The Indemnity Medical Benefit Plan provides benefits 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 $100 of eligible expenses (inpatient hospital services are not subject to the calendar year deductible). The $100 deductible needs to be satisfied only once during a calendar year even if the individual has several accidents and sicknesses. The Plan will begin to pay eligible expenses once you have satisfied your deductible. Satisfaction of your $100 deductible is accomplished by submission of charges to your Area Administrative Office, who will apply all eligible charges until an amount equal to the $100 has been reached.

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.

Overall Medical Maximum for Each Individual
The overall maximum benefit 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. If you are covered under this Retiree Plan and have benefits paid under Program One for those not eligible for U.S. Medicare, those payments will be used to reduce your overall maximum under this Plan.

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.

Request for Reinstatement - At any time after the benefits charged to an individual’s overall maximum reach a total of at least $1,000, you may arrange to have the full maximum reinstated by furnishing the Trust with satisfactory proof the individual is in good health.

Overall Maximum for Mental, Psychoneurotic and Personality Disorders - Not more than 45 days of benefit will be paid for the treatment of all mental, psychoneurotic and personality disorders whether paid in one year or over a period of years.

Eligibile Expenses Under the Medical Benefit Plan
You and your dependents, while eligible, are entitled to benefit payments for the medical services and supplies described below, if medically necessary for the treatment of sickness or injury and if ordered by a physician. Benefit payments are subject to all other provisions of this Plan including those relating to PPO providers, care management, definitions, and specific and general exclusions.

Inpatient Hospital Expenses

Hospital Room and Board - Hospital charges for room and board. For private accommodations, the eligible expenses are subject to the daily limit.

Other Hospital Services - Hospital charges for other services and supplies furnished by the hospital for medical care such as operating room, medicines, drugs, anesthesia, X-ray examinations, treatment with X-ray, radiation and other radioactive substances, laboratory tests, ambulance service for local travel, surgical dressings and supplies, etc., but not professional services.

Other Covered Expenses In or Out of the Hospital

Doctors Services - Surgery, home, office and hospital visits, and other medical care and treatment.

Nursing Care - Private duty nursing by a registered nurse.

Speech Therapy - Treatment by a qualified speech therapist to restore or rehabilitate any speech loss or impairment caused by injury or sickness (except a mental, psychoneurotic or personality disorder), or by surgery for that injury or sickness. In the case of congenital defect, speech therapy expenses will be considered only if incurred after corrective surgery for the defect.

Physical and Occupational Therapy - Treatment by a licensed or registered physical or occupational therapist.

Ambulance - Ambulance service for local travel if medically necessary.

Anesthesia - Cost of anesthetics and their administration.

X-ray and Laboratory Tests and analysis.

X-ray and Radiation Treatments and treatments with other radioactive substances.

Durable Medical Equipment and Medical Supplies - Artificial limbs, eyes and larynx; surgical dressings; casts, splints, trusses, braces, crutches, blood glucose monitor; rental of wheel chair, hospital bed, or respirator; oxygen and rental of equipment for its administration. The rental cost of durable medical equipment is covered but not to exceed the purchase price of the equipment.

Dental Services - The plan covers charges made for the treatment or removal of a malignant tumor or for treatment by a doctor, dentist or dental surgeon of injuries to natural teeth caused by an accident (including replacement of such teeth, and related X-rays) if incurred within 12 months after an accident. Not covered are charges for doctor’s services or X-ray exams involving one or more teeth, the tissue or structure around them, the alveolar process or the gums. This applies even if a condition requiring any of these services involves a part of the body other than the mouth such as treatment of Temporomandibular Joint Disorders (TMJD) or malocclusion involving joints or muscles by methods including but not limited to, crowning, wiring or repositioning teeth.

Mental, Psychoneurotic and Personality Disorders - In the case of mental, psychoneurotic and personality disorders, the benefits for doctors services will be payable at the rate of 20%, after satisfaction of the yearly deductible. Not more than 50 visits in a calendar year, with a maximum payment up to $12.50 a visit, will be counted as eligible expenses. These limits do not apply for administering convulsive therapy.

Orthotics - When determined to be medically necessary.

Services of the Spine - Charges for medically necessary treatment of the spine and its suppor ting structures (including, but not limited to, physical therapy and chiropractic services) will be covered to a maximum of 30 (combined PPO/Non-PPO) treatments per calendar year. You or your doctor may be required to provide supportive materials to establish medical necessity including X-ray, chart notes and treatment plans.

Inpatient Well Baby Care For Newborns - Eligible inpatient hospital expenses for well newborns from birth for up to the first seven days of life. For the child’s charges to be covered, the Mother must also be hospital confined.

Routine Mammography - Diagnostic and screening mammography recommended by your physician.

Hospital and Professional Obstetrical Care - Pregnancy and childbir th are covered on the same basis as any other condition for the member or the spouse.

Dietary Formula - Which is medically necessary for the treatment of phenylketonuria (PKU).

Blood Transfusions - Including the cost of blood and blood derivatives.