LETTER 7
Group Insurance
Plans
Mr. James M.
Parent
Assistant
Directing Business
Representative
District Lodge
No. 26
I.A.M.A.W.,
AFL-CIO
365 New Britain
Road
Kensington,
Connecticut 06037
Dear Mr. Parent:
This is to confirm the
understanding and agreement between the Company and the Union concerning
amendments to the group health insurance, life insurance, disability
insurance and the group dental plan referred to in Article 22. The
following represents a summary of benefits and amendments to contractual
provisions.
Reimbursement
Accounts -- Effective December 6, 2004:
|
Health Care
Reimbursement Account |
$120 to $3,000 per year, pre-tax for eligible medical and dental
expenses.
$120 to
$4,000 per year, pre-tax, effective April 1, 2005 |
|
Dependent Day
Care Reimbursement Account |
$120 to
$5,000 per year, pre-tax for eligible child and/or adult/elder day
care expenses. |
Life/Accidental
Death & Dismemberment/Weekly Disability and
Total and
Permanent Disability Table -- Effective January 1, 2005:
|
Base Rate
Wage Class |
Life & AD&D |
Weekly
Disability |
TPD |
|
$18.00 and
Under |
$55,500 |
$370 |
$1,005.66 |
|
$18.01 -
$18.50 |
$57,000 |
$380 |
$1,032.84 |
|
$18.51 -
$19.00 |
$58,500 |
$390 |
$1,060.02 |
|
$19.01 -
$19.50 |
$60,000 |
$400 |
$1,087.20 |
|
$19.51 -
$20.00 |
$61,500 |
$410 |
$1,114.38 |
|
$20.01 -
$20.50 |
$63,000 |
$420 |
$1,141.56 |
|
$20.51 -
$21.00 |
$64,500 |
$430 |
$1,168.74 |
|
$21.01 -
$21.50 |
$66,000 |
$440 |
$1,195.92 |
|
$21.51 -
$22.00 |
$67,500 |
$450 |
$1,223.10 |
|
$22.01 -
$22.50 |
$69,000 |
$460 |
$1,250.28 |
|
$22.51 -
$23.00 |
$70,500 |
$470 |
$1,277.46 |
|
$23.01 -
$23.50 |
$72,000 |
$480 |
$1,304.64 |
|
$23.51 -
$24.00 |
$73,500 |
$490 |
$1,331.82 |
|
$24.01 -
$25.00 |
$75,000 |
$500 |
$1,359.00 |
|
$25.01 -
$26.00 |
$78,000 |
$520 |
$1,413.36 |
|
$26.01 -
$27.00 |
$81,000 |
$540 |
$1,467.72 |
|
$27.01 -
$28.00 |
$84,000 |
$560 |
$1,522.08 |
|
$28.01 and
Above |
$87,000 |
$580 |
$1,576.44 |
Survivor Income
-- Effective January 1, 2005:
|
Part I and Part II |
$250 per
month |
Medical
Contributions -- Effective December 6, 2004:
|
Employee Only |
$5.50 per week
|
|
Employee plus One |
$11.00 per
week |
|
Employee plus Family |
$16.50 per week
|
Medical
Contributions -- Effective April 1, 2005:
|
|
Effective
4-1-05 |
Effective
1-1-06 |
Effective
1-1-07 |
|
Employee Only |
$8.25 |
$9.49 |
$10.91 |
|
Employee plus
Spouse |
$19.50 |
$22.43 |
$25.79 |
|
Employee plus
Family |
$26.50 |
$30.48 |
$35.05 |
|
Employee plus
Child(ren) |
$15.25 |
$17.54 |
$20.17 |
Special Open Enrollment; Effective
April 1, 2005
During the first quarter of 2005 a
special open enrollment will be scheduled during which employees may
choose either the Company’s Managed Care Plan (if in the health plan
area), an indemnity out-of-area plan (if out of the health plan area), or
a qualified alternative plan. Election will be effective April 1, 2005.
During this special open enrollment employees will be able to change their
medical flexible spending account election.
Plan Provisions – Effective April 1, 2005:
R&C=Reasonable and
Customary
PCP=Primary Care
Physician
|
|
CIGNA Point of Service (POS) |
CIGNA Preferred Provider Organization
(PPO) |
CIGNA Medical (Out-of Area) |
|
Service |
In-Network |
Out-of-Network |
In-Network
|
Out-of-Network |
All Providers |
|
Ambulance Service
to nearest hospital, if medically necessary |
80% of negotiated
rates after deductible |
80% of billed
charges after deductible if true emergency; otherwise 60% of R&C after
deductible |
80% of negotiated
rates after deductible |
80% of billed
charges after deductible if true emergency; otherwise 60% of R&C after
deductible |
80% of R&C after
deductible |
|
Deductible* |
$200/$400/$500 |
$1,000/$2,000/$3,000 |
$200/$400/$500 |
$1,000/$2,000/$3,000 |
$200/$400/$500 |
|
Dependents,
Adding of |
Within 30 days |
Within 30 days |
Within 30 days |
Within 30 days |
Within 30 days |
|
Emergency
Hospital Notification |
Within 48 hours
or the next business day. |
Within 48 hours
or the next business day. |
Within 48 hours
or the next business day. |
Within 48 hours
or the next business day. |
Within 48 hours
or the next business day. |
|
Emergency Room |
100% after $75
copay
(waived if
admitted) |
$75 copay then
100% of billed charges if true emergency (no deductible); otherwise
60% of R&C after deductible |
80% of negotiated
rates after deductible |
80% of billed
charges after deductible if true emergency; otherwise 60% of R&C after
deductible |
80% of R&C after
deductible |
|
Hearing Aids,
Initial purchase, fitting, maintenance and repairs. Expenses must be
over $200 and pre-authorized by CIGNA |
80% of negotiated
rates after deductible when authorized by PCP |
60% of R&C after deductible, when authorized
by physician |
80% of negotiated
rates after deductible when authorized by physician |
|
80% of R&C after
deductible, when authorized by physician |
|
Home Health Care |
100% of
negotiated rates (no deductible), when medically necessary.
Unlimited visits |
60% of R&C after
deductible (80 visits per calendar year combined with in-network) |
80% of negotiated
rates after deductible, when medically necessary. Unlimited visits. |
60% of R&C after
deductible (80 visits per calendar year combined with in-network) |
80% of R&C after
deductible (80 visits per calendar year) |
|
Hospice |
100% of
negotiated rates with prior approval (no deductible) |
100% with prior
approval (no deductible); otherwise 80% of R&C after deductible |
100% of
negotiated rates with prior approval (no deductible) |
100% with prior
approval (no deductible); otherwise 80% of R&C after deductible |
100% with prior
approval (no deductible); otherwise 80% of R&C |
* Deductible and
Out-Of-Pocket limits stay at “employee only”, “employee plus one
dependent” and “employee plus family”.
|
|
CIGNA Point of Service (POS) |
CIGNA Preferred Provider Organization
(PPO) |
CIGNA Medical (Out-of Area) |
|
Service |
In-Network |
Out-of-Network |
In-Network
|
Out-of-Network |
All Providers |
|
Hospitalization |
80% of negotiated
rates after deductible |
60% of R&C after
deductible. Pre-certifica-tion required. Must be medically necessary. |
80% of negotiated
rates after deductible. Pre-certification required. Must be
medically necessary. |
60% of R&C after
deductible. Pre-certifica-tion required. Must be medically necessary |
80% of R&C.
Pre-certification required. Must be medically necessary. |
|
Laboratory and
Radiology Services – MRI, MRA, CAT, PET |
$150 copay per
procedure; then 100% of negotiated rates with prior approval
|
60% of R&C after
deductible |
80% of negotiated
rates after deductible with prior approval |
60% of R&C after
deductible |
80% of R&C after
deductible with prior approval |
|
Other Laboratory
Tests in independent x-ray and/or Lab Facility (including doctor’s
office) |
100% of
negotiated rates (no deductible) |
60% of R&C after
deductible |
80% of negotiated
rates after deductible |
60% of R&C after
deductible |
80% of R&C after
deductible |
|
Other Laboratory
Tests not in independent facility |
80% of negotiated
fees after deductible |
60% of R&C after
deductible |
80% of negotiated
rates after deductible |
60% of R&C after
deductible |
80% of R&C after
deductible |
|
Maternity fee,
Global (includes charges for pre- and post-natal exams and delivery,
but not initial office visit) |
80% of negotiated
rates after deductible. Covers birth and newborn until Mother’s
discharge. |
60% of R&C after
deductible (CIGNA certification required). Covers birth and newborn
until Mother’s discharge. |
80% of negotiated
rates after deductible. Covers birth and newborn until Mother’s
discharge. |
60% of R&C after
deductible (CIGNA certification required). Covers birth and newborn
until Mother’s discharge. |
80% of R&C after
deductible (CIGNA certification required). Covers birth and newborn
until Mother’s discharge. |
|
Medical
Equipment, Durable |
100% of
negotiated rates (no deductible) with prior authorization |
60% of R&C after
deductible ($10,000 annual maximum combined w/in-network) |
80% of negotiated
rates after deductible |
60% of R&C after
deductible ($10,000 annual maximum combined w/in-network) |
80% of R&C after
deductible ($10,000 annual maximum) |
|
Medical Supplies,
Consumable |
80% of negotiated
rates after deductible with prior authorization |
60% of R&C after
deductible |
80% of negotiated
rates after deductible |
60% of R&C after
deductible |
80% of R&C after
deductible |
|
|
CIGNA Point of Service (POS) |
CIGNA Preferred Provider Organization
(PPO) |
CIGNA Medical
(Out-of Area) |
|
Service |
In-Network |
Out-of-Network |
In-Network |
Out-of-Network |
All Providers |
|
Mental Health and
Substance Abuse:
- Outpatient |
Must call
ValueOptions.
100% after $10
copay for visits 1 - 10 and $25 copay for visits 11 – 50. 50 visits
per plan year for in-network and out-of-network combined. |
Must call
ValueOptions.
50% of
ValueOptions’ program cost. 50 visits per plan year for in-network and
out-of network combined. |
Must call
ValueOptions.
100% after $10
copay for visits 1 - 10 and $25 copay for visits 11 – 50. 50 visits
per plan year for in-network and out-of-network combined. |
Must call
ValueOptions.
50% of
ValueOptions’ program cost. 50 visits per plan year for in-network and
out-of network combined. |
Same as
In-Network or Out-of-Network coverage.
|
|
- Inpatient |
80% of network
fee. Admission limits apply. |
50% of
ValueOptions’ program cost. Admission limits apply. |
80% of network
fee. Admission limits apply. |
50% of
ValueOptions’ program cost. Admission limits apply. |
Same as
In-Network and Out-of-Network coverage. |
|
OB/GYN Services
(not selected as PCP) |
100% of
negotiated rates after $30 copay by network provider |
60% of R&C after
deductible |
100% of
negotiated rates after $30 copay by network provider |
60% of R&C after
deductible |
|
|
Office Visits,
PCP |
100% of
negotiated rates after $20 copay by network provider (no deductible) |
60% of R&C after
deductible |
100% of
negotiated rates after $20 copay by network provider (no deductible) |
60% of R&C after
deductible |
100% of R&C less
$20 (80% of R&C for ancillary services) |
|
Office Visits,
Specialist |
100% after $30
copay with referral |
60% of R&C after
deductible |
100% after $30
copay |
60% of R&C after
deductible |
100% of R&C less
$30 (80% of R&C for ancillary services) |
|
PCP Referrals |
Yes, but not for
OB/GYN Network services. |
No, but services
must be medically necessary. |
No, but services
must be medically necessary. |
No, but services
must be medically necessary. |
No, but services
must be medically necessary. |
|
PCP Selection |
Mandatory |
No |
No |
No |
No |
|
|
Physical Therapy
and Rehabilitative Services |
100% of
negotiated rates, no deductible, after $30 copay per visit (Up to a
max of 30 treatment days per calendar year combined w/out-of-network) |
60% of R&C after
deductible (Up to a max of 30 treatment days per calendar year
combined w/in-network) |
100% of
negotiated rates, no deductible, after $30 copay per visit (Up to a
max of 30 treatment days per calendar year combined w/out-of-network) |
60% of R&C after
deductible (Up to a max of 30 treatment days per calendar year
combined w/in-network) |
100% of R&C after
$30 per visit (Up to a max of 30 treatment days per calendar year).
80% of R&C after deductible for ancillary services. |
|
|
|
CIGNA Point of Service (POS) |
CIGNA Preferred Provider Organization
(PPO) |
CIGNA Medical (Out-of Area) |
|
Service |
In-Network |
Out-of-Network |
In-Network |
Out-of-Network |
All Providers |
|
Pre-admission
Certification and Utilization Review |
PCP
responsibility |
Employee responsibility. 10 days prior to
hospital admission and surgery not performed in doctor’s office. |
Employee
responsibility. Must get approval from Intracorp 10 days prior to
hospital admission and surgery not performed in doctor’s office |
Employee
responsibility. Must get approval from Intracorp 10 days prior to
hospital admission and surgery not performed in doctor’s office |
Employee
responsibility. Must get approval from Intracorp 10 days prior to
hospital admission and surgery not performed in doctor’s office. |
|
Pre-certification
Penalties |
NA |
$500
in-hospital/50% of facility fee for outpatient surgery. 100% denial
for days or services deemed medically unnecessary. |
$500
in-hospital/50% of facility fee for outpatient surgery. 100% denial
for days or services deemed medically unnecessary. |
$500
in-hospital/50% of facility fee for outpatient surgery. 100% denial
for days or services deemed medically unnecessary. |
$500
in-hospital/50% of facility fee for outpatient surgery. 100% denial
for days or services deemed medically unnecessary. |
|
Pregnancy,
initial office visit to confirm pregnancy (see Maternity) |
100% of
negotiated rates, no deductible, after $30 copay (specialist) |
60% of R&C after
deductible |
100% of
negotiated rates, no deductible, after $30 copay (specialist) |
60% of R&C after
deductible |
100% of R&C after
$30 copay (specialist). 80% of R&C after deductible for ancillary
services. |
|
Prescription
Drugs
(Caremark/Advance
PCS provides prescription drug benefits) |
Retail $8
generic; $16 brand name on Caremark/Advance PCS Preferred Drug List (PDL);
$35 brand name not on Caremark/ Advance PCS PDL; max 34 day supply
retail.
Mail order 30 -
90 day supply: $12 generic, $35 brand name on Caremark/Advance PCS PDL;
$70 brand name not on Caremark/ Advance PCS PDL. |
Reimbursement for
the price that would have been charged at a participating pharmacy,
less the applicable copay.
No mail order
benefit. |
Retail $8
generic; $16 brand name on Caremark/Advance PCS Preferred Drug List (PDL);
$35 brand name not on Caremark/ Advance PCS PDL; max 34 day supply
retail.
Mail order 30 -
90 day supply: $12 generic, $35 brand name on Caremark/Advance PCS PDL;
$70 brand name not on Caremark/ Advance PCS PDL. |
Reimbursement for
the price that would have been charged at a participating pharmacy,
less the applicable copay.
No mail order
benefit. |
Retail $8
generic; $16 brand name on Caremark/Advance PCS Preferred Drug List (PDL);
$35 brand name not on Caremark/Advance PCS PDL; max 34 day supply
retail.
Reimbursed what
would have been charged at participating pharmacy minus copay, if
non-PCS pharmacy.
Mail order 30 -
90 day supply: $12 generic, $35 brand name on Caremark/Advance PCS PDL;
$70 brand name not on Caremark/Advance PCS PDL. |
|
|
CIGNA Point of Service (POS) |
CIGNA Preferred Provider Organization
(PPO) |
CIGNA Medical
(Out-of Area) |
|
Service |
In-Network |
Out-of-Network |
In-Network |
Out-of-Network |
All Providers |
|
Prosthetic
Devices |
80% of negotiated
rates after deductible up to $25,000 annual maximum (combined with
out-of-network) |
60% of R&C after
deductible (up to $25,000 annual maximum combined with in-network) |
80% of negotiated
rates after deductible up to $25,000 annual maximum (combined with
out-of-network) |
60% of R&C after
deductible (up to $25,000 annual maximum combined with in-network) |
80% of R&C after
deductible ($25,000 annual maximum) |
|
R & C Limits |
None |
Yes. Employee
responsible for costs over R&C. |
None |
Yes. Employee
responsible for costs over R&C. |
Yes. Employee
responsible for costs over R&C. |
|
Second Opinion
Specialist office
visit (Voluntary) |
100% of
negotiated rates after $30 copay with referral, no deductible; 100%
for x-ray/lab billed by independent facility |
60% of R&C after
deductible |
100% of
negotiated rates after $30 copay no deductible; 80% of negotiated
rates after deductible for x-ray/lab |
60% of R&C after
deductible |
|
|
Stop-Loss
Provision (Out-of-Pocket Annual Limit) |
$1,200/$2,400/$3,000 |
$4,800/$9,600/$12,000 |
$1,200/$2,400/$3,000 |
$4,800/$9,600/$12,000 |
$1,250/$2,500/$3,125 |
|
Surgery,
Inpatient |
See
Hospitalization |
See
Hospitalization |
See
Hospitalization |
See
Hospitalization |
See
Hospitalization |
|
Surgery,
Outpatient; Not in Doctor’s Office |
80% of negotiated
rates after deductible |
60% of R&C after
deductible. Pre-certification required. Paid at 50% of facility fee
when not certified. |
80% of negotiated
rates after deductible. Pre-certification required. Paid at 50% of
facility fee when not certified. |
60% of R&C after
deductible. Pre-certification required. Paid at 50% of facility fee
when not certified. |
80% of R&C after
deductible. Pre-certification required. Paid at 50% of facility fee
when not certified. |
|
Surgery,
Outpatient; In Doctor’s Office (Specialist) |
100% of
negotiated rates, no deductible after $30 copay |
60% of R&C after
deductible |
80% of negotiated
rates after deductible |
60% of R&C after
deductible |
80% of R&C after
deductible |
|
Urgent Care
Centers |
100% of
negotiated rates after $75 copay per visit, no deductible |
100% of billed
charges if true emergency, no deductible after $75 copay; otherwise
60% of R&C after deductible |
80% of negotiated
rates after deductible |
80% of billed
charges after deductible if true emergency; otherwise 60% of R&C after
deductible |
80% of R&C after
deductible |
|
|
CIGNA Point of Service (POS) |
CIGNA Preferred Provider Organization
(PPO) |
CIGNA Medical
(Out-of Area) |
|
Service |
In-Network |
Out-of-Network |
In-Network |
Out-of-Network |
All Providers |
|
Vision, Eye Exams
-Routine
-Non-Routine |
100% after $10
copay once per 12 months
|
Reimbursed at $20
once per 12 months. No deductible.
|
100% after $15
copay once per 12 months
Non-routine exams
for treatment of injury or disease 100% after $15 copay |
Reimbursed at $20
once per 12 months. No deductible.
60% of R&C after
deductible for non-routine exams for treatment of injury or disease |
Reimbursed at $20
once per 12 months. No deductible.
80% of R&C after
deductible for non-routine exams for treatment of injury or disease
|
|
Vision Care Items
-Single vision
lenses
-Bifocal Lenses
-Trifocal lenses
-Lenticular lens
-Contact lens (if
needed following cataract surgery or if conventional lenses cannot
bring the better eye to 20/70)
-Other Contact
lens (no more than one pair of lenses every 12 months)
-Frames (no more
than one frame every 24 months) |
$15
$30
$42
$54
$72
$30
$15 |
$15
$30
$42
$54
$72
$30
$15 |
$15
$30
$42
$54
$72
$30
$15
|
$15
$30
$42
$54
$72
$30
$15
|
$15
$30
$42
$54
$72
$30
$15
|
Administrative
Items -- Effective December 6, 2004:
|
COBRA |
Continue
health, dental and health care reimbursement account after termination
as provided under COBRA. |
|
Medical and
Dental Dependent Eligibility |
Spouse and
unmarried dependent children to age 19 (to age 23 if full-time
student); and totally disabled dependent children who meet eligibility
requirements. |
|
Dental
Coverage |
Continue
services for accidental injury to sound, natural teeth,
tempromandibular joint disorder, routine and complex oral surgery.
Complex oral surgery may require use of medical plan and adherence to
plan procedures, either in-network or out-of-network.
Hospitalization, if required, is covered under the medical plan. |
|
Coordination
of Benefits |
Maintenance
of benefits for medical plan benefits. No coordination of managed
care fees or HMO fees or benefits. No coordination for prescription
drugs. Continue dental coordination so that the dental plan will pay
only the difference, if any, between the benefit from a spouse’s plan
and the employee’s normal dental plan payment. |
|
Medical Plan
Maximum |
$1,500,000
lifetime maximum for in-network covered services under Managed Care
Plans and Medical Plan less out-of-network. $1,000,000 lifetime
maximum for out-of-network plans less in-network. |
Dental Contributions – Effective December
6, 2004:
|
Employee Only |
Employee + One |
Employee + Family |
|
$ 0.50 |
$ 1.00 |
$ 1.50 |
Dental
Contributions -- Effective April 1, 2005:
|
|
Effective
4-1-05 |
Effective
1-1-06 |
Effective
1-1-07 |
|
Employee Only
|
$1.00 |
$1.50 |
$2.00 |
|
Employee plus
Spouse |
$2.18 |
$3.27 |
$4.36 |
|
Employee plus
Family |
$3.55 |
$5.32 |
$7.09 |
|
Employee plus
Child(ren) |
$2.36 |
$3.55 |
$4.73 |
Dental Plan
Schedule -- Effective January 1, 2006
|
Class I
Schedule |
100% of
reasonable and customary charges. |
|
Class II
Schedule |
80%
reimbursement level, not to exceed an actual 25% increase in schedule. |
|
Class III
Schedule |
50%
reimbursement level, not to exceed an actual 25% increase in schedule. |
|
Class IV
Schedule |
|
This benefit summary is
intended to provide an easy-to-understand benefits guide. If any conflict
arises between this summary and the official plan documents, the official
plan documents will always govern. Employees do not gain any new rights
because of a misstatement in or omission from these summaries.
Sincerely,
James R. Miller
Vice President,
Industrial Relations
Accepted this 6th day of December 2004
|