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Retiree Plans |
Retiree Rates
(Hartford
Plans I, II, III, IV)
MEDICARE
(PART A) - HOSPITAL SERVICES - PER BENEFIT
PERIOD*
*A benefit period begins on
the first day you receive service as an
inpatient in a hospital and ends after you
have been out of the hospital and have not
received skilled care in any other
facility for 60 days in a row.
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SERVICES
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MEDICARE
PAYS
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PLAN
I
PAYS
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PLAN
II
PAYS
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PLAN II
PAYS
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PLAN IV
PAYS
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HOSPITALIZATION*
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Semiprivate room
and board, general nursing and
miscellaneous services and
supplies:
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First 60
days
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All
but $840
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$0
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$840
(Part A Deductible)
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$840
(Part A Deductible)
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$840
(Part A Deductible)
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61st thru
90th day
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All
but $210
a
day
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$210
a day
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$210
a day
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$210
a day
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$210
a day
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91st day and
after:
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While using
60 lifetime reserve days
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All
but $420
a
day
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$420
a day
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$420
a day
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$420
a day
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$420
a day
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Once
lifetime reserve days are
used:
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Additional
365 days
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$0
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100% of Medicare Eligible
Expenses
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100%
of Medicare Eligible
Expenses
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100%
of Medicare Eligible
Expenses
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100%
of Medicare Eligible
Expenses
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Beyond the
Additional 365 days
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$0
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$0
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$0
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$0
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$0
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SKILLED
NURSING FACILITY CARE*
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You must meet
Medicare's requirements,
including having been in a
hospital for at least 3 days and
entered a Medicare-approved
facility within 30 days after
leaving the hospital:
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First 20
days
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All
approved amounts
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$0
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$0
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$0
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$0
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21st thru 100th
day
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All
but $105/day
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$0
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Up
to $105 a day
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Up
to $105 a day
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Up
to $105 a day
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101st day thru
365th day
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$0
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$0
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$0
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$0
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$0
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366th day and
after
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$0
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$0
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$0
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$0
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$0
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BLOOD
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First 3
pints
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$0
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3
pints
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3
pints
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3
pints
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3
pints
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Additional
amounts
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100%
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$0
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$0
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$0
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$0
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MEDICARE (PART B) - MEDICAL
SERVICES - PER CALENDAR YEAR*
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SERVICES
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MEDICARE
PAYS
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PLAN
IPAYS
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PLAN
II
PAYS
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PLAN
III
PAYS
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PLAN
IV
PAYS
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MEDICAL
EXPENSES - In or
Out of the Hospital and
Outpatient Hospital
Treatment, such as
Physician's services, inpatient
and outpatient medical and
surgical services and supplies,
physical and speech therapy,
diagnostic tests, durable medical
equipment:
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First
$100 of Medicare Approved
Amounts**
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$0
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$0
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$100
(Part B Deductible)
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$0
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$100
(Part B Deductible)
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Remainder of
Medicare Approved Amounts
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80%
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20%
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20%
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20%
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20%
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Part B Excess
Charges
(Above Medicare
Approved Amounts)
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$0
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$0
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$0
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$0
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100%
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BLOOD
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First 3
pints
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$0
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All
costs
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All
costs
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All
costs
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All
costs
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Next $100
of Medicare Approved
Amounts**
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$0
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$0
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$100
(Part B Deductible)
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$0
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$100
(Part B Deductible)
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Remainder of
Medicare Approved Amounts
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80%
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20%
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20%
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20%
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20%
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CLINICAL
LABORATORY SERVICES
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Blood tests for
Diagnostic Services
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100%
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$0
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$0
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$0
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$0
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MEDICARE PARTS A & B
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SERVICES
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MEDICARE
PAYS
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PLAN
I
PAYS
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PLAN
II
PAYS
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PLAN
III
PAYS
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PLAN IV
PAYS
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HOME
HEALTH CARE
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Medicare
Approved Services:
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Medically
necessary skilled care services
and medical supplies
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100%
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$0
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$0
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$0
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$0
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Durable medical
equipment:
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First $100
of Medicare Approved
Amounts**
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$0
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$0
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$100
(Part B Deductible)
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$0
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$100
(Part B Deductible)
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Remainder of
Medicare Approved Amounts
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80%
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20%
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20%
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20%
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20%
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AT
HOME RECOVERY SERVICES
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Home care certified by your doctor, for
personal care during recovery
from an injury or sickness for
which Medicare approved a Home
Care Treatment Plan:
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Benefit for each visit:
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$0
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$0
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$0
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Actual
charges up to $40 per
visit
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$0
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Number of visits covered
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$0
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$0
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$0
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Up
to the number of Medicare
approved visits, not to exceed 7
each week
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$0
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Calendar year maximum
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$0
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$0
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$0
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$1,600
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$0
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OTHER
BENEFITS - NOT COVERED BY MEDICARE
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SERVICES
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MEDICARE
PAYS
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PLAN
I
PAYS
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PLAN
II
PAYS
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PLAN
III
PAYS
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PLAN IV
PAYS
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FOREIGN
TRAVEL
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Medically
necessary emergency care services
beginning during the first 60
days of each trip outside the
USA:
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First
$250 each calendar year
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$0
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$0
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$0
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$0
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$0
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Remainder
of charges
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$0
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$0
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80% to a lifetime maximum of
$50,000
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80%
to a lifetime maximum of
$50,000
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80%
to a lifetime maximum of
$50,000
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OUTPATIENT
PRESCRIPTION DRUGS***
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Retail:ÝÝÝÝ
Generic Drugs
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$0
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Balance
after $10 copay
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Balance after $10 copay
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Balance
after $10 copay
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Balance
after $10 copay
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ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ
Brand Name
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$0
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Discount
on Brand
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50%
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50%
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50%
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Mail Order (90
day supply):
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ÝÝÝÝÝÝÝÝÝÝÝÝÝ
Generic Drugs
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$0
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N/A
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Balance after $15 copay
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Balance
after $15 copay
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Balance
after $15 copay
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ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ
Brand Name
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$0
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N/A
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50%
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50%
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50%
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*A benefit period begins on the first day
you receive service as an inpatient in a
hospital and ends after you have been out
of the hospital and have not received
skilled care in any other facility for 60
days in a row.
**Once
you have been billed $100 of Medicare
approved amounts for covered services,
your Medicare Part B Deductible will have
been met for the calendar year.
***Prescription
drugs are covered through CBCA,
who offers a network of over 50,000
pharmacies nationwide (some of these
pharmacies include Costco, CVS, Drug
Emporium, Farmer Jackís, Kmart,
Krogerís, Meijerís, Publix
Super Markets, Rite Aid, Sav-Mor, Target,
Walgreenís, WalmMart, and
Winn-Dixie just to name a few).
The summary of program
benefits described herein is for
illustrative purposes only.Ý In
case of differences or errors, the Group
Policy governs.
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