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Summary Plan DescriptionUPS Package Plans U1/U3
Active Plan Benefit Booklet | Your Plan Benefits | Plan Year 2017
BOOKLET1 OF 2
From the Board of Trustees
Welcome! We are very pleased to have you as a participant in what we truly believe
is an excellent and comprehensive plan of benefits.
This is your Health Plan – a plan that we, as your Trustees, have been given the
responsibility to administer exclusively in your interests and in the interests of nearly 500,000
other Participants and their dependents who are entitled to share in its benefits. When the
Health Fund was started in 1950, the Trustees in place at that time had only one purpose in
mind: To provide our members and their families with the highest level of benefits possible.
Concern for the security and well-being of you and your family has always been the
cornerstone of our benefits philosophy. We pledge our efforts to continue providing nothing
less than the very best benefits your Plan can reasonably afford.
We are pleased to provide you with this Summary Plan Description (SPD) describing the
comprehensive benefit program available to you and your family members who qualify for
coverage under your TeamCare Health Plan. This SPD provides information about your
eligibility for benefits, the covered services under TeamCare, how to file a claim and your
rights under the Health Plan. Please review this information carefully and keep your SPD
available for future reference. Whenever the benefits outlined in the SPD materially change,
information will be sent to you. You should keep these updates with your SPD so that you
will always have current information about your Health Plan. At any time you may also view
the current Health Plan SPD and all updated information at MyTeamCare.org.
Every effort has been made to ensure that this SPD is easy to understand and provides an
accurate and comprehensive information source regarding your Health Plan. All information
in this SPD, however, is subject to the terms of the actual Health Plan Document. The Health
Plan Document will, at all times, serve as the final written authority on all matters regarding
this Plan. Only the Board of Trustees is authorized to interpret the Health Plan and this SPD.
No employer or union, or any representative of any employer or union, is authorized to
interpret this Plan.
We hope that learning about the benefits your Plan offers will bring you and your family
comfort and peace of mind. In addition, the “Plan Benefit Profile” section will provide
you information about your specific Plan. Please visit our website at MyTeamCare.org to
download additional copies of your Plan Benefit Profile.
If you have questions as you read through this SPD, please login into MyTeamCare.org, and
send a secure message (question) through the Message Center, or call a Benefits Specialist
in our Participant Services Department at 800-TEAMCARE (832-6227). Our Participant
Services Department is open Monday through Friday and a Benefits Specialist will make
every effort to assist you.
Employee Trustees
Charles A. Whobrey
George J. Westley
Marvin Kropp
Gary Dunham
Employer Trustees
Arthur H. Bunte, Jr.
Gary F. Caldwell
Greg R. May
Christopher J. Langan
About This Benefits Booklet
Please read these Benefits
Booklets in conjunction with one
another as together they form
the Summary Plan Description
for your benefit plan. “Benefits
Booklet (1 of 2)” contains your
Plan Benefit Profile, a summary
of any provisions unique to your
Plan, and your Plan’s government
mandated Summary of Benefits
and Coverage form. “Benefits
Booklet (2 of 2)” contains
general benefits information and
provisions applicable to all plans.
Table of Contents
Plan Benefit Profile .......................3
Additional Plan Provisions............7
Summary of Benefits
and Coverage ..............................11
Plans U1/U3Plan Benefit Profile
UPS PACKAGE Plan U1 (Full-Time) and Plan U3 (Part-Time) Benefit Profile
Coverage Period: Beginning on or after 01/01/2016
PLAN BENEFIT LIMIT (ANNUAL) PLAN DEDUCTIBLE (ANNUAL) MEDICAL OUT-OF-POCKET EXPENSE LIMIT (ANNUAL) None 2016-2017: None
2018: $100 Individual / $200 Family $1,000 per Individual
$2,000 per Family
TEAMCARE PPO OFFICE VISIT OUT-OF-NETWORK PENALTY $10 co-payment for in-network office visit
(Plan Deductible does not apply) For non-emergency medical care, your cost is 10% greater than an in-network provider plus all charges above Reasonable and Customary and the loss of TeamCare Family Protection Benefit.
MEDICAL PLAN BENEFITS For further information, including a full Summary Plan Description (SPD), visit our website at MyTeamCare.org.
TeamCare Wellness A TeamCare Physician must be used.
Wellness benefits are payable at 100% of covered charges. PPO office visit co-payment does not apply.
Hospital Expense Benefit After Plan Deductible, 100% of covered charges.
Surgical and Obstetrical Benefit After Plan Deductible, 100% of covered charges.
Ambulance Service Benefit After Plan Deductible, 100% of covered charges subject to medical necessity review.
Outpatient Accidental Bodily Injury Benefit After Plan Deductible, on the first day of treatment, 100%.
TeamCare Lab Benefit
For more information call 800-646-7788 or visit labcard.com
The TeamCare Lab Benefit is a voluntary program that covers lab testing at 100% (Plan Deductible does not apply) provided the Physician submits the requisition through Quest Lab Card. If a Physician does not submit specimens through Quest Lab Card, simply visit a Quest Diagnostics collection site.
If you do not use the TeamCare Lab Benefit, after Plan Deductible the outpatient lab benefit is 80%; then 100% after Medical Out-of-Pocket Expense Limit is met.
TeamCare Imaging Benefit
For more information call 877-674-0674 or visit usimagingnetwork.com
The TeamCare Imaging Benefit is a voluntary program that covers MRI, CT, and PET scans at 100% (Plan Deductible does not apply) provided that the scans are scheduled directly through US Imaging.
If you do not use the TeamCare Imaging Benefit, after Plan Deductible the outpatient imaging benefit (including x-rays) is paid under Major Medical at 80%; then 100% after Medical Out-of-Pocket Expense Limit is met.
Outpatient Cancer Treatment Benefit After Plan Deductible, 100% of covered charges for outpatient nuclear therapy, radiation therapy, chemotherapy, x-ray and lab procedures for the treatment of cancer. If treatment is provided in a doctor’s office, a $10 TeamCare office visit co-payment is due.
Organ Transplant Benefit and Organ Donor Benefit
Prior to an Organ Transplant, a predetermination of benefits must be submitted through the TeamCare network for review. The Organ Donor Benefit covers charges for medical treatment the donor receives for the donation of an organ.
Hearing Aid Benefit After Plan Deductible, 100% of covered charges to a maximum of $1,000 per ear ($2,000 total) every 36 months. The Medical Out-of-Pocket Expense Limit does not apply.
Chiropractic Benefit After Plan Deductible, 80% of covered charges to a maximum $1,000 per person per calendar year. The Medical Out-of-Pocket Expense Limit does not apply.
Behavioral Health Benefits – Inpatient Facility: After Plan Deductible, 100% of covered charges.
Physician: After Plan Deductible, 80% of covered charges; then 100% after Medical Out-of-Pocket Expense Limit is met.
Behavioral Health Benefits – Outpatient $10 co-payment for in-network office visit (Plan Deductible does not apply). Otherwise, after Plan Deductible, 80% of covered charges; then 100% after Medical Out-of-Pocket Expense Limit is met.
Major Medical Benefit After Plan Deductible, 80% of covered charges; then 100% after Medical Out-of-Pocket Expense Limit is met. CM CUSTOM – ACTIVEGF – BASE PLAN U1 - SPD U1U3
his group health plan believes this plan is a “grandfathered health plan” under the Patient Protection and Affordable Care Act (the Affordable Care Act, or PPACA). As permitted by the Affordable Care Act, arandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your plan may not include certainonsumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered healthlans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits. Questions regarding which protections apply and whichrotections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the plan administrator at Research and Correspondenceepartment, TeamCare – A Central States Health Plan, 9377 West Higgins Road, Rosemont IL 60018-4938 or call 800-TEAMCARE. You may also contact the Employee Benefits Security Administration, U.S.epartment of Labor at 866-444-3272 or www.dol.gov/ebsa/healthreform. This website has a table summarizing which protections do and do not apply to grandfathered health plans.
UPS PACKAGE Plan U1 (Full-Time) and Plan U3 (Part-Time) Benefit Profile
Coverage Period: Beginning on or after 01/01/2016
TEAMCARE Rx PRESCRIPTION DRUG BENEFIT
RETAIL PHARMACY STORE: Under Retail Pharmacy program, the Participant pays $5 co-payment for short-term prescription fills and non-maintenance medications.
MAINTENANCE CHOICE / MAIL SERVICE PHARMACY: Under the CVS/Caremark Mail Service Pharmacy or Maintenance Choice, the Participant pays $0 co-payment for a 90-day supply of medication. Under Maintenance Choice, Participant can receive a 90-day supply of medication at a local CVS pharmacy store. For more information call
888-483-2650 or visit caremark.com 88ca After the second fill of the same prescription, long-term maintenance medications must be filled through Maintenance
Choice or CVS/Caremark Mail Service Pharmacy or be subject to a 50% co-payment if filled through the Retail Pharmacy Program. On both Retail and Mail Order, if a generic equivalent is available, the Participant must take the generic or be responsible for the cost difference plus any co-payment. The Medical Out-of-Pocket Expense Limit does not apply.
TeamCare does not cover drugs or medicines on a formulary exclusion list compiled by CVS/Caremark. The formulary exclusion list is available at MyTeamCare.org or by contacting CVS/Caremark.
DENTAL BENEFITS Annual Dental Maximum None TeamCare offers a voluntary network through Humana Dental (Group: TC60018) that provides negotiated discounts and protection from balance billing. To find a provider, call 800-592-3112 or visit:
. To find a provider, call 800-59
.humanadentalnetwork.com
You may use any dental provider for services without an out-of-network penalty. However, TeamCare does offer a voluntary dental network through TeamCareDental.
Annual Dental Deductible None Preventive Services 100% Diagnostic and Restorative 100% Crown and Bridge Work 80% Dentures (Full and Partial) 100% Orthodontic (Child/Adult Child) 50% Orthodontic Maximum
(Child/Adult Child) No Lifetime MaximumVISION BENEFITS TeamCareVision is a voluntary vision network offered through EyeMed Vision Care (Advantage Plan H):
Routine Eye Exam $10 co-payment Frames $0 co-payment up to $100 allowance Lenses (per pair) $0 co-payment Contacts (in lieu of glasses) $0 co-payment up to $80 allowance
For a directory of EyeMed providers in the Advantage Plan H network, call 866-393-3401 or visit eyemedvisioncare.com.
You can use any vision provider for services. However, TeamCare does offer a voluntary vision network through the TeamCareVision program.
Vision Plan Benefits do not have an out-of-network penalty but there is a maximum reimbursement per service as indicated.
The Vision Plan Benefits are payable once every 12 months.
For non-EyeMed providers, the maximum reimbursement for Vision Plan Benefits is: Routine Eye Exam $50.00 * * Routine Eye Exam charges from non-
EyeMed providers for Covered Dependents under age 19 will be subject to Reasonable and Customary limits and paid at 80%.
Frames $75.00Lenses (per pair) $50.00 Bi-Focal Lenses (per pair) $50.00 Tri-Focal Lenses (per pair) $50.00 Lenticular Lenses (per pair) $60.00 Contacts (in lieu of glasses) $80.00
SHORT-TERM DISABILITY BENEFITS (Participant Only)
Benefit provides 60% of average weekly base pay up to $500 per week for a maximum of 26 weeks; and includes continued coverage while on Short-Term Disability.
LIFE INSURANCE BENEFITS Member Death Full-Time Plan U1: 2080 hours x hourly wage to max of $100,000 (minimum of $40,000) Part-Time Plan U3: 1040 hours x hourly wage to max of $100,000 (minimum of $40,000)
Accidental Death Full-Time Plan U1: 2080 hours x hourly wage to maxof $100,000 (minimum of $40,000)Part-Time Plan U3: 1040 hours x hourly wage to max of $100,000 (minimum of $40,000)
Spouse Death * $5,000 * Dependent Life Insurance Benefits are only payable on Covered Dependents.Child/Adult Child Death * $2,500
Total Permanent Disability (Waiver of Premium)
$16,000
ASKMAYO CLINIC Participants have access to the AskMayo Clinic nurse line which provides reliable health information 24 hours a day. Experienced registered nurses, who draw on the resources of Mayo Clinic, are available to answer your health-related questions. Health information is only a phone call away – 800-700-MAYO (6296).
TEAMCARE FAMILY PROTECTION BENEFIT
In the event of a Participant’s death, the TeamCare Family Protection Benefit provides a maximum of five years of free coverage for the Covered Spouse and Dependents provided that during the two year period prior to death, TeamCare providers were used exclusively for all non-emergency care. Please refer to the TeamCare Summary Plan Description for further information.
MyTeamCare.org or 800-TEAMCARE We’re here to help. For further benefit information on your benefits, visit our website at MyTeamCare.org. You can review detailed claims information, re-print your Explanation of Benefits, review benefit accumulators, download forms, and link to all of your TeamCare benefits and networks. You can also call TeamCare at 800-TEAMCARE (832-6227) and speak to a Benefits Specialist.
If there is a discrepancy between the Plan Benefit Profile and Plan Document, the Plan Document will be the controlling document in determining the benefit. his group health plan believes this plan is a “grandfathered health plan” under the Patient Protection and Affordable Care Act (the Affordable Care Act, or PPACA). As permitted by the Affordable Care Act, arandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your plan may not include certainonsumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered healthlans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits. Questions regarding which protections apply and whichrotections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the plan administrator at Research and Correspondenceepartment, TeamCare – A Central States Health Plan, 9377 West Higgins Road, Rosemont IL 60018-4938 or call 800-TEAMCARE. You may also contact the Employee Benefits Security Administration, U.S.epartmentofLaborat866-444-3272orwww.dol.gov/ebsa/healthreform.Thiswebsitehasatablesummarizingwhichprotectionsdoanddonotapplytograndfatheredhealthplans.
U1/U3Additional Plan Provisions
ADDITIONAL PLAN PROVISIONSGRANDFATHERED HEALTH PLAN
OUT-OF-POCKET EXPENSE LIMIT
The Out-of-Pocket Expense Limit is your portion of eligible covered medical expenses that you must pay after the Plan has paid its required percentage. Once your eligible out-of-pocket expenses reach the maximum (see Plan Benefit Profile), the Plan pays 100% of most covered charges for the rest of the calendar year.
The Out-of-Pocket Limit includes the balance of any Major Medical expenses that you must pay, including co-insurance amounts and balances from the outpatient diagnostic x-ray and laboratory charges. However, it excludes any non-covered expenses such as fees over the Reasonable and Customary limitation. The Out-of-Pocket Limit applies only to covered medical expenses payable under the Major Medical Benefit and does not apply to the Prescription Drug Benefit; the Hearing Aid Benefit; the Chiropractic, Dental or Vision Benefits.
PATIENT PROTECTION AND AFFORDABLE CARE ACT (PPACA)
This group health plan believes this plan is a “grandfathered health plan” under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits.
Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the plan administrator at Research and Correspondence Department, TeamCare – A Central States Health Plan, 9377 West Higgins Road, Rosemont IL 60018-4938 or call TeamCare at 800-TEAMCARE (832-6227). You may also contact the Employee Benefits Security Administration, U.S. Department of Labor at 866-444-3272 or www.dol.gov/ebsa/healthreform. This website has a table summarizing which protections do and do not apply to grandfathered health plans.
WOMEN’S HEALTH & CANCER RIGHTS
If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:
All stages of reconstruction of the breast on which the mastectomy was performed;Surgery and reconstruction of the other breast to produce a symmetrical appearance;Prostheses; andTreatment of physical complications of the mastectomy, including lymphedema.
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this Plan. Therefore, the following deductibles and coinsurance apply:
Plan Deductible: None per Individual, None per FamilyMedical Out-of-Pocket Expense Limit: $1,000 per Individual, $2,000 per FamilyCoinsurance: 0% after Deductible.
If you would like more information on WHCRA benefits, call your Plan administrator at 800-TEAMCARE (832-6227) or visit MyTeamCare.org.
Plans U1/U3Summary of Benefits and Coverage
CEN
TRAL
STA
TES
HEA
LTH
AN
D W
ELFA
RE
FUN
D -
UPS
Pac
kage
Pla
n U
1 an
d Pl
an U
3C
over
age
Perio
d: B
egin
ning
on
or a
fter 0
1/01
/201
7 C
over
age
for:
You
and
You
r Ele
cted
Dep
ende
nts
Sum
mar
y of
Ben
efits
and
Cov
erag
e: W
hat t
his
Pla
n C
over
s &
Wha
t it C
osts
Plan
Typ
e: P
PO
Que
stio
ns:C
all 8
00-T
EAM
CA
RE
or v
isit u
s at M
yTea
mC
are.o
rg.
If yo
u ar
en’t
clear
abou
t any
of t
he u
nder
lined
term
s use
d in
this
form
, see
the G
loss
ary.
You
can
view
the G
loss
ary
at M
yTea
mC
are.o
rgor
call
800-
TEA
MCA
REto
requ
est a
copy
. C
CM
CU
STO
M –
10/
7/20
16PL
AN
U1/
U3
Page
1 o
f 9
This
is o
nly
a su
mm
ary.
If yo
u wa
nt m
ore d
etail a
bout
your
cove
rage
and
costs
, you
can
get t
he co
mpl
ete te
rms i
n th
e pol
icy o
r plan
doc
umen
t at
MyT
eam
Car
e.or
g or
by c
allin
g 800
-TE
AM
CA
RE
(832
-622
7).
Impo
rtant
Que
stio
nsAn
swer
sW
hy th
is M
atte
rs:
Wha
t is t
he ov
erall
ded
uctib
le?
No de
ducti
ble un
til 20
18 of
contr
act; t
hen $
100 p
er In
divid
ual,
$200
per F
amily
. Doe
s not
appl
y to i
n-ne
twor
k offi
ce vi
sits
and i
n-ne
twor
k Pres
cripti
on be
nefit
s.
You m
ust p
ay al
l the c
osts
up to
the d
educ
tible
amou
nt be
fore
this
planb
egin
s to
pay f
or m
ost c
over
ed se
rvice
s you
use.
The a
nnua
l ded
uctib
le is
base
d on a
ca
lenda
r yea
r fro
m 1/
1 thr
ough
12/31
. See
the c
hart
starti
ng on
page
2 fo
r how
m
uch y
ou pa
y for
cove
red se
rvice
s afte
r you
mee
t the d
educ
tible.
Ar
e the
re ot
her d
educ
tibles
for
spec
ific s
ervic
es?
No
Is th
ere a
n ou
t–of
–poc
ket l
imit
on
my e
xpen
ses?
$1,00
0 Per
Indi
vidua
l, $2,0
00 P
er Fa
mily
The o
ut-o
f-poc
ket l
imit
is the
mos
t you
could
pay d
urin
g the
calen
dar y
ear f
or
your
share
of th
e cos
t of c
over
ed se
rvice
s. Th
islim
it help
s you
plan
for h
ealth
ca
re ex
pens
es.
Wha
t is n
ot in
clude
d in
the o
ut–o
f–po
cket
limit?
Not in
clude
d in t
he ou
t-of-p
ocke
t lim
it are:
Ded
uctib
les; I
n ne
twor
k co-
paym
ents;
Out-
of-n
etwor
k pen
alty;
Co-in
suran
ce
from
Chir
oprac
tic, P
rescri
ption
Dru
gs,D
ental
and V
ision
be
nefit
s; P
remium
s, an
d hea
lth ca
re se
rvice
s this
plan
does
n’t
cove
r.
Even
thou
gh yo
u pay
thes
e exp
ense
s, the
y don
’t co
unt to
war
d the
out-o
f-po
cket
limit.
Is th
ere a
n ov
erall
annu
al lim
iton
w
hat t
he p
lan p
ays?
NoTh
e cha
rt sta
rting
on pa
ge 2
desc
ribes
spec
ific c
over
age s
ervic
es, s
uch a
s offi
ce
visits
.
Doe
s thi
s pla
n us
e a n
etwor
kof
pr
ovid
ers?
Ye
s. F
or a
list o
f pre
ferr
ed p
rovid
ers i
n the
Tea
mCa
re ne
twor
kcall
800-
TEAM
CARE
or vi
sit M
yTea
mCa
re.or
g.
If yo
u use
an in
-netw
ork
docto
r or o
ther h
ealth
care
prov
ider, t
his pl
an w
ill pa
y so
me o
r all o
f the
costs
of co
vered
serv
ices.
For a
list o
f pre
ferr
ed p
rovid
ers i
n th
e Tea
mCa
re ne
twor
k, vis
it MyT
eam
Care
.orgo
r call
800-
TEAM
CARE
. Do
I ne
ed a
refe
rral
to se
e a
spec
ialist
? No
You c
an se
e the
spec
ialist
you c
hoos
e with
out p
ermiss
ion fr
om th
is pla
n.
Are t
here
serv
ices t
his p
lan d
oesn
’t co
ver?
Yes
Som
e of t
he se
rvice
s this
plan
does
n’t c
over
are l
isted
on pa
ge 6.
See
your
Plan
Do
cum
ent f
or ad
dition
al inf
orm
ation
on ex
clude
d se
rvice
s.
OM
B C
ontro
l Num
bers
154
5-22
29,
1210
-014
7, a
nd 0
938-
1146
R
elea
sed
on A
pril
23, 2
013
(cor
rect
ed)
CEN
TRAL
STA
TES
HEA
LTH
AN
D W
ELFA
RE
FUN
D -
UPS
Pac
kage
Pla
n U
1 an
d Pl
an U
3C
over
age
Perio
d: B
egin
ning
on
or a
fter 0
1/01
/201
7 C
over
age
for:
You
and
You
r Ele
cted
Dep
ende
nts
Sum
mar
y of
Ben
efits
and
Cov
erag
e: W
hat t
his
Pla
n C
over
s &
Wha
t it C
osts
Plan
Typ
e: P
PO
Que
stio
ns:C
all 8
00-T
EAM
CA
RE
or v
isit u
s at M
yTea
mC
are.o
rg.
If yo
u ar
en’t
clear
abou
t any
of t
he u
nder
lined
term
s use
d in
this
form
, see
the G
loss
ary.
You
can
view
the G
loss
ary
at M
yTea
mC
are.o
rgor
call
800-
TEA
MCA
REto
requ
est a
copy
. C
CM
CU
STO
M –
10/
7/20
16PL
AN
U1/
U3
Page
2 o
f 9
Co-
paym
ents
are f
ixed
dol
lar am
ount
s (fo
r exa
mpl
e, $1
5) yo
u pa
y for
cove
red h
ealth
care
, usu
ally w
hen
you
rece
ive t
he se
rvice
.C
oins
uran
ceis
your
shar
e of t
he co
sts o
f a co
vere
d se
rvice
, calc
ulate
d as
a pe
rcen
t of t
he a
llow
ed a
mou
ntfo
r the
serv
ice. F
or ex
ampl
e, if
the p
lan’s
allo
wed
amou
ntfo
r an
over
nigh
t hos
pital
stay
is $
1,00
0, yo
ur co
insu
ranc
epay
men
t of 2
0% w
ould
be $
200.
Thi
s may
chan
ge if
you
have
n’t m
et yo
ur d
educ
tible.
The a
mou
nt th
e pl
anpa
ys fo
r cov
ered
serv
ices i
s bas
ed o
n th
e allo
wed
am
ount
. If a
n ou
t-of-n
etwor
kpr
ovid
erch
arge
s mor
e th
an th
e al
low
ed a
mou
nt, y
oum
ay h
ave t
o pa
y th
e diff
eren
ce. F
or ex
ampl
e, if
an o
ut-o
f-netw
ork
hosp
ital c
harg
es $
1,50
0 fo
r an
over
nigh
t stay
and
the a
llow
ed a
mou
ntis
$1,0
00, y
ou m
ayha
ve to
pay t
he $
500
diffe
renc
e. (T
his i
s call
ed b
alan
ce b
illin
g.)Th
is pl
anm
ay en
cour
age y
ou to
use
Tea
mCa
re in
-netw
ork p
rovi
ders
by ch
argi
ng yo
u lo
wer
ded
uctib
les,c
opay
men
tsan
d coi
nsur
ance
amou
nts.
Com
mon
M
edic
al E
vent
Serv
ices
You
May
Nee
dYo
ur C
ost I
f You
Use
an
In-n
etw
ork
Prov
ider
Your
Cos
t If Y
ou U
se a
nO
ut-o
f-net
wor
k Pr
ovid
erLi
mita
tions
& E
xcep
tions
If yo
u vi
sit a
hea
lth
care
pro
vide
r’so
ffice
or
clin
ic
Prim
ary c
are v
isit to
trea
t an
injur
y illn
ess
$10c
o-pa
ymen
t per
visit
After
dedu
ctible
, 30%
plus
any
charg
es de
term
ined t
o be a
bove
Re
ason
able
and C
ustom
ary.
Addit
ional
costs
may
be ow
ed fo
r m
edica
l ser
vices
paya
ble b
eyon
d the
of
fice v
isit (
e.g. x
-rays
, injec
tions
, lab
tests,
etc.)
.Sp
ecial
ist vi
sit$1
0co-
paym
ent p
er vis
itOt
her p
ractiti
oner
offic
e visi
t$1
0co-
paym
ent p
er vis
itPr
even
tive c
are/
scree
ning
/imm
uniza
tion
$0N
ot Co
vered
At re
com
men
ded f
reque
ncies
.
If yo
u ha
ve a
test
Diag
nosti
c tes
t (x-
ray,
blood
wor
k)
20%
after
Ded
uctib
le, 0%
after
Med
ical O
ut-
of-P
ocke
t Exp
ense
Lim
it is m
et.or
0%
for
lab w
ork i
f thr
ough
Que
st La
bCard
bene
fit.
For a
Que
st La
bCard
prov
ider,
call L
ab C
ard
Clien
t Ser
vices
at 80
0-64
6-77
88 or
visit
lab
card
.com
.
10%
grea
ter th
an yo
ur co
st fo
r an
in-ne
twor
k pro
vider.
You
are a
ls ores
pons
ible f
or ch
arge
s abo
ve
Reas
onab
le an
d Cus
tomar
y.
------
------
----N
one
------
------
----
Imag
ing (
CT/P
ET sc
ans,
MRI
s)
20%
after
Ded
uctib
le, 0%
after
Med
ical O
ut-
of-P
ocke
t Exp
ense
Lim
it is m
et.; o
r 0%
if
thro
ugh U
S Im
agin
g. F
or a
US
Imag
ing
prov
ider,
visit u
simag
ingn
etwor
k.com
.
10%
grea
ter th
an yo
ur co
st fo
r an
in-ne
twor
k pro
vider.
You
are
also r
espo
nsibl
e for
char
ges
abov
e Rea
sona
ble an
d Cu
stom
ary.
------
------
----N
one
------
------
----
CEN
TRAL
STA
TES
HEA
LTH
AN
D W
ELFA
RE
FUN
D -
UPS
Pac
kage
Pla
n U
1 an
d Pl
an U
3C
over
age
Perio
d: B
egin
ning
on
or a
fter 0
1/01
/201
7C
over
age
for:
You
and
You
r Ele
cted
Dep
ende
nts
Sum
mar
y of
Ben
efits
and
Cov
erag
e: W
hat t
his
Pla
n C
over
s &
Wha
t it C
osts
Plan
Typ
e: P
PO
Que
stio
ns:C
all 8
00-T
EAM
CA
RE
or v
isit u
s at M
yTea
mC
are.o
rg.
If yo
u ar
en’t
clear
abou
t any
of t
he u
nder
lined
term
s use
d in
this
form
, see
the G
loss
ary.
You
can
view
the G
loss
ary
at M
yTea
mC
are.o
rgor
call
800-
TEA
MCA
REto
requ
est a
copy
. C
CM
CU
STO
M –
10/7
/201
6PL
AN
U1/
U3
Page
3of
9
Com
mon
M
edic
al E
vent
Serv
ices
You
May
Nee
dYo
ur C
ost I
f You
Use
an
In-n
etw
ork
Prov
ider
Your
Cos
t If Y
ou U
se a
n O
ut-o
f-net
wor
k Pr
ovid
erLi
mita
tions
& E
xcep
tions
If y
ou n
eed
drug
s to
trea
t you
r ill
ness
or
cond
ition
Mor
e in
form
atio
n ab
out p
resc
ript
ion
drug
cov
erag
eis
av
aila
ble
at
MyT
eam
Car
e.or
g
or care
mar
k.co
m
Gen
eric D
rugs
$5 R
etail
$0 M
ail O
rder
How
ever
, if yo
u pu
rcha
sea b
rand
nam
e pr
escr
iptio
n w
hen
a gen
eric
is av
ailab
le,
you
are r
espo
nsib
le fo
r the
cost
diffe
renc
e an
d th
e per
pre
scrip
tion
max
imum
doe
s not
ap
ply.
25%
of R
easo
nable
and
Custo
mar
y cha
rges
and
Or
der i
s not
avail
able.
The
per
pres
cript
ion m
axim
um d
oes n
ot
appl
y.
By th
e thi
rd fi
ll, m
ainten
ance
m
edica
tions
mus
t be f
illed t
hrou
gh th
e Ca
remark
Ord
er Pr
ogra
m /
Main
tenan
ce C
hoice
or be
subje
ct to
a 50
% co
-pay
if fi
lled t
hrou
gh th
e Reta
il Ca
rd pr
ogram
.
There
are s
ome n
on-p
refer
red br
and
drug
s tha
t are
exclu
ded f
rom
cove
rage
as
deter
mine
d by C
arem
ark. F
or a
list
of th
ese e
xclud
ed dr
ugs,
visit o
ur
webs
ite at
MyT
eam
Care
.org.
If yo
u co
ntinu
e usin
g one
of th
ese d
rugs
after
thi
s date
, you
will
be re
quire
d to p
ayth
e full
cost.
Walm
art is
not a
parti
cipati
ng
pharm
acy.
Prefe
rred b
rand d
rugs
Non
-pre
ferred
bran
d dru
gs
Spec
ialty
drug
s$5
Reta
il$0
Ord
er
25%
of R
easo
nable
and
Custo
mar
y cha
rges
and M
ail
Orde
r is n
ot av
ailab
le. T
he pe
r pr
escri
ptio
n max
imum
doe
s not
ap
ply.
If yo
u use
injec
table
med
icatio
ns, th
e pla
n pro
vides
$1,00
0 per
mem
ber p
er ca
lenda
r yea
r out
-of-p
ocke
t m
axim
um. O
nce t
he $1
,000 o
ut-o
f-po
cket
max
imum
is m
et, al
l in-
netw
ork i
njec
table
med
icatio
ns w
ill be
pa
id by
the P
lan at
100%
.
If y
ou h
ave
outp
atie
nt su
rger
y
Facil
ity fe
e (e.g
., am
bulat
ory s
urge
ry
cent
er)
0% af
ter D
educ
tible.
10%
grea
ter th
an yo
ur co
st fo
r an
in-ne
twor
k pro
vider.
You
are
also r
espo
nsibl
e for
char
ges a
bove
Re
ason
able
and C
ustom
ary.
Addit
ional
costs
may
be ow
ed fo
r m
edica
l ser
vices
paya
ble b
eyon
d the
su
rger
y (e.g
. x-ra
ys, la
b tes
ts).
Phys
ician
/surg
eon f
ees
0% af
ter D
educ
tible.
CEN
TRAL
STA
TES
HEA
LTH
AN
D W
ELFA
RE
FUN
D -
UPS
Pac
kage
Pla
n U
1 an
d Pl
an U
3C
over
age
Perio
d: B
egin
ning
on
or a
fter 0
1/01
/201
7 C
over
age
for:
You
and
You
r Ele
cted
Dep
ende
nts
Sum
mar
y of
Ben
efits
and
Cov
erag
e: W
hat t
his
Pla
n C
over
s &
Wha
t it C
osts
Plan
Typ
e: P
PO
Que
stio
ns:C
all 8
00-T
EAM
CA
RE
or v
isit u
s at M
yTea
mC
are.o
rg.
If yo
u ar
en’t
clear
abou
t any
of t
he u
nder
lined
term
s use
d in
this
form
, see
the G
loss
ary.
You
can
view
the G
loss
ary
at M
yTea
mC
are.o
rgor
call
800-
TEA
MCA
REto
requ
est a
copy
. C
CM
CU
STO
M –
10/
7/20
16PL
AN
U1/
U3
Page
4 o
f 9
Com
mon
M
edic
al E
vent
Serv
ices
You
May
Nee
dYo
ur C
ost I
f You
Use
an
In-n
etw
ork
Prov
ider
Your
Cos
t If Y
ou U
se a
nO
ut-o
f-net
wor
k Pr
ovid
erLi
mita
tions
& E
xcep
tions
If y
ou n
eed
imm
edia
te m
edic
al
atte
ntio
n
Emerg
ency
room
serv
ices
20%
after
Ded
uctib
le, 0%
after
Med
ical O
ut-
of-P
ocke
t Exp
ense
Lim
it is m
et.Em
ergen
cy ca
re is
paid
the s
ame
as if
in-n
etwor
k. Ho
weve
r, yo
u are
resp
onsib
le fo
r cha
rges
abov
e Re
ason
able
and C
ustom
ary.
If ad
mitte
d, the
Em
ergen
cy ro
om
serv
ices w
ill be
paya
ble u
nder
the
Hosp
ital b
enefi
t. Add
itiona
l cos
ts m
ay
be ow
ed fo
r ser
vices
paya
ble be
yond
the
urge
nt ca
re vis
it (e.g
. x-ra
ys, la
b).
Emerg
ency
med
ical tr
ansp
ortat
ion
0% af
ter D
educ
tible.
Urg
ent c
are20
% af
ter D
educ
tible,
0% af
ter M
edica
l Out
-of
-Poc
ket E
xpen
se L
imit i
s met.
10%
grea
ter th
an yo
ur co
st fo
r an
in-n
etwor
k pro
vider.
You
are
also r
espo
nsibl
e for
char
ges a
bove
Re
ason
able
and C
ustom
ary.
If y
ou h
ave
a ho
spita
l st
ay
Facil
ity fe
e (e.g
., hos
pital
room
)0%
after
Ded
uctib
le.
------
------
----N
one
------
------
----
Phys
ician
/surg
eon f
eePh
ysici
an fe
e is 2
0% af
ter D
educ
tible,
0%
after
the M
ajor M
edica
l Out
-of-P
ocke
t Ex
pens
e Lim
it is m
et. S
urge
on fe
e is 0
%
after
Dedu
ctibl
e.
If yo
u ha
ve m
enta
l he
alth
, beh
avio
ral
heal
th, o
r sub
stanc
e ab
use n
eeds
Men
tal/B
ehav
ioral
healt
h ou
tpati
ent s
ervic
es
$10c
o-pa
ymen
t for
phys
ician
visit
(Plan
D
educ
tible
does
not a
pply)
. Oth
erwise
, 20%
aft
er De
ducti
ble, 0
% af
ter M
edica
l Out
-of-
Pock
et Ex
pens
e Lim
it is m
et.
10%
grea
ter th
an yo
ur co
st fo
ran
in-n
etwor
k pro
vider
plus
dedu
ctible
if ap
plica
ble. Y
ou ar
e als
o res
pons
ible f
or ch
arge
s abo
ve
Reas
onab
le an
d Cus
tomar
y.
------
------
----N
one
------
------
----
Men
tal/B
ehav
ioral
healt
h in
patie
nt se
rvice
sFa
cility
fee i
s 0%
after
Ded
uctib
le. P
hysic
ian
fee is
20%
after
Ded
uctib
le, 0%
after
Med
ical
Out-o
f-Poc
ket E
xpen
se L
imit i
s met.
------
------
----N
one
------
------
----
Subs
tance
use d
isord
er ou
tpati
ent s
ervic
es
$10c
o-pa
ymen
t for
phys
ician
visit
(Plan
D
educ
tible
does
not a
pply)
. Oth
erwise
, 20%
aft
er De
ducti
ble, 0
% af
ter M
edica
l Out
-of-
Pock
et Ex
pens
e Lim
it is m
et.---
------
------
-Non
e ---
------
------
-
Subs
tance
use d
isord
er in
patie
nt se
rvice
sFa
cility
fee i
s 0%
after
Ded
uctib
le. P
hysic
ian
fee is
20%
after
Ded
uctib
le, 0%
after
Med
ical
Out-o
f-Poc
ket E
xpen
se L
imit i
s met.
------
------
----N
one
------
------
----
CEN
TRAL
STA
TES
HEA
LTH
AN
D W
ELFA
RE
FUN
D -
UPS
Pac
kage
Pla
n U
1 an
d Pl
an U
3C
over
age
Perio
d: B
egin
ning
on
or a
fter 0
1/01
/201
7C
over
age
for:
You
and
You
r Ele
cted
Dep
ende
nts
Sum
mar
y of
Ben
efits
and
Cov
erag
e: W
hat t
his
Pla
n C
over
s &
Wha
t it C
osts
Plan
Typ
e: P
PO
Que
stio
ns:C
all 8
00-T
EAM
CA
RE
or v
isit u
s at M
yTea
mC
are.o
rg.
If yo
u ar
en’t
clear
abou
t any
of t
he u
nder
lined
term
s use
d in
this
form
, see
the G
loss
ary.
You
can
view
the G
loss
ary
at M
yTea
mC
are.o
rgor
call
800-
TEA
MCA
REto
requ
est a
copy
. C
CM
CU
STO
M –
10/7
/201
6PL
AN
U1/
U3
Page
5of
9
Com
mon
M
edic
al E
vent
Serv
ices
You
May
Nee
dYo
ur C
ost I
f You
Use
an
In-n
etw
ork
Prov
ider
Your
Cos
t If Y
ou U
se a
n O
ut-o
f-net
wor
k Pr
ovid
erLi
mita
tions
& E
xcep
tions
If yo
u ar
e pre
gnan
t
Pren
atal a
nd po
stnata
l care
$10c
o-pa
ymen
t for
initia
l visi
t10
%gr
eater
than
your
cost
for
anin-
netw
ork p
rovid
er. Y
ou ar
e als
o res
pons
ible f
or ch
arge
s abo
ve
Reas
onab
le an
d Cus
tomar
y.
Addit
ional
costs
may
be ow
ed fo
r m
edica
l ser
vices
paya
ble b
eyon
d the
su
rger
y (e.g
. x-ra
ys, la
b tes
ts).
Deliv
ery a
nd al
l inpa
tient
serv
ices
0% af
ter D
educ
tible
If yo
u ne
ed h
elp
reco
verin
g or h
ave
othe
r spe
cial h
ealth
ne
eds
Hom
e hea
lth ca
re
20%
after
Ded
uctib
le, 0%
after
Med
ical O
ut-
of-P
ocke
t Exp
ense
Lim
it is m
et.
10%
grea
ter th
an yo
ur co
st fo
r an
in-ne
twor
k pro
vider.
You
are
also r
espo
nsibl
e for
char
ges a
bove
Re
ason
able
and C
ustom
ary.
Charg
es fo
r ser
vices
that
are no
t co
nside
red S
tanda
rd M
edica
l Care
, Tr
eatm
ent, S
ervic
es or
Sup
plies
are
not c
over
ed. I
n add
ition,
Main
tenan
ce
Care
is no
t cov
ered.
Reha
bilita
tion s
ervic
esHa
bilita
tion s
ervic
esSk
illed n
ursin
g care
Durab
le m
edica
l equ
ipm
ent
Hosp
ice se
rvice
If yo
ur ch
ild n
eeds
de
ntal
or e
ye ca
re
Eye e
xam
$10 c
o-pa
ymen
t und
er the
Tea
mCa
re Vi
sion
prog
ram.
After
Ded
uctib
le, yo
ur co
st fo
r an
Eye
Exa
m fo
r a ch
ild is
20%
of
cove
red ch
arges
plus
char
ges
abov
e Rea
sona
ble an
d Cu
stom
ary.
Team
Care
will p
ay a
max
imum
of
$75 f
or fr
ames
and $
50 fo
r sta
ndard
lens
es. A
ny ch
arge
s ab
ove t
hese
max
imum
s paid
by
Team
Care
will b
e the
res
pons
ibilit
y of t
he P
artic
ipan
t.
If yo
ur pl
an pr
ovide
s Visi
on co
vera
ge,
it is p
rovid
ed to
cove
red ch
ildren
thr
ough
age 2
5 and
only
once
ever
y 12
mon
ths. A
lso, in
lieu o
f glas
ses,
cont
act le
nses
are c
over
ed to
$80
max
imum
.Fo
r Tea
mCa
re Vi
sionp
rovid
ers,
conta
ct Ey
eMed
at 86
6-39
3-34
01 or
ey
emed
visio
ncare
.com
.
Glas
ses
$0 co
-pay
men
t for
Len
ses,
and $
0 co-
paym
ent f
or F
rames
. Stan
dard
lens
es an
d fra
mes
up to
$100
are i
nclud
ed in
the c
o-pa
ymen
t. Th
e Par
ticipa
nt is
respo
nsibl
e for
an
y diff
erenc
e in c
ost.
Dent
al ch
eck-
up0%
Team
Care
will p
ay 10
0% of
Re
ason
able
and C
ustom
ary
charg
es. Y
ou w
ould
be
respo
nsibl
e for
char
ges a
bove
Re
ason
able
and C
ustom
ary.
If yo
ur pl
an pr
ovide
s Den
tal co
vera
ge,
a Den
tal ch
eck-
up is
prov
ided t
o co
vered
child
ren th
roug
h age
25 on
ly on
ce ev
ery s
ix m
onths
. Fo
r Tea
mCa
re De
ntal
prov
iders
call
800-
592-
3112
or vi
sit
hum
anad
ental
netw
ork.c
om.
CEN
TRAL
STA
TES
HEA
LTH
AN
D W
ELFA
RE
FUN
D -
UPS
Pac
kage
Pla
n U
1 an
d Pl
an U
3C
over
age
Perio
d: B
egin
ning
on
or a
fter 0
1/01
/201
7 C
over
age
for:
You
and
You
r Ele
cted
Dep
ende
nts
Sum
mar
y of
Ben
efits
and
Cov
erag
e: W
hat t
his
Pla
n C
over
s &
Wha
t it C
osts
Plan
Typ
e: P
PO
Que
stio
ns:C
all 8
00-T
EAM
CA
RE
or v
isit u
s at M
yTea
mC
are.o
rg.
If yo
u ar
en’t
clear
abou
t any
of t
he u
nder
lined
term
s use
d in
this
form
, see
the G
loss
ary.
You
can
view
the G
loss
ary
at M
yTea
mC
are.o
rgor
call
800-
TEA
MCA
REto
requ
est a
copy
. C
CM
CU
STO
M –
10/
7/20
16PL
AN
U1/
U3
Page
6 o
f 9
Excl
uded
Ser
vice
s &
Oth
er C
over
ed S
ervi
ces:
Serv
ices
You
r Pla
n Do
es N
OT
Cove
r (T
his
isn’
t a c
ompl
ete
list.
Che
ck y
our p
olic
y or
pla
n do
cum
ent f
or o
ther
exc
lude
d se
rvic
es.)
Lon
g T
erm
Car
e.In
fert
ility
Tre
atm
ent:
char
ges
for
serv
ices
and
drug
s re
late
d to
th
e tre
atm
ent
ofin
ferti
lity,
in
clud
ing
char
ges
in
conn
ectio
nw
ith
in-v
itro
ferti
lizat
ion,
ar
tific
ial
inse
min
atio
n an
d re
vers
al
of
prio
rst
erili
zatio
n.Pr
ivat
e D
uty
Nur
sing
Wei
ght l
oss p
rogr
ams
Acu
punc
ture
Inju
ry
or
illne
ss
that
is
w
ork-
rela
ted
orco
vere
d by
Wor
ker’
s C
ompe
nsat
ion
or a
nO
ccup
atio
nal D
isea
se L
aw.
Cos
met
ic S
urge
ry:
(exc
ept t
o th
e ex
tent
it’s
requ
ired
due
to a
n ac
cide
ntal
bod
ilyin
jury
). Su
rgic
al
proc
edur
es
that
ar
eco
nsid
ered
C
osm
etic
un
less
th
ey’r
e a
resu
lt of
an
acci
dent
al in
jury
incl
ude
but
are
not l
imite
d to
:o
Aug
men
tatio
n m
amm
opla
sty
(bre
ast e
nlar
gem
ent s
urge
ry),
unle
ssit
is p
art o
f rec
onst
ruct
ion
follo
win
gbr
east
surg
ery
due
to c
ance
r.o
Rhi
nopl
asty
(pla
stic
surg
ery
on th
eno
se),
unle
ss su
rger
y is
the
resu
lt of
an a
ccid
ent o
r chr
onic
nas
alob
stru
ctio
n.o
Oto
plas
ty (p
last
ic su
rger
y on
ear
s),
som
etim
es re
ferr
ed to
as “
lope
ars”
or “
caul
iflow
er e
ars.”
oB
leph
arop
last
y (r
epai
r of d
roop
ing
eyel
ids)
, unl
ess t
he d
roop
rest
ricts
the
field
of v
isio
n as
ver
ified
by
anop
htha
lmol
ogis
t.o
Ker
atec
tom
y or
ker
atot
omy–
for
diag
nosi
s of m
yopi
a(n
ears
ight
edne
ss) w
hen
the
myo
pia
is c
orre
ctab
le b
y le
nses
.o
Rhy
tidec
tom
y (f
ace
lift),
Dys
chro
mia
(tat
too
rem
oval
),G
enio
plas
ty (c
hin
augm
enta
tion)
.
Cha
rges
fo
r m
edic
al
serv
ices
th
at
are
not
cons
ider
ed S
tand
ard
Med
ical
Car
e, T
reat
men
t,Se
rvic
es o
r Sup
plie
s.R
ever
sal o
f ste
riliz
atio
n pr
oced
ures
.C
harg
es fo
r sta
nd-b
y su
rgeo
ns.
Pers
onal
co
mfo
rt ite
ms,
stat
e ta
xes
orsu
rcha
rges
.Ey
e ex
amin
atio
ns
for
the
corr
ectio
n of
visi
on
and
fittin
g of
gl
asse
s or
co
ntac
tle
nses
, ex
cept
con
tact
len
ses
or g
lass
es f
ortre
atm
ent
of
glau
com
a,
kera
toco
nus
orre
sulti
ng f
rom
cat
arac
t sur
gery
(se
e “V
isio
nB
enef
it” in
the
Sum
mar
y Pl
an D
escr
iptio
n).
Hos
pita
l con
finem
ents
long
er th
an a
ccep
ted
stan
dard
s of m
edic
al p
ract
ice.
CEN
TRAL
STA
TES
HEA
LTH
AN
D W
ELFA
RE
FUN
D -
UPS
Pac
kage
Pla
n U
1 an
d Pl
an U
3C
over
age
Perio
d: B
egin
ning
on
or a
fter 0
1/01
/201
7 C
over
age
for:
You
and
You
r Ele
cted
Dep
ende
nts
Sum
mar
y of
Ben
efits
and
Cov
erag
e: W
hat t
his
Pla
n C
over
s &
Wha
t it C
osts
Plan
Typ
e: P
PO
Que
stio
ns:C
all 8
00-T
EAM
CA
RE
or v
isit u
s at M
yTea
mC
are.o
rg.
If yo
u ar
en’t
clear
abou
t any
of t
he u
nder
lined
term
s use
d in
this
form
, see
the G
loss
ary.
You
can
view
the G
loss
ary
at M
yTea
mC
are.o
rgor
call
800-
TEA
MCA
REto
requ
est a
copy
. C
CM
CU
STO
M –
10/
7/20
16PL
AN
U1/
U3
Page
7 o
f 9
Oth
er C
over
ed S
ervi
ces
(Thi
s is
n’t a
com
plet
e lis
t. C
heck
you
r pol
icy
or p
lan
docu
men
t for
oth
er c
over
ed s
ervi
ces
and
your
cos
ts fo
r the
se s
ervi
ces.
)
Chi
ropr
actic
Car
eR
outin
e Foo
t Car
e N
on-e
mer
genc
y car
ewhe
n tra
velin
g out
side U
.S.
Emer
genc
y car
e whe
n tra
velin
g out
side t
he U
.S.
Hea
ring
Aid
sR
outin
e E
ye C
are
(Adu
lt)D
enta
l Car
e (A
dult)
Your
Rig
hts
to C
ontin
ue C
over
age:
If y
ou lo
se c
over
age
unde
r th
e pl
an, t
hen,
dep
endi
ng u
pon
the
circ
umst
ance
s, Fe
dera
l and
Sta
te la
ws
may
pro
vide
pro
tect
ions
that
allo
w y
ou to
kee
p he
alth
cov
erag
e. A
ny s
uch
right
s m
ay b
e lim
ited
in d
urat
ion
and
will
requ
ire y
outo
pay
a p
rem
ium
, whi
ch m
ay b
e si
gnifi
cant
ly h
ighe
r tha
n th
e pr
emiu
m
you
pay
whi
le c
over
ed u
nder
the
plan
. Oth
er li
mita
tions
on
your
righ
ts to
con
tinue
cov
erag
e m
ay a
lso
appl
y.
For m
ore
info
rmat
ion
on y
our r
ight
s to
con
tinue
cov
erag
e, c
onta
ct th
e pl
an a
t 800
-TEA
MC
AR
E (8
32-6
227)
. You
may
als
o co
ntac
t you
r sta
te in
sura
nce
depa
rtmen
t, th
e U
.S. D
epar
tmen
t of
Lab
or, E
mpl
oyee
Ben
efits
Sec
urity
Adm
inis
tratio
n at
866
-444
-327
2 or
dol
.gov
/ebs
a , o
r th
e U
.S. D
epar
tmen
t of
H
ealth
and
Hum
an S
ervi
ces a
t 877
-267
-232
3 x6
1565
or c
ciio
.cm
s.gov
.
Your
Grie
vanc
e an
d Ap
peal
s Ri
ghts
:If
you h
ave a
com
plain
t or a
re di
ssati
sfied
with
a de
nial
of co
vera
ge fo
r clai
ms u
nder
your
plan
, you
may
be ab
le to
appe
alor
file
a grie
vanc
e. F
or qu
estio
ns ab
out y
our r
ight
s, th
is no
tice,
or as
sistan
ce, y
ou ca
n con
tact th
e Tea
mCa
re R
esea
rch a
nd C
orre
spon
denc
e Dep
artm
ent, 9
377 W
. Hig
gins
Rd.,
Ros
emon
t IL
6001
8, or
call 8
00-T
EAM
CARE
(8
32-6
227)
. In a
dditi
on, y
ou ca
n con
tact th
e Dep
artm
ent o
f Lab
or’s
Empl
oyee
Ben
efits
Sec
urity
Adm
inist
ratio
n at 8
66-4
44-E
BSA
(327
2) or
dol
.gov/
ebsa
/hea
lthre
form
.La
ngua
ge A
cces
s Ser
vice
s: S
pani
sh (E
spañ
ol):
Para
obten
er as
isten
cia en
Esp
añol
, llam
e al 8
00-8
32-6
227.
Does
this
Cov
erag
e Pr
ovid
e M
inim
um E
ssen
tial C
over
age?
The A
fford
able
Care
Act
requ
ires m
ost p
eopl
e to h
ave h
ealth
care
cove
rage
that
quali
fies a
s “m
inim
um es
sent
ial co
vera
ge.”
Thi
s plan
does
prov
ide m
inim
um es
sent
ial co
vera
ge.
Does
this
Cov
erag
e M
eet t
he M
inim
um V
alue
Sta
ndar
d?Th
e Affo
rdab
le Ca
re A
ct es
tablis
hes a
min
imum
valu
e stan
dard
of be
nefit
s of a
healt
h plan
. The
min
imum
valu
e stan
dard
is 60
%(a
ctuar
ial va
lue)
. Thi
s hea
lth co
vera
ge do
es
mee
t the m
inim
um va
lue s
tanda
rd fo
r the
bene
fits i
t pro
vide
s.
Lang
uage
Acc
ess
Serv
ices
:Es
paño
l: Pa
ra o
bten
er as
isten
cia en
Esp
añol
, llam
e al 8
00-8
32-6
227.
Ta
galo
g K
ung
kaila
ngan
nin
yo an
g tu
long
sa T
agalo
g tu
maw
ag sa
800
-832
-622
7. Ch
ines
e ():
800-
832-
6227
. N
avajo
(Din
e): D
inek
'ehgo
shik
a at'o
hwol
nin
ising
o, h
olne
' 800
-832
-622
7. ––
––––
––––
––––
––––
––––
To se
e exa
mples
of ho
w thi
s plan
migh
t cover
costs
for a
samp
le medi
cal sit
uatio
n, see
the n
ext p
age.––
––––
––––
––––
––––
––––
CEN
TRAL
STA
TES
HEA
LTH
AN
D W
ELFA
RE
FUN
D -
UPS
Pac
kage
Pla
n U
1 an
d Pl
an U
3C
over
age
Perio
d: B
egin
ning
on
or a
fter 0
1/01
/201
7C
over
age
for:
You
and
You
r Ele
cted
Dep
ende
nts
Sum
mar
y of
Ben
efits
and
Cov
erag
e: W
hat t
his
Pla
n C
over
s &
Wha
t it C
osts
Plan
Typ
e: P
PO
Que
stio
ns:C
all 8
00-T
EAM
CA
RE
or v
isit u
s at M
yTea
mC
are.o
rg.
If yo
u ar
en’t
clear
abou
t any
of t
he u
nder
lined
term
s use
d in
this
form
, see
the G
loss
ary.
You
can
view
the G
loss
ary
at M
yTea
mC
are.o
rgor
call
800-
TEA
MCA
REto
requ
est a
copy
. C
CM
CU
STO
M –
10/7
/201
6PL
AN
U1/
U3
Page
8of
9
Man
agin
g ty
pe 2
dia
bete
s(ro
utin
e m
ainte
nanc
e of
a
wel
l-con
trolle
d co
nditi
on)
Hav
ing
a ba
by(n
orm
al de
liver
y)
Ab
out t
hese
Cov
erag
e Ex
ampl
es:
Thes
e exa
mpl
es sh
ow h
ow th
is pl
an m
ight c
over
m
edica
l car
e in
given
situ
ation
s. U
se th
ese e
xam
ples
to
see,
in ge
nera
l, how
muc
h fin
ancia
l pro
tectio
n a
sam
ple p
atien
t migh
t get
if th
ey ar
e cov
ered
und
er
diffe
rent
plan
s.
Amou
nt o
wed
to p
rovi
ders
:$7,
540
Plan
pay
s$7
,490
Patie
nt p
ays
$50
Sam
ple
care
cos
ts:
Hos
pital
char
ges (
mot
her)
$2,70
0 Ro
utin
e obs
tetric
care
$2
,100
Hos
pital
char
ges (
baby
) $9
00
Anes
thes
ia $9
00
Labo
rato
ry te
sts
$500
Pr
escr
iptio
ns
$200
Ra
diolo
gy
$200
Va
ccin
es, o
ther
pre
vent
ive
$40
Tot
al$7
,540
Pa
tient
pay
s:D
educ
tibles
$0
Co
pays
$1
0 Co
insu
ranc
e $4
0 Li
mits
or e
xclus
ions
$0
T
otal
$50
Amou
nt o
wed
to p
rovi
ders
:$5,
400
Plan
pay
s$4
,271
Patie
nt p
ays
$1,1
29
Sam
ple
care
cos
ts:
Pres
crip
tions
$2
,900
Med
ical E
quip
men
t and
Supp
lies
$1,30
0 O
ffice
Visi
ts an
d Pr
oced
ures
$7
00
Educ
ation
$3
00
Labo
rato
ry te
sts
$100
Va
ccin
es, o
ther
pre
vent
ive
$100
T
otal
$5,4
00
Patie
nt p
ays:
Ded
uctib
les
$0
Copa
ys
$60
Coin
sura
nce
$1,03
0 Li
mits
or e
xclus
ions
$3
9 T
otal
$1,1
29
NO
TE:
Th
e ab
ove
exam
ples
are
bas
ed o
n us
ing
in n
etw
ork
PPO
pro
vide
rs in
clud
ing
the
us
e of
Que
st D
iagno
stics
for l
abor
ator
y te
sts.
This
is
nota
cos
t es
timat
or.
Don
’t us
e th
ese
exam
ples
to
estim
ate
your
act
ual c
osts
un
der t
his p
lan. T
he a
ctua
l ca
re y
ou re
ceiv
e w
ill b
e di
ffere
nt fr
om th
ese
exam
ples
, and
the
cost
of
that
car
e w
ill a
lso b
e di
ffere
nt.
See
the
next
pag
e fo
r im
porta
nt in
form
atio
n ab
out
thes
e ex
ampl
es.
CEN
TRAL
STA
TES
HEA
LTH
AN
D W
ELFA
RE
FUN
D -
UPS
Pac
kage
Pla
n U
1 an
d Pl
an U
3C
over
age
Perio
d: B
egin
ning
on
or a
fter 0
1/01
/201
7 C
over
age
for:
You
and
You
r Ele
cted
Dep
ende
nts
Sum
mar
y of
Ben
efits
and
Cov
erag
e: W
hat t
his
Pla
n C
over
s &
Wha
t it C
osts
Plan
Typ
e: P
PO
Que
stio
ns:C
all 8
00-T
EAM
CA
RE
or v
isit u
s at M
yTea
mC
are.o
rg.
If yo
u ar
en’t
clear
abou
t any
of t
he u
nder
lined
term
s use
d in
this
form
, see
the G
loss
ary.
You
can
view
the G
loss
ary
at M
yTea
mC
are.o
rgor
call
800-
TEA
MCA
REto
requ
est a
copy
. C
CM
CU
STO
M –
10/
7/20
16PL
AN
U1/
U3
Page
9 o
f 9
Que
stio
ns a
nd a
nsw
ers
abou
t the
Cov
erag
e Ex
ampl
es:
Wha
t are
som
e of
the
assu
mpt
ions
be
hind
the
Cove
rage
Exa
mpl
es?
Costs
don
’t in
clude
pre
miu
ms.
Sam
ple c
are c
osts
are b
ased
on n
ation
al av
erag
es su
pplie
d by
the U
.S. D
epar
tmen
t of
Hea
lth an
d H
uman
Ser
vice
s, an
d are
n’t
spec
ific t
o a p
artic
ular
geog
raph
ic ar
ea or
he
alth
plan
.Th
e pati
ent’s
cond
ition
was
not a
n ex
clude
d or
pree
xisti
ng co
nditi
on.
All
serv
ices a
nd tr
eatm
ents
starte
d and
ende
d in
the s
ame c
over
age p
erio
d.Th
ere a
re n
o ot
her m
edica
l exp
ense
s for
any
mem
ber c
over
ed u
nder
this
plan
.O
ut-o
f-poc
ket e
xpen
ses a
re ba
sed o
nly o
n tre
ating
the c
ondi
tion
in th
e exa
mpl
e.Th
e pati
ent r
eceiv
ed al
l car
e fro
m in
-netw
ork
prov
ider
s. If
the p
atien
t had
rece
ived
care
fro
m o
ut-o
f-netw
ork
prov
ider
s, co
sts w
ould
ha
ve be
en hi
gher
.
Wha
t doe
s a
Cove
rage
Exa
mpl
e sh
ow?
For e
ach
treatm
ent s
ituati
on, th
e Cov
erag
e Exa
mpl
e he
lps y
ou se
e how
ded
uctib
les,c
opay
men
ts, an
d co
insu
ranc
ecan
add u
p. It
also
help
s you
see w
hat
expe
nses
mig
ht be
left u
p to
you
to pa
y bec
ause
the
serv
ice o
r tre
atmen
t isn
’t co
vere
d or
paym
ent i
s lim
ited.
Does
the
Cove
rage
Exa
mpl
e pr
edic
t my
own
care
nee
ds?
No.
Tre
atmen
ts sh
own
are j
ust e
xam
ples
. The
ca
re yo
u w
ould
rece
ive f
or th
is co
nditi
on co
uld
be di
ffere
nt ba
sed o
n yo
ur d
octo
r’s ad
vice
, you
r ag
e, ho
w se
rious
your
cond
ition
is, a
nd m
any
othe
r fac
tors.
Does
the
Cove
rage
Exa
mpl
e pr
edic
t my
futu
re e
xpen
ses?
No.
Cov
erag
e Exa
mpl
es ar
e not
cost
estim
ators.
You
can’
t use
the e
xam
ples
to
estim
ate co
sts fo
r an a
ctual
cond
ition
. The
y are
fo
r com
para
tive p
urpo
ses o
nly.
You
r ow
n cos
ts w
ill be
diffe
rent
depe
ndin
g on
the c
are y
ou
rece
ive,
the p
rices
your
pro
vide
rsch
arge
, and
th
e reim
burse
men
t you
r hea
lth p
lanall
ows.
Can
I use
Cov
erag
e Ex
ampl
es to
co
mpa
re p
lans
?
Yes
. Whe
n yo
u lo
ok at
the S
umm
ary o
f Be
nefit
s and
Cov
erag
e for
othe
r plan
s, yo
u’ll
find
the s
ame C
over
age E
xam
ples
. Whe
n yo
u co
mpa
re p
lans,
chec
k th
e “Pa
tient
Pay
s” b
ox in
ea
ch ex
ampl
e. Th
e sm
aller
that
num
ber,
the
mor
e cov
erag
e the
plan
prov
ides
.
Are
ther
e ot
her c
osts
I sh
ould
co
nsid
er w
hen
com
parin
g pl
ans?
Yes
. An
impo
rtant
cost
is th
e pre
miu
myo
upa
y. G
ener
ally,
the l
ower
your
pre
miu
m, t
he
mor
e you
’ll pa
y in
out-o
f-poc
ket c
osts,
such
as
copa
ymen
ts,de
duct
ibles
, and
coin
sura
nce.
You
shou
ld al
so co
nsid
er co
ntrib
utio
ns to
ac
coun
ts su
ch as
healt
h sa
ving
s acc
ount
s (H
SAs),
flex
ible
spen
ding
arra
ngem
ents
(FSA
s) or
healt
h re
imbu
rsem
ent a
ccou
nts (
HRA
s) th
at he
lp yo
u pa
y out
-of-p
ocke
t exp
ense
s.
OM
B C
ontro
l Num
bers
154
5-22
29,
1210
-014
7, a
nd 0
938-
1146
R
elea
sed
on A
pril
23, 2
013
(cor
rect
ed)
CENTRAL STATES, SOUTHEAST
AND SOUTHWEST AREAS HEALTH
AND WELFARE PLAN
is a jointly administered, defined
benefit employee benefit plan.
EXECUTIVE DIRECTOR
Thomas C. Nyhan
ADDRESS OF ADMINISTRATIVE OFFICE
9377 West Higgins Road
Rosemont, IL 60018-4938
ADDRESS FOR CORRESPONDENCE
P.O. Box 5126
Des Plaines, IL 60017-5126
TELEPHONE NUMBER
847-518-9800
PARTICIPANT SERVICES
800-TEAMCARE (800-832-6227)
INTERNET WEBSITE
MyTeamCare.org
EMPLOYER IDENTIFICATION
36-2154936
PLAN NUMBER
501
PLAN YEAR
January 1 through December 31
The agent for service of legal process is
Thomas C. Nyhan, Executive Director, Central States,
Southeast and Southwest Areas Health and Welfare
Fund, at the Administrative Office address.
IMPORTANT
Para obtener asistencia en Español, llame al
800-832-6227
Kung kailangan ninyo ang tulong sa
Tagalog tumawag
800-832-6227
800-832-6227
Dinek’ehgo shika at’ohwol ninisingo,
kwiijigo holne’
800-832-6227
The information in this Benefits Booklet
reflects all Health Plan amendments enacted
through January 1, 2017. Amendments
enacted after this date may impact the
information in this Benefits Booklet.
9377 West Higgins Road • Rosemont, IL 60018-4938 • 800-TEAMCARE • MyTeamCare.org
January 2017
Questions? We’re here to help!
Call us toll-free at 800-TEAMCARE (800-832-6227) or visit MyTeamCare.org.
