Summary Plan Description

Medical Plan Maximums

The following services and supplies have specific maximums:

  • Allergy testing – Annual maximum of 12 blood tests and 60 skin tests.
  • Chiropractic care – Annual maximum of 24 spinal manipulations.
  • Hearing aids – Maximum of $1,000 per ear paid in any three consecutive year period. The hearing aid benefit is not available under Retiree Coverage.
  • Home health care – Annual maximum of 30 visits.
  • Hospice care – Maximum of 14 inpatient days for hospice care. Skilled care in the home is limited to 60 visits. Respite care is limited to 120 hours per three-month period.
  • Orthognathic surgery – Lifetime maximum of $5,000. The orthognathic surgery benefit is not available under Retiree Coverage.
  • Orthotics (foot) – Maximum of $400 paid in any two consecutive year period. The orthotics benefit is not available under Retiree Coverage.
  • Preventive health services – Subject to services recommended by the Affordable Care Act.
  • Rehabilitative and habilitative – Annual maximum of 15 inpatient days and 30 outpatient visits.
  • Skilled nursing facility – Annual maximum of 25 days. Medicare-eligible retirees and dependents are eligible for 80 coinsurance days.
  • TMJ and MPDS – Lifetime maximum of $2,500. The TMJ and MPDS benefit is not available under Retiree Coverage.