United Airlines 2008 Retiree Pre-Medicare PPO Medical Plan Benefit Summary
Customer Services
1-800-535-9825
www.bcbsil.com/united |
| Benefit
Features |
2008
Medical Preferred Provider Organization (PPO)
Benefits |
| Annual Deductibles |
$250 single / $500 family
aggregate |
| Annual
Out-of-Pocket Limits |
$1,500
single / $3,000 family aggregate including
deductible |
|
OFFICE VISIT |
In-network: Covered up to
80% after deductible
Out-of-network: Covered 60%; Subject to
reasonable and customary limits |
| Diagnostic
X-Ray and Laboratory |
In-network:
Covered up to 80%
Out-of-network: Covered 60%; Subject to
reasonable and customary limits |
| PREVENTIVE
SERVICES |
Refer to Wellness
Chart |
| Annual PAP Smears and
Expenses for PSA Tests for Men Over 50 |
In-network: Covered up to
80%
Out-of-network: Covered 60%; Subject to reasonable and
customary limits |
| Screenings |
Refer to
Wellness Chart |
| Immunizations |
Refer to Wellness
Chart |
| In-Area |
Covered up to
80% |
| Out-of-Area |
Covered up
to 80%; Subject to reasonable and customary limits
|
| AMBULANCE |
Covered up to
80% |
| HOSPITAL
CARE |
|
| Semiprivate Room and
Board |
In-network: Covered up to
80% |
| Intensive
Care |
In-network:
Covered up to 80%
Out-of-network: Covered 60%; Subject to
reasonable and customary limits |
| Surgery-Noncosmetic |
In-network: Covered up to
80%
Out-of-network: Covered 60%; Subject to reasonable and
customary limits |
| Surgery-Cosmetic |
Not
covered |
| Diagnostic X-Ray and
Laboratory |
In-network: Covered up to
80%
Out-of-network: Covered 60%; Subject to reasonable and
customary limits |
| Anesthesia |
In-network: Covered up to
80%
Out-of-network: Covered 60%; Subject to reasonable and
customary limits |
| Prescribed Care in a Skilled
Nursing Facility |
Covered up to
80% |
| Therapy (physical,
occupational, etc.) |
In-network: Covered up to
80%
Out-of-network: Covered 60%; Subject to reasonable and
customary limits |
| Physician Hospital
Visit |
In-network: Covered up to
80%
Out-of-network: Covered 60%; Subject to reasonable and
customary limits |
| MATERNITY
CARE |
|
| Physician's Office:
Pre-/Post-Natal Care-Global Billing |
In-network: Covered up to
80%
Out-of-network: Covered 60%; Subject to reasonable and
customary limits |
| In Hospital:
Physician's Services |
In-network:
Covered up to 80%
Out-of-network: Covered 60%; Subject to
reasonable and customary limits |
| Newborn Nursery
Services |
In-network: Covered up to
80%
Out-of-network: Covered 60%; Subject to reasonable and
customary limits |
| Covers Birthing Centers,
Licensed and Certified |
In-network: Covered up to
80%
Out-of-network: Covered 60%; Subject to reasonable and
customary limits |
| Covers Midwives, Licensed
and Certified |
In-network: Covered up to
80%
Out-of-network: Covered 60%; Subject to reasonable and
customary limits |
| PRESCRIPTION
DRUGS |
|
| Retail Drugs |
Covered up to 80%; limit of
3 fills for maintenance drugs |
| Mail Order /
Home Delivery Drugs |
AMFA
Represented employees: $20 copay for generic; $63 copay for brand;
90-day supply; Medco Health 1-800-864-1425
Non-AMFA Retirees
prior to 7/1/2003: $16 copay for generic; $48 copay for brand;
90-day supply
Retirees after 7/1/2003: $63 for a 90-day supply
|
| Oral
Contraceptives |
Covered |
| Annual Rx
Maximum |
Unlimited |
| VISION |
|
| Routine Exam |
Not
covered |
| Hardware-Regular Lenses and Frames |
Not
covered |
| Hardware-Contact
Lenses |
Not
covered |
| HEARING |
|
| Annual Exam |
Covered up to
80% |
| Hardware
(including exam) |
$5,000
lifetime maximum |
| MENTAL HEALTH SERVICES BY
AN ELIGIBLE PROVIDER |
| Outpatient-Copay/Visits |
In-network: Covered up to
80%
Out-of-network: Covered 50%; Subject to reasonable and
customary limits |
| Inpatient-Copay/Days |
In-network:
Covered up to 80%
Out-of-network: Covered 60%; 30 days per person
per year; Subject to reasonable and customary limits
|
| SUBSTANCE ABUSE SERVICES
BY AN ELIGIBLE PROVIDER |
| Outpatient
Detoxification-Copay/Visits |
In-network: Covered up to
80%
Out-of-network: Covered 50%; Subject to reasonable and
customary limits |
| Inpatient
Detoxification-Copay/Visits |
In-network:
Covered up to 80%
Out-of-network: Covered 60%; 30 days per person
per year; Subject to reasonable and customary limits
|
| Outpatient
Rehabilitation-Copay/Visits |
In-network: Covered up to
80%
Out-of-network: Covered 50%; Subject to reasonable and
customary limits |
| Inpatient
Rehabilitation-Copay/Visits |
In-network:
Covered up to 80%
Out-of-network: Covered 60%; 30 days per person
per year; Subject to reasonable and customary limits
|
| CHIROPRACTIC
SERVICES |
In-network: Covered up to
80%; Maintenance not covered
Out-of-network: Covered 60%;
Maintenance not covered; Subject to
reasonable and customary limits |
| THERAPY OUTPATIENT
SERVICES |
|
| Physical |
In-network: Covered up to
80%
Out-of-network: Covered 60%; Subject to reasonable and
customary limits |
| Occupational |
In-network:
Covered up to 80%
Out-of-network: Covered 60%; Subject to
reasonable and customary limits |
| Speech |
In-network: Covered up to
80%
Out-of-network: Covered 60%; Subject to reasonable and
customary limits |
| ACUPUNCTURE BY AN
ELIGIBLE PROVIDER |
Covered up to 80% up to 15
visits |
| DURABLE MEDICAL
EQUIPMENT |
In-network: Covered up to
80%
Out-of-network: Covered 60%; Subject to reasonable and
customary limits |
| OUTPATIENT
SURGERY |
In-network: Covered up to
80%
Out-of-network: Covered 60%; Subject to reasonable and
customary limits |
| DENTAL |
|
| Implants |
Covered up to 80% only if no
alternative procedure can be performed |
| Surgical
Removal of Tumors, Cysts |
Tumors,
cysts-inpatient/outpatient: Covered up to 80%
|
| TRANSPLANTS |
|
| Heart |
In-network covered up to
80%
Out-of-network: Covered 60%; Subject to reasonable and
customary limits |
| Kidney |
In-network
covered up to 80%
Out-of-network: Covered 60%; Subject to
reasonable and customary limits |
| Liver |
In-network covered up to
80%
Out-of-network: Covered 60%; Subject to reasonable and
customary limits |
| Lung |
In-network
covered up to 80%
Out-of-network: Covered 60%; Subject to
reasonable and customary limits |
| Cornea |
In-network covered up to
80%
Out-of-network: Covered 60%; Subject to reasonable and
customary limits |
| Bone
marrow |
In-network
covered up to 80%
Out-of-network: Covered 60%; Subject to
reasonable and customary limits |
| Other Covered
Services |
|
| Blood and blood components,
private duty nursing, allergy shots, oxygen and its administration;
surgical dressings, casts and splints, durable medical equipment,
prosthetic devices. |
In-network: Covered up to
80%
Out-of-network: Covered 60%; Subject to reasonable and
customary limits |
Medical necessity is required. The
deductible must be met before services are paid. Precertification
within the U.S. for inpatient stay is required; if no
precertification, payment is at 50%. This is only an overview of
your UAL benefits.
Please refer to your Summary Plan Description
for more details on benefits, or call the Customer Full Service
Unit.
See the telephone number at the top of the
page-1-800-535-9825. |
| Maintenance of Benefits will replace
the Coordination of Benefits. When an employee is covered under two
group plans, those plans work together to reimburse the employee up
to the benefit amount provided by the higher plan. This means that
employees covered by their own and a spouse's plan will no longer
receive payment for up to 100% of their bills under United's plans.
If for instance, United is the secondary carrier for your dependent,
Untied's plan will only pay on a claim if the primary insurance
covers the claim at a lower amount than United's plan.
| |
