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Retiree H&W - Deductibles and Co-payments

The retiree medical plans have deductibles that you must pay before the Plan will pay at the specified co-payment rate.  To determine your deductible, out-of-pocket limits, and co-payment rate (% payable by the Plan), you may review the following summary for your plan:

• Retiree Plan Summaries

Once deductibles have been met, payment will equal the co-payment rate multiplied by the actual charge (or the usual and customary charge for that service, whichever is lower), until the out-of-pocket limit is met.  Once the out-of-pocket limit is met, payment will equal the actual charge (or the usual and customary charge for that service, whichever is lower).

Please note that the following items are not applied towards your annual medical deductible or out-of-pocket limit: 

• $20 (or $50) fee paid at a Wellness and Minor Care clinic
• Out-of-network penalties
• Expenses in excess of the usual and customary
• Prescription drug co-payments
• Any expense not covered by the Plan

There are no annual or lifetime maximums for general medical benefits; however, treatment for alcohol and/or substance abuse is limited. For details, see the Plan Documents or review your Plan Booklet.

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