THE COOPER UNION FOR THE ADVANCEMENT OF SCIENCE AND ART
Group #2260
SCHEDULE OF BENEFITS
Effective July 2010
Medical Benefits:
Maximum Benefit Per Covered Person Per Lifetime While Covered By
This Plan For:
Medical
$2,000,000
Hair Wig (in the event of cancer treatment)
Temporomandibular Joint (TMJ)
Dysfunction (MPD) Treatment
$350
and
Myofascial
Pain
$1,000
Hospice Care
Family Counseling
$500
Bereavement Counseling
$200
Notwithstanding any provision of this Plan to the contrary, all benefits received by an individual under any benefit option,
package or coverage under the Plan shall be applied toward the maximum benefit paid by this Plan for any one covered
person during the entire time he is covered by this Plan for such option, package or coverage under the Plan, and also toward
the maximum benefit under any other options, packages or coverages under the Plan in which the individual may participate
in the future.
Maximum Benefit Per Covered Person Per Calendar Year For:
Flu Shot
One
Rehabilitation Facility
180 Days
Routine Mammograms
One Mammogram
$300
Routine Gynecological Examination
Well Child Care – Birth to age 6
Unlimited
$300
Routine Physical Examination - age 6 and over
Extended Care Facility (Skilled Nursing Facility)
60 Days
Other Benefits Per Covered Person For:
Routine Colorectal Screening
Beginning at age fifty (50)
Pre-Existing Conditions:
Limitation Time Period and dollar Limits
No more than $1,000 toward
eligible expenses unless no
treatment for 3 months prior to
enrollment date or covered under
the Plan for 12 consecutive
months
1
Preferred
Provider
Nonpreferred
Provider
Individual (Per Person)
None
$2001
Family (Aggregate)
None
$4001
Deductible Per Calendar Year:
If two or more covered members of a family are injured in the same accident and, as a result of that accident,
incur covered expenses, only one individual deductible amount will be deducted from the total covered expenses
of all covered family members related to the accident for the remainder of the calendar year.
Out-of-Pocket Expense Limit Per Calendar Year: (includes deductible)
Individual (Per Person)
Family (Aggregate)
$500
$7501
$1,500
$2,0001
Refer to Medical Expense Benefit, Out-of-Pocket Expense Limit for a listing of charges not applicable to the outof-pocket expense limit.
Amounts applied toward satisfaction of the preferred provider out-of-pocket expense limit may also be applied
toward satisfaction of the nonpreferred provider out-of-pocket expense limit and vice versa.
Coinsurance:
The Plan pays the percentage listed on the following pages for covered expenses incurred by a covered person
during a calendar year after the individual or family deductible has been satisfied and until the individual or
family out-of-pocket has been reached. Thereafter, the Plan pays one hundred percent (100%) of covered
expenses for the remainder of the calendar year or until the maximum benefit has been reached. Refer to
Medical Expense Benefit, Out-of-Pocket Limit, for a listing of charges not applicable to the one hundred percent
(100%) coinsurance.
1
Retirees under VSIP 1988 and 1992 – Calendar year Deductibles $100/person, $300 family. Out-of-Pocket
maximum $600/person, $1,800 family
Preferred
Provider
Nonpreferred
Provider
(% of negotiated
rate, if applicable,
otherwise
% of customary
and reasonable
amount)
(% of customary
and reasonable
amount after the
deductible)
First $100,000 per confinement
100%
100%
Thereafter
80%
80%
Preadmission Testing
100%
*100%
Outpatient Surgery/Ambulatory Surgical Facility
80%
80%
BENEFIT DESCRIPTION
Inpatient Hospital
Pre-certification is required and failure to obtain will result in a penalty of
$250, the penalty is waived if hospital charge is less than $1,000 (refer to
Health Care Management)
(Penalty is waived for CUFCT covered persons who retired under the early
retirement program dated 1988 and 1992)
2
Preferred
Provider
Nonpreferred
Provider
(% of negotiated
rate, if applicable,
otherwise
% of customary
and reasonable
amount)
(% of customary
and reasonable
amount after the
deductible)
Emergency Room (Hospital/Physician/Diagnostic)
80%
*80%
Non-Emergency Care
80%
80%
Out-of-Area Emergency Room Services
80%
*80%
Urgent Care Facility
80%
80%
100%
First $300;
80%
*100%
First $300;
80% after
deductible
80%
80%
80%
80%
Office Visit
(general practitioner, family practitioner, pediatrician, general internist,
gynecologist) (diagnostic services billed separately)
100%
(after $12
copay per
visit)
80%
Specialist Office Visit
(diagnostic services billed separately)
100%
(after $12
copay per
visit)
80%
Surgery - Physician's Office**
80%
80%
Surgery – Inpatient/Outpatient (Hosptial/ASC)**
80%
80%
Injections and Allergy Injections
80%
80%
Allergy Testing/Serum
80%
80%
Pathology
80%
80%
Anesthesiology
80%
80%
Radiology
80%
80%
Infertility Diagnostic
80%
80%
Not Covered
Not Covered
80%
80%
BENEFIT DESCRIPTION
Accident Expense Benefit
Limitation:
$300 maximum benefit per accident
Ambulance Services
Physician Services
Inpatient Visit
Infertility/AI-IVF
Diagnostic Services and Supplies
Inpatient or Outpatient
*
Deductible Waived
**
Anesthesia is paid at the same level as surgery
3
Preferred
Provider
Nonpreferred
Provider
(% of negotiated
rate, if applicable,
otherwise
% of customary
and reasonable
amount)
(% of customary
and reasonable
amount after the
deductible)
100%
(after $12
copay per
visit)
80%
Extended Care Facility
80%
80%
Home Health Care
80%
80%
Hospice Care
80%
80%
Durable Medical Equipment
80%
80%
Prostheses
80%
80%
100%
(after $12
copay per
visit)
80%
100%
80%
100%
80%
100%
(after $12
copay per
visit)
*80%
BENEFIT DESCRIPTION
Second and Third Surgical Opinion
Well Child Care
Limitation:
Birth to age 6
Immunization
Limitation:
child-birth to age 6
Immunization
Limitation:
adult-child-age 6 and older
Routine Preventive Care/Wellness Benefits
Limitation:
$300 maximum benefit per person per calendar year
age 6 and older
Routine Diagnostic Procedures (included in calendar maximum)
100%
100%
80%
Routine Mammograms
If sponsored by employer, covered at 100%
100%
(after $12
copay per
visit)
80%
Routine Gynecological Examination
Limitation:
$300 maximum benefit per calendar year
100%
(after $12
copay per
visit)
80%
4
Preferred
Provider
Nonpreferred
Provider
(% of negotiated
rate, if applicable,
otherwise
% of customary
and reasonable
amount)
(% of customary
and reasonable
amount after the
deductible)
100%
(after $12
copay per
visit)
80%
100%
*100%
First $100,000 per confinement
100%
100%
Thereafter
80%
80%
100%
(after $12
copay per
visit)
80%
Therapy Services (Cardiac Rehab, Chemotherapy/Radiation, Dialysis,
Physical, Occupational, Respiratory)
80%
80%
Speech Therapy
Limitation:
For restorative purposes only
80%
80%
Birthing Center
80%
80%
Private Duty Nursing
80%
80%
Acupuncture
Limitation:
80%
80%
Chiropractic Care
80%
80%
Contraceptive Management
Limitation:
Prescribed devices and injectables
80%
80%
*100%
*100%
80%
80%
BENEFIT DESCRIPTION
Routine Colorectal Screenings
Limitation:
age 50 and over
(See Medical Expenses Benefit, Routine Colorectal Screenings for details)
Flu Shots
Limitation:
1shot maximum benefit per calendar year
for all covered persons
Mental & Nervous Disorders and Chemical Dependency Care
Inpatient Services (including Rehab and Detox)
Outpatient Services (including Rehab and Detox)
Administered by a licensed provider
Hair Wig (in the event of cancer treatment)
All Other Covered Expenses
Prescription Drugs
(% of customary and reasonable amount)
Pharmacy Option
Generic
80% After Deductible
Brand Name
80% After Deductible
Limitation: 30 day supply
*
Deductible Waived
5
Prescription Drug Program:
Mail Order Option Includes Oral Contraceptives
Mail Order Option
Mail Order Prescription
100% after copay
Copay
Generic: $10 copay Per Prescription
Brand Name: $10 copay Per Prescription
Limitation:
90 day supply
6
Dental Benefits:
All benefits are available for full-time employees and proportional faculty employees only.
Deductible Per Calendar Year:
Individual (Per Person)
$50
Family
$150
The deductible is waived for diagnostic & preventive dental services.
Orthodontic Benefit:
Orthodontic services per individual lifetime while covered by this
Plan not subject to retroactive and $500 maximum benefit
$1,500
Maximum Benefit Per Covered Person Per Calendar Year For:
Class I - Diagnostic & Preventive Dental Services
Class II - Basic Dental Services - Restorative
80% after deductible
Class III - Major Dental Services
60% after deductible
Class IV - Orthodontic services
50% after deductible
Preliminary Benefits for Class I, II, II combined**
services per calendar year (other than Orthodontics)
**
**
100% with no deductible
$500
Per Person
Plus Retroactive amount, if applicable
The Dental Plan is a Retroactive plan, which means you may receive an additional benefit at the end
of the calendar year. See “How the Dental and Vision Plans Work” for more information.
7
Vision Benefits:
All benefits are available for full-time, retired and proportional faculty employees.
Maximum Benefit Per Covered Person Every Two Calendar Years For:
$250**
Eye Examination
Conventional Lenses - Single Vision - Bi-focal - Tri-focal – Lenticular and/or
Contact lenses – Medically Necessary – All Other Corrective Contact Lenses
only for corrective vision
Frames (maximum to $250)
**
The Vision Plan is a Retroactive plan, which means you may receive an additional benefit (except for
frames) at the end of every two (2) calendar years. See “How the Dental and Vision Plans Work” for
more information.
8