The Indemnity medical benefits are payable for medically necessary expenses incurred by you or your dependent, while covered under the Plan, for eligible expenses which are ordered by a physician and, except for newborns, are as a result of injury or sickness.

The Deductible
You and each of your covered dependents have a calendar year deductible of $300 of eligible expenses. The $300 deductible needs to be satisfied only once during a calendar year even if the individual has several accidents and/ or illnesses. The Plan will begin to pay eligible expenses once you have satisfied your deductible. Satisfaction of your $300 deductible is accomplished by submission of charges to your Area Administrative Office, which will apply all eligible charges until an amount equal to the $300 has been reached.

Deductible Carry-over Provision - The deductible for a calendar year must be satisfied by eligible expenses incurred during that year. However, if any eligible expenses incurred during the last three months of the immediately preceding calendar year are applied against that year’s deductible, (whether or not the full deductible was accumulated for that year), it will also be applied toward the deductible for the next year and thus reduce or eliminate the next year’s deductible.

Common Accident Provision - If two or more covered family members are injured in the same accident, only one yearly deductible will be charged to their combined eligible expenses due to the accident.

The Benefits
If you use a non-PPO provider, your indemnity medical benefits will pay 75% of Usual, Customary and Reasonable fees for eligible expenses in excess of the deductible. If you use a preferred provider, the Medical Plan will pay 90% of the doctor’s contractual fee for eligible expenses in excess of the deductible.

Covered PPO services are paid at 90% until $1,500 in eligible out-of-pocket expenses have been accumulated for an individual during a calendar year. Then the Plan pays 100% of eligible expenses for the remainder of the calendar year for that individual.

Covered Non-PPO services are paid at 75% until $2,500 in eligible out-of-pocket expenses have been accumulated during a calendar year. Then the Plan pays 100% of eligible expenses for the remainder of the calendar year for that individual.

Eligible out-of pocket expenses do not incude deductible or amounts in excess of UCR.

Overall Major Medical Maximum for Each Individual
The overall indemnity medical benefits maximum for each participant and each covered dependent, while otherwise eligible, is $1,000,000 whether paid in one year or over a period of years. Whenever medical benefits are paid, they are charged against the individual’s overall maximum.

Automatic Reinstatement - On the first day of each year, each covered person who has benefits charged to his or her overall maximum will automatically have an amount reinstated for future use. The amount to be reinstated each year will be $3,000, or the amount needed to bring the maximum back to the full amount, whichever is less.