BENEFIT PLANS EFFECTIVE JANUARY 1, 2022
YOUR BENEFITS
Below you will find copies of all the Plans covered by Indiana Teamsters Health Benefits Fund, please select the Plan that you are enrolled in.
YOUR BENEFITS
DENTAL BENEFITS FOR ACTIVE PLANS
VISION BENEFITS FOR ACTIVE PLANS
VISION BENEFITS FOR ACTIVE PLANS
Dental Benefits
Annual Maximum Benefit per Adult Covered Person: $1,500
(excluding Orthodontic)
Lifetime Maximum Orthodontic Benefit per Covered Dependent:
$1,000 up to age 26
Percentage of Reasonable and Customary Charges Payable By Plan:
Crowns, fixed bridgework, gold inlays and
onlays, and other related services only 60%
All other covered services 100%
Deductibles, Co-insurance and balance bill amounts do not accumulate to your medical Out-of-Pocket Maximum limit.
VISION BENEFITS FOR ACTIVE PLANS
VISION BENEFITS FOR ACTIVE PLANS
VISION BENEFITS FOR ACTIVE PLANS
Vision Benefits
Annual Maximum Benefit per Adult Covered Person:
Examinations $50
Contact Lenses $80/pair
Lenses $50-$70 (depending upon Rx)
Frames $80
Balance bill amounts for optical services do not accumulate to your annual Out-of-Pocket Maximum.
LIVEHEALTH ONLINE
VISION BENEFITS FOR ACTIVE PLANS
PLAN 400 DEDUCTIBLE AND OUT OF POCKET
QUICK EASY PRIVATE
At home or on the go,
see a doctor or therapist
Using LiveHealth Online, you can have a
private video visit on your smartphone,
tablet or computer, LiveHealth
- Immediate, 24/7 access to board-certified doctors
- Secure and private video chats
- Prescriptions that can be sent to your pharmacy, if needed
- Sign up today at LiveHealthOnline.com
- You’re just a few clicks away from seeing a doctor
PLAN 400 DEDUCTIBLE AND OUT OF POCKET
RETIREE PLAN DEDUCTIBLE AND OUT OF POCKET
PLAN 400 DEDUCTIBLE AND OUT OF POCKET
PLAN 400
Deductible
(No Deductible for Services Provided in the ITHBF FREE Clinics)
Single $250 In Network - $500 Out of Network
Family $500 In Network- $1,000 Out of Network
Out of Pocket
(ITHBF FREE Clinics services not subject to Out of Pocket Limits)
Single $2,000 In Network - $6,000 Out of Network
Family $4,000 In Network - $12,000 Out of Network
Co-insurance %
(No Co-insurance for Services Provided in the ITHBF FREE Clinics)
Single 80% In Network - 60% Out of Network
Family 80% In Network - 60% Out of Network
SEE BELOW DOWNLOADS FOR COMPLETE PLAN BENEFITS
PLANS 500 DEDUCTIBLE AND OUT OF POCKET
RETIREE PLAN DEDUCTIBLE AND OUT OF POCKET
RETIREE PLAN DEDUCTIBLE AND OUT OF POCKET
PLANS 500
Deductible
(No Deductible for Services Provided in the ITHBF FREE Clinics)
Single $250 In Network - $500 Out of Network
Family $500 In Network - $1,000 Out of Network
Out of Pocket
(ITHBF FREE Clinics services not subject to Out-of-Pocket Limits)
Single $1,200 In Network - $3,500 Out of Network
Family $2,400 In Network - $7,000 Out of Network
Co-insurance %
(No Co-insurance for Services Provided in the ITHBF FREE Clinics)
Single 85% In Network - 70% Out of Network
Family 85% In Network - 70% Out of Network
SEE BELOW DOWNLOADS FOR COMPLETE PLAN BENEFITS
RETIREE PLAN DEDUCTIBLE AND OUT OF POCKET
RETIREE PLAN DEDUCTIBLE AND OUT OF POCKET
RETIREE PLAN DEDUCTIBLE AND OUT OF POCKET
RETIREE PLAN
Deductible
(No Deductible for Services Provided in the ITHBF FREE Clinics)
Covered Person
$200 In Network - $400 Out of Network
Co-insurance %
(No Co-insurance for Services Provided in the ITHBF FREE Clinics)
Covered Person
80% In Network - 70% Out of Network
MAXIMUM ANNUAL BENEFIT
$100,000
SEE BELOW DOWNLOADS FOR COMPLETE PLAN BENEFITS