Health & Security Retiree Health Plan > SPD > Medical Plan Maximums

Summary Plan Description

Medical Plan Maximums

This plan provides you with up to $750,000 of coverage for covered medical expenses each calendar year. Included within the $750,000 maximum are the following benefit maximums. If expenses exceed these maximums, this plan will not pay the additional costs.

  • Allergy testing—Blood testing for allergies is limited to 12 allergens per year. Skin testing for allergies is limited to 60 allergens per year.
  • Autism spectrum disorders (children age twelve and under)—Annual maximum of 15 visits.

Key Point

When you move from the Employee Health Plan to the Retiree Health Plan during a calendar year, the annual maximums for specific benefits will not be reinstated until the first of the following calendar year. Lifetime maximums are not reinstated under the Retiree Health Plan.

  • Chemical dependency—Inpatient treatment not to exceed 28 days in a 24-month period. Outpatient treatment not to exceed 36 visits in a 24-month period. Lifetime maximum of three episodes of treatment.
  • Chiropractic care—Annual maximum of 24 spinal manipulations.
  • Home health care—Annual maximum of 30 visits.
  • Hospice care—Maximum of 14 inpatient days for hospice care. Skilled care in the home is limited to 60 visits. Respite care is limited to 120 hours per three-month period.
  • Mental health care (inpatient)—Annual maximum of 15 days.
  • Mental health care (outpatient)—Annual maximum of 30 visits.
  • Neurodevelopmental therapy (children age six and under)—Annual maximum of 15 visits.
  • Neuropsychological or psychological assessments or tests—Lifetime maximum of $1,200.
  • Orthognathic surgery—Lifetime maximum of $5,000.
  • Orthotics (foot)—Maximum of $400 paid in any two consecutive year period.
  • Physical examinations—subject to the Preventive Health Benefit Schedule.
  • Rehabilitation (inpatient)—Annual maximum of 15 days.
  • Rehabilitation (outpatient)—Annual maximum of 30 visits.
  • Skilled nursing facility—Annual maximum of 25 days.
  • TMJ and MPDS—Lifetime maximum of $2,500.
  • Transplants (donor organ procurement costs)—Maximum of $25,000 per transplant.