5000 true family deductible* $5000 single only $10,000 true family deductible* HSA Seed Amount (pro- pro-rated per paycheck) NA NA $750 single / $1500 family Annual Out-of- Pocket (OOP) Limits $2000 single/ $4000 family (includes medical coinsurance and deductible, but not copays) $4000 single/ $8000 family (includes medical coinsurance and deductible, but not copays) $1,500/$3,000 (includes medical coinsurance and deductible, but not copays) $3000 single only $6000 true family maximum* (includes deductible and coinsurance) $6000 single only $12000 true family maximum* (includes deductible and coinsurance) Cross Application Out-of-Network Deductibles and OOP to In- In-Network Yes NA Yes Office Visit PCP $25 co-pay Covered at 60% after deductible $25 co-pay Covered at 95% after deductible Covered at 60% after deductible Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-Network Out-of-Network In-Network In-Network Out-of-Network Office Visit Specialist $40 co-pay Covered at 60% after deductible Covered at 60% after deductible $40 co-pay Covered at 60% after deductible Covered at 60% after deductible Preventive Services (comprehensive array; See Appendix C) 100% preventive 100% preventive 100% preventive APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-Network Out-of- Network In-Network In-Network Out-of- Network Laboratory, x-ray and diagnostic testing Covered at 80% after deductible Covered at 60% after deductible Included w/office visit Covered at 95% after deductible Covered at 60% after deductible Hospital/Inpatient Covered at 90% after deductible Outpatient Facilities/Surgical Covered at 90% after deductible Urgent Care Center $50 $50 co-pay Emergency Room $200 flat copay, waived if admitted $200 co-pay, waived if admitted Retail Generic Drugs $10 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs* (Workaround for lower costs Rx at Target/Costco) $10 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs (Workaround for lower costs Rx at Target/Costco) Covered at 100% after deductible Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-Network Out-of-Network In-Network In-Network Out-of-Network Retail Brand Preferred Drugs $30 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs- only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) $30 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs- only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) Covered at 95% after deductible APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-Network Out-of- Network In-Network In-Network Out-of- Network Retail Brand Non-Non- Preferred Drugs $50 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs - only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) $50 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs - only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) Covered at 95% after deductible Retail Drug Supply Limit 30 day supply 30 day supply 30 day supply Mail Order Generic Drugs $25 co-pay $25 co-pay Covered at 100% after deductible (plan provides coverage for drugs that are allowed to be covered pre- pre-deductible) Mail Order Brand Preferred Drugs $75 co-pay $75 co-pay Covered at 95% after deductible Mail Order Brand Non- Non-preferred $125 co-pay $125 co-pay Covered at 95% after deductible Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-Network Out-of-Network In-Network In-Network Out-of-Network Mail Order Drug Supply Limit 90 day supply 90 day supply 90 day supply Covered Services and Excluded Services will be the same for employees under this Agreement as for all other employee groups participating in such plans. APPENDIX B – PLAN DESIGN FOR CORE DENTAL OPTION Benefit Features Traditional PPO Dental Benefits In-network: Out-of-network: Annual Deductibles Individual $50 $50 Family (2 members of family must each satisfy individual deductible) $100 $100 Annual Benefit Maximum $2,000 $2,000 Orthodontics Lifetime Maximum $2,000 $2,000 Office Visit Copay $0 $0

Appears in 1 contract

Samples: Fleet Service Employees

Profit Sharing Plan. For profit-sharing for covered employees effective for 2013 profit sharing paid in 2014 and subsequent years of this agreement, the profit sharing plan for IAM represented employees shall be funded with five percent (5%) of pre-tax profit up to a pre-tax margin of six and nine-tenths percent (6.9%) plus ten percent (10%) of pre-tax profit covered under this agreement will cease any future participation in excess of a pre-tax margin of six and nine-tenths percent (6.9%). Special and unusual items shall be excluded from pre-tax profit when making these calculationsthe Company’s Profit Sharing Plan effective January 1, 2014. APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-Network Out-of- Network In-Network In-Network Out-of- Network Annual Deductibles $300 single/ $600 family $600 single/ $1200 family $200 single/ $400 family $2500 single only $5000 true family deductible* $5000 single only $10,000 true family deductible* HSA Seed Amount (pro- rated per paycheck) NA NA $750 single / $1500 family Annual Out-of- Pocket (OOP) Limits $2000 single/ $4000 family (includes medical coinsurance and deductible, but not copays) $4000 single/ $8000 family (includes medical coinsurance and deductible, but not copays) $1,500/$3,000 (includes medical coinsurance and deductible, but not copays) $3000 single only $6000 true family maximum* (includes deductible and coinsurance) $6000 single only $12000 true family maximum* (includes deductible and coinsurance) Cross Application Out-of-Network Deductibles and OOP to In- Network Yes NA Yes Office Visit PCP $25 co-pay Covered at 60% after deductible $25 co-pay Covered at 95% after deductible Covered at 60% after deductible Office Visit Specialist $40 co-pay $40 co-pay Preventive Services (comprehensive array; See Appendix C) 100% preventive 100% preventive 100% preventive APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-Network Out-of- Network In-Network In-Network Out-of- Network Laboratory, x-ray and diagnostic testing Covered at 80% after deductible Covered at 60% after deductible Included w/office visit Covered at 95% after deductible Covered at 60% after deductible Hospital/Inpatient Covered at 90% after deductible Outpatient Facilities/Surgical Covered at 90% after deductible Urgent Care Center $50 $50 co-pay Emergency Room $200 flat copay, waived if admitted $200 co-pay, waived if admitted Retail Generic Drugs $10 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs* (Workaround for lower costs Rx at Target/Costco) $10 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs (Workaround for lower costs Rx at Target/Costco) Covered at 100% after deductible Retail Brand Preferred Drugs $30 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs- only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) $30 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs- only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) Covered at 95% after deductible APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-Network Out-of- Network In-Network In-Network Out-of- Network Retail Brand Non-Preferred Drugs $50 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs - only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) $50 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs - only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) Covered at 95% after deductible Retail Drug Supply Limit 30 day supply 30 day supply 30 day supply Mail Order Generic Drugs $25 co-pay $25 co-pay Covered at 100% after deductible (plan provides coverage for drugs that are allowed to be covered pre- deductible) Mail Order Brand Preferred Drugs $75 co-pay $75 co-pay Covered at 95% after deductible Mail Order Brand Non- preferred $125 co-pay $125 co-pay Covered at 95% after deductible Mail Order Drug Supply Limit 90 day supply 90 day supply 90 day supply Covered Services and Excluded Services will be the same for employees under this Agreement as for all other employee groups participating in such plans. APPENDIX B – PLAN DESIGN FOR CORE DENTAL OPTION Benefit Features Traditional PPO Dental Benefits In-network: Out-of-network: Annual Deductibles Individual $50 $50 Family (2 members of family must each satisfy individual deductible) $100 $100 Annual Benefit Maximum $2,000 $2,000 Orthodontics Lifetime Maximum $2,000 $2,000 Office Visit Copay $0 $0

Appears in 1 contract

Samples: Security Officer Employees

Profit Sharing Plan. For profit-sharing for covered employees effective for 2013 2014 profit sharing paid in 2014 2015 and subsequent years of this agreement, the profit sharing plan for IAM represented employees shall be funded with five percent (5%) of pre-tax profit up to a pre-tax margin of six and nine-tenths percent (6.9%) plus ten percent (10%) of pre-tax profit in excess of a pre-tax margin of six and nine-tenths percent (6.9%). Special and unusual items shall be excluded from pre-tax profit when making these calculations. APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-In- Network Out-of- Network In-Network In-Network Out-of- Network Annual Deductibles $300 single/ $600 family $600 single/ $1200 family $200 single/ $400 family $2500 single only $5000 true family deductible* $5000 single only $10,000 true family deductible* HSA Seed Amount (pro- rated per paycheck) NA NA $750 single / $1500 family Annual Out-of- Pocket (OOP) Limits $2000 single/ $4000 family (includes medical coinsurance coinsuranc e and deductible, but not copays) $4000 single/ $8000 family (includes medical coinsurance coinsuranc e and deductible, but not copays) $1,500/$3,000 1,500/$3,00 0 (includes medical coinsurance and deductible, but not copays) $3000 single only $6000 true family maximum* (includes deductible and coinsurancecoinsurance ) $6000 single only $12000 true family maximum* (includes deductible and coinsurancecoinsurance ) Cross Application Out-Out- of-Network Deductibles and OOP to In- Network Yes NA Yes Office Visit PCP $25 co-pay Covered at 60% after deductible $25 co-pay Covered at 95% after deductible Covered at 60% after deductible Office Visit Specialist $40 co-pay $40 co-pay Preventive Services (comprehensive array; See Appendix C) 100% preventive 100% preventive 100% preventive APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-In- Network Out-of- Network In-Network In-Network Out-of- Network Laboratory, x-x- ray and diagnostic testing Covered at 80% after deductible Covered at 60% after deductible Included w/office visit Covered at 95% after deductible Covered at 60% after deductible Hospital/Inpatient Inpatien t Covered at 90% after deductible Outpatient Facilities/Surgical Surgica l Covered at 90% after deductible Urgent Care Center $50 $50 co-pay Emergency Room $200 flat copay, waived if admitted $200 co-pay, waived if admitted Retail Generic Drugs $10 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs* (Workaround for lower costs Rx at Target/Costco) $10 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs (Workaround for lower costs Rx at Target/CostcoCostco ) Covered at 100% after deductible APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In- Network Out-of- Network In-Network In-Network Out-of- Network Retail Brand Preferred Drugs $30 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs- only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) $30 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs- only if less expensive than retail (Workaround for lower costs Rx at Target/CostcoCostco ) Covered at 95% after deductible APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-Network Out-of- Network In-Network In-Network Out-of- Network Retail Brand Non-Preferred Drugs $50 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs - only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) $50 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs - only if less expensive than retail (Workaround for lower costs Rx at Target/CostcoCostco ) Covered at 95% after deductible Retail Drug Supply Limit 30 day supply 30 day supply 30 day supply Mail Order Generic Drugs $25 co-pay $25 co-pay Covered at 100% after deductible (plan provides coverage for drugs that are allowed to be covered pre- deductible) Mail Order Brand Preferred Drugs $75 co-pay $75 co-pay Covered at 95% after deductible Mail Order Brand Non- preferred $125 co-pay $125 co-pay Covered at 95% after deductible APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In- Network Out-of- Network In-Network In-Network Out-of- Network Mail Order Drug Supply Limit 90 day supply 90 day supply 90 day supply Covered Services and Excluded Services will be the same for employees under this Agreement as for all other employee groups participating in such plans. APPENDIX B – PLAN DESIGN FOR CORE DENTAL OPTION Benefit Features Traditional PPO Dental Benefits In-network: Out-of-network: Annual Deductibles Individual $50 $50 Family (2 members of family must each satisfy individual deductible) $100 $100 Annual Benefit Maximum $2,000 $2,000 Orthodontics Lifetime Maximum $2,000 $2,000 Office Visit Copay $0 $0

Appears in 1 contract

Samples: Instructor Employees

Profit Sharing Plan. For profit-sharing for covered employees effective for 2013 profit sharing paid in 2014 and subsequent years of this agreement, the profit sharing plan for IAM represented employees shall be funded with five percent (5%) of pre-tax profit up to a pre-tax margin of six and nine-tenths percent (6.9%) plus ten percent (10%) of pre-tax profit in excess of a pre-tax margin of six and nine-tenths percent (6.9%). Special and unusual items shall be excluded from pre-tax profit when making these calculations. APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-In- Network Out-of- Network In-Network In-Network Out-of- Network Annual Deductibles $300 single/ $600 family $600 single/ $1200 family $200 single/ $400 family $2500 single only $5000 true family deductible* $5000 single only $10,000 true family deductible* HSA Seed Amount (pro- rated per paycheck) NA NA $750 single / $1500 family Annual Out-of- Pocket (OOP) Limits $2000 single/ $4000 family (includes medical coinsurance coinsuranc e and deductible, but not copays) $4000 single/ $8000 family (includes medical coinsurance coinsuranc e and deductible, but not copays) $1,500/$3,000 1,500/$3,00 0 (includes medical coinsurance and deductible, but not copays) $3000 single only $6000 true family maximum* (includes deductible and coinsurancecoinsurance ) $6000 single only $12000 true family maximum* (includes deductible and coinsurancecoinsurance ) Cross Application Out-Out- of-Network Deductibles and OOP to In- Network Yes NA Yes Office Visit PCP $25 co-pay Covered at 60% after deductible $25 co-pay Covered at 95% after deductible Covered at 60% after deductible Office Visit Specialist $40 co-pay $40 co-pay Preventive Services (comprehensive array; See Appendix C) 100% preventive 100% preventive 100% preventive APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-In- Network Out-of- Network In-Network In-Network Out-of- Network Laboratory, x-x- ray and diagnostic testing Covered at 80% after deductible Covered at 60% after deductible Included w/office visit Covered at 95% after deductible Covered at 60% after deductible Hospital/Inpatient Inpatien t Covered at 90% after deductible Outpatient Facilities/Surgical Surgica l Covered at 90% after deductible Urgent Care Center $50 $50 co-pay Emergency Room $200 flat copay, waived if admitted $200 co-pay, waived if admitted Retail Generic Drugs $10 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs* (Workaround for lower costs Rx at Target/Costco) $10 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs (Workaround for lower costs Rx at Target/CostcoCostco ) Covered at 100% after deductible Retail Brand Preferred Drugs $30 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs- only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) $30 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs- only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) Covered at 95% after deductible APPENDIX A – PLAN DESIGNS FOR CORE MEDICAL OPTIONS Core PPO Option Core EPO Option Core HDHP PLAN DESIGN In-In- Network Out-of- Network In-Network In-Network Out-of- Network Target/Costco ) Retail Brand Non-Preferred Drugs $50 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs - only if less expensive than retail (Workaround for lower costs Rx at Target/Costco) $50 co-pay Mandatory Mail – Limit 3 retail fills for maintenance drugs - only if less expensive than retail (Workaround for lower costs Rx at Target/CostcoCostco ) Covered at 95% after deductible Retail Drug Supply Limit 30 day supply 30 day supply 30 day supply Mail Order Generic Drugs $25 co-pay $25 co-pay Covered at 100% after deductible (plan provides coverage for drugs that are allowed to be covered pre- deductible) Mail Order Brand Preferred Drugs $75 co-pay $75 co-pay Covered at 95% after deductible Mail Order Brand Non- preferred $125 co-pay $125 co-pay Covered at 95% after deductible Mail Order Drug Supply Limit 90 day supply 90 day supply 90 day supply Covered Services and Excluded Services will be the same for employees under this Agreement as for all other employee groups participating in such plans. APPENDIX B – PLAN DESIGN FOR CORE DENTAL OPTION Benefit Features Traditional PPO Dental Benefits In-network: Out-of-network: Annual Deductibles Individual $50 $50 Family (2 members of family must each satisfy individual deductible) $100 $100 Annual Benefit Maximum $2,000 $2,000 Orthodontics Lifetime Maximum $2,000 $2,000 Office Visit Copay $0 $00 PREVENTIVE SERVICES and DIAGNOSTIC SERVICES Dental cleaning Topical Application of Fluoride, Sealants and Space Maintainers 100% Covered frequency and/or age limitations may apply to these services 100% Covered frequency and/or age limitations may apply to these services MINOR RESTORATIVE SERVICES Fillings, Endodontics, Periodontics, Oral Surgery Covered up to 80%; after deductible Covered up to 80%; after deductible; Subject to reasonable and customary limits MAJOR RESTORATIVE AND PROSTHODONTICS Initial placement of Dentures or Bridges to 1 or more natural teeth which are lost while covered by the Plan. Inlays and Crowns (Porcelain or Stainless Steel) Covered up to 50%; after deductible; frequency and/or age limitations may apply to these services Covered up to 50% after deductible; Subject to reasonable and customary limits; frequency and/or age limitations may apply to these services ORTHODONTICS Exams, X-Rays, Models, Appliances (Adult and Child) Covered up to 50%; after deductible; frequency and/or age limitations may apply to these services Covered up to 50% after deductible; Subject to reasonable and customary limits; frequency and/or age limitations may apply to these services Covered Services and Excluded Services will be the same for employees under this Agreement as for all other employee groups participating in such plan. Preventive Exams and Screenings – Adult Male Physical Exam 100% annually Prostate-Specific Antigen (PSA) 100% annually Lipid Panel 100% annually Glucose Testing 100% annually Colorectal Screening 100% annually Complete Blood Count (CBC) 100% annually Immunizations – Adult Male Tetanus Injections (with or without diphtheria) 100% as often as recommended by physician Meningitis 100% Herpes Zoster 100% Influenza Vaccine 100% annually Pneumococcal Vaccine 100% Travel Vaccinations 100% as often as recommended by physician Measles, Mumps, Rubella (MMR) for Adults 100% Preventive Exams and Screenings – Adult Female Physical Exam 100% annually, 1 general and 1 well-woman exam annually Lipid Panel 100% annually Glucose Testing 100% annually Colorectal Screening 100% annually Chlamydia Infection Screening 100% annually Mammogram 100% annually Bone Density 100% annually Pap Test 100% annually Complete Blood Count (CBC) 100% annually Immunizations – Adult Female Tetanus Injections (with or without diphtheria) 100% as often as recommended by physician Meningitis 100% Herpes Zoster 100% Influenza Vaccine 100% annually Human Papillomavirus (HPV) 100% Pneumococcal Vaccine 100% Travel Vaccinations 100% as often as recommended by physician Measles, Mumps, Rubella (MMR) for Adults 100% Preventive Exams and Screenings – Children Birth to 18 (Covered as Well-Child Care) Office Visits; Examinations Includes: ■ Physical and medical history ■ Height and weight ■ Head circumference (<1 year) ■ Ocular prophylaxis (at birth) 100%, as often as recommended by physician up to age 2, annually as of age 2 ■ Hemoglobin (<1 year) ■ Preventive health counseling, injury prevention and education ■ Dental health ■ Subjective assessment of vision and hearing (0–4 years) ■ Vision and hearing screen (4–18 years) ■ Developmental screening (up to 4 years) ■ Blood pressure (>1 year) ■ Administration of immunizations as indicated below Immunizations – Children Birth to 18 (Covered as Well-Child Care) Hepatitis B Series Hepatitis A Series Diptheria/Tetanus/Pertussis (DTaP) Adult Tetanus/Diphtheria (Td) Haemophilus Influenza (Hib) Series Xxxxxxxxx Xxxxxxx 100%, as often as recommended by physician Rotavirus Polio Series (IPV) Pneumococcal Conjugate (PCV) Measles/Mumps/Rubella (MMR) Chickenpox Vaccine (VZV) Travel Vaccinations

Appears in 1 contract

Samples: Service Employees

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