DATE: February 10, 2023
TO: All CWA Local 1168 Members at Kaleida Health Enrolled in the Master Union Align Medical Plan
FROM: Executive Board and Special Directors of CWA Local 1168
RE: Co-pay Reimbursements
All Kaleida Employees covered under the Master Union Align Medical Plan have the option to submit for co-pay reimbursements as captioned in the chart below from Article 29 of the Collective Bargaining Agreement.
Also attached is the form needed for submission.
Chart From Article 29 – Medical and Prescription Drug Benefits:
| Benefit Level | Premium Medical and Prescription
Drug Plan Design |
Master Union Align Plan Design | |||||||
| In-Network (deleting CHS) | Out-of-Network | Optimum Choice (deleting CHS) | Flexible Choice | Out of Network | |||||
| Up Front | Refund | Up Front | Refund | Up Front | Refund | ||||
| Deductible | N/A | $750/$1250 | N/A | $1000/$2000 | $1000/$2000 | ||||
| Coinsurance | N/A | 30% | N/A | 30% | 30% | ||||
| OOP Maximum |
$6,350 single/ $12,700 Family |
$2,500/$5,000 | $2,500/$5,000 | $2,500/$5,000 | $2,500/$5,000
|
||||
| Medical Services | |||||||||
| PCP Office Visits | $20 | Ded/Coinsurance | $20 | N/A | $35 | $15 | Ded/Coinsurance | ||
| Specialist Office visits | $20 | Ded/Coinsurance | $35 | $15 | $65 | $45 | Ded/Coinsurance | ||
| Preventative Office Visits & Immunizations | $0 | Ded/Coinsurance | $0 | N/A | $0 | N/A | Ded/Coinsurance | ||
| Diagnostic x-rays, including MRI | $20 | Ded/Coinsurance | $30 | $10 | Ded/Coinsurance | Ded/Coinsurance | |||
| Laboratory testing * | $0 | Ded/Coinsurance | $0 | N/A | Ded/Coinsurance | Ded/Coinsurance | |||
| Occupational, speech, physical therapy | $15 | Ded/Coinsurance | $30 | $15 | $30 | $15 | Ded/Coinsurance | ||
| Chiropractor Office Visits | $15 | Ded/Coinsurance | $30 | $15 | $30 | $15 | Ded/Coinsurance | ||
| Hospital Care | |||||||||
| Inpatient $500 First Family Discount | $500 | Ded/Coinsurance | $500 | N/A | Ded/Coinsurance | Ded/Coinsurance | |||
| Outpatient surgery facility | $15 | Ded/Coinsurance | $75 | $60 | Ded/Coinsurance | Ded/Coinsurance | |||
| Emergency room visit (waived if admitted) | $75 | $75 | $120 | $45 | $120 | $45 | $120 | $45 | |
| Emergency ambulance (medically necessary) | $75 | $75 | $120 | $45 | $120 | $45 | $120 | $45 | |
| Other Services | |||||||||
| Durable medical equipment | 50% | Ded/50% | 50% | 50% | Ded/50% | ||||
| Annual maximum | $1,000 | $1,000 | |||||||
| Home health care | $15 | Ded/Coinsurance | $15 | N/A | Ded/Coinsurance | Ded/Coinsurance | |||
| Orthotics | Not covered | Not covered | Not covered | Not covered | Not covered | ||||
| Urgent Care | $45 | $45 | $60 | $15 | Ded/Coinsurance | Ded/Coinsurance | |||
| Away from Home Guest Membership | Not Available | Not Available | Available | ||||||
| OB Deliveries at CHS (Notes below) | Considered In-Network | Ded/Coinsurance | Considered In-Network | Ded/Coinsurance | Ded/Coinsurance | ||||
| Medical Services & Cancer Center
(conditions under treatment prior to 1/1/2020) |
Considered In-Network | Ded/Coinsurance | Considered In-Network | Ded/Coinsurance | Ded/Coinsurance | ||||
| Prescription Drugs | |||||||||
| Retail Pharmacy through December 31, 2022
Retail Pharmacy effective January 1, 2023 |
$10/$20/$40
$5/$15/$35 |
Not covered | $5/$20/$40
$0/$15/$35 |
N/A | N/A | ||||
RVA/mg UAW 55 DATA\BANDRUSZKO\ALIGN MEDICAL CO-PAY REIMBURSEMENT MEMO
