United Airlines 2008 Retiree United Medicare Select Benefit Summary
Customer Services
1-800-535-9825
www.bcbsil.com/united |
| Benefit
Features |
2008 Plan
Benefits |
| Annual Deductibles |
$100 single, medical only
|
| Annual
Out-of-Pocket Limits |
$1,500
single including deductible, medical only
|
| OFFICE
VISIT |
Covered up to 80% after
Medicare |
| Diagnostic
X-Ray and Laboratory |
Covered up
to 80% after Medicare |
| PREVENTIVE
SERVICES |
|
| Annual PAP Smears and
Expenses for PSA Tests for Men Over 50 |
Covered up to 80% after
Medicare |
| Screenings |
Refer to
Wellness Chart |
| Immunizations |
Refer to Wellness
Chart |
| In-Area |
Covered up to 80% after
Medicare |
| Out-of-Area |
Covered up
to 80% after Medicare |
| AMBULANCE |
Covered up to 80% after
Medicare; when medically necessary |
| HOSPITAL
CARE |
|
| Semiprivate Room and
Board |
Covered up to 80% after
Medicare |
| Intensive
Care |
Covered up
to 80% after Medicare |
| Surgery-Noncosmetic |
Covered up to 80% after
Medicare |
| Surgery-Cosmetic |
Not
covered |
| Diagnostic X-Ray and
Laboratory |
Covered up to 80%
after Medicare |
| Blood
Transfusions (if not replaced) |
Covered up
to 80% after Medicare |
| Anesthesia |
Covered up to 80% after
Medicare |
| Special Duty
Nursing When Prescribed |
Covered up
to 80% after Medicare |
| Prescribed Care in a Skilled
Nursing Facility |
Covered up to 80%
after Medicare |
| Therapy
(physical, occupational, etc.) |
Covered up
to 80% after Medicare |
| Physician Hospital
Visit |
Covered up to 80% after
Medicare |
| PRESCRIPTION
DRUGS |
|
| Annual Deductible |
$150 single, combined retail
and mail order; pharmacy only |
| Retail
Generic Drugs |
Covered up
to 80%; Limit of 3 fills for maintenance drugs
|
| Retail Brand Drugs
|
Covered up to 80%; Limit of 3 fills for
maintenance drugs |
| Retail Non-Preferred Brand
Drugs |
Covered up to 50%; limit of
3 fills for maintenance drugs |
| Mail Order Generic
Drugs |
$20 copay; 90-day supply;
Medco Health 1-800-864-1425 |
| Mail Order Brand Name
Drugs |
$63 copay; 90-day supply; Medco Health
1-800-864-1425 |
| Mail Order Non-Perferred
Brand Drugs |
$106 copay; 90-day supply;
Medco Health 1-800-864-1425 |
Prescription Contraceptives
for
Women - Retail |
Covered |
| Annual Rx Maximum |
Unlimited |
| Out-of-Pocket Maximum
|
After out-of-pocket expenses
reach $4,050 (for 2008) your copay will be the greater of 5%
coinsurance or $2.25 for generic and preferred brand drugs/$5.60 for
non-preferred brand drugs (for both retail and mail)
|
| VISION |
|
| Routine Exam |
Not
covered |
| Hardware-Regular Lenses and Frames |
Not
covered |
| Hardware-Contact
Lenses |
Not
covered |
| HEARING |
|
| Routine
Exam/Hardware |
Covered up to 80% after
Medicare; $5,000 lifetime maximum |
| MENTAL HEALTH SERVICES BY
AN ELIGIBLE PROVIDER |
| Outpatient |
Covered up to 80% after
Medicare |
| Inpatient |
Covered up
to 80% after Medicare |
| SUBSTANCE ABUSE SERVICES
BY AN ELIGIBLE PROVIDER |
| Outpatient
Detoxification |
Covered up to 80% after
Medicare |
| Inpatient
Detoxification |
Covered up
to 80% after Medicare |
| Outpatient
Rehabilitation |
Covered up to 80% after
Medicare |
| Inpatient
Rehabilitation |
Covered up
to 80% after Medicare |
| CHIROPRACTIC
SERVICES |
Covered up to 80% after
Medicare; maintenance care is not covered
|
| THERAPY OUTPATIENT
SERVICES |
|
| Physical |
Covered up to 80% after
Medicare |
| Occupational |
Covered up
to 80% after Medicare |
| Speech |
Covered up to 80% after
Medicare |
| ACUPUNCTURE BY AN
ELIGIBLE PROVIDER |
Covered up to 80% after
Medicare; for up to 15 visits for pain
relief |
| DURABLE MEDICAL
EQUIPMENT |
Covered up to 80% after
Medicare |
| OUTPATIENT
SURGERY |
Covered up to 80% after
Medicare |
| DENTAL |
|
| Implants |
Covered up to 80% after
Medicare; only if no alternative procedure can be
performed |
| Surgical
Removal of Tumors, Cysts |
Covered up
to 80% after Medicare |
| TRANSPLANTS |
|
| Heart |
Covered up to 80% after
Medicare |
| Kidney |
Covered up
to 80% after Medicare |
| Liver |
Covered up to 80% after
Medicare |
| Lung |
Covered up
to 80% after Medicare |
| Cornea |
Covered up to 80% after
Medicare |
| Bone
marrow |
Covered up
to 80% after Medicare |
This
summary is only an overview of your UAL medical benefits. Please
refer to the Summary Plan Description (SPD) for details, or call the
Blue Cross Blue Shield Customer Full Service Unit at
1-800-535-9825.
The annual deductible must be met before the
Plan's copayment is applied. Only medically necessary expenses are
covered by the Plan. The term "medically necessary" is defined in
the SPD. |
|
Maintenance of Benefits:
When a retiree
is covered under two plans, including Medicare, those plans work
together to reimburse the retiree up to the benefit amount provided
by the higher plan. If Medicare pays up to the amount that would be
payable under the Medical PPO Option, you will receive no additional
benefit from United's plan. However, once your annual out-of-pocket
is reached ($1,500) the United plan pays up to 100% of your Covered
Expenses not paid by Medicare.
| |
