Benefits & Plans

The following tables show the benefit plan options offered through TACT. Any benefit changes are subject to approval by the TACT board of trustees and require verification that the benefit(s) or options are acceptable under state and federal regulations.

Life and AD&D Plans

Minimum Life/AD&D Benefit	$10,000 per employee
Standard Life/AD&D Benefit	$25,000 per employee
Maximum Life/AD&D Benefit	$500,000 per employee
Age Cutback Schedule	At age 65, 65% of original amount; At age 70, 65% of the amount at age 65; At age 75, 65% of the amount at age 70; At age 80, 65% of the amount at age 75; Benefits cease at retirement
AD&D Coverage Type	Occupational coverage standard
Dependent Life (optional)	Plan A ("Low"): $5,000 spouse benefit; $2,500 child benefit; and $1,000 infant benefit Plan B ("High"): $10,000 spouse benefit; $5,000 child benefit; and $2,500 infant benefit

Medical Plans

In Network

	Plan A "Platinum"	Plan B "Gold"	Plan C "Silver"	Plan D "Bronze"	Plan E "Copper"
Calendar Year Deductible
Per Member	$500	$750	$1,000	$2,000	$5,000
Per Family	$1,500	$2,250	$3,000	$6,000	$15,000
Coinsurance	80%/20%	80%/20%	80%/20%	80%/20%	100%/0%
Calendar Year Out of Pocket Maximum (excluding deductible)
Per Member	$2,000	$2,500	$3,000	$4,000	Not applicable
Per Family	$6,000	$7,500	$9,000	$12,000	Not applicable
Office Visit Co-Pay (up to $500 per visit reimburseable at 100%; amount in excess subject to deductible and coinsurance)	$20	$25	$30	$35	$40
Outpatient Diagnostic Procedures Co-pay (after copyament, 100% up to $300, then subject to deductible and coinsurance)	$10	$12.50	$15	$17.50	$20

Out of Network

	Plan A "Platinum"	Plan B "Gold"	Plan C "Silver"	Plan D "Bronze"	Plan E "Copper"
Eligible charges limited to 100% of Medicare allowable amount.
Calendar Year Deductible
Per Member	$1,000	$1,500	$2,000	$4,000	$7,500
Per Family	$3,000	$4,500	$6,000	$12,000	$22,500
Coinsurance	50%/50%	50%/50%	50%/50%	50%/50%	50%/50%
Calendar Year Out of Pocket Maximum (excluding deductible)
Per Member	$5,000	$6,000	$7,000	$10,000	Unlimited
Per Family	$15,000	$18,000	$21,000	$30,000	Unlimited

Maximums

	Plan A "Platinum"	Plan B "Gold"	Plan C "Silver"	Plan D "Bronze"	Plan E "Copper"
Lifetime	$2,000,000	$2,000,000	$2,000,000	$2,000,000	$2,000,000
Calendar Year	$1,000,000	$1,000,000	$1,000,000	$1,000,000	$1,000,000
Preventive Care (in-network only benefit)	$1,000)	$1,000	$1,000	$1,000	$1,000
Hospice	$7,500	$7,500	$7,500	$7,500	$7,500
Home Health Care	60 days	60 days	60 days	60 days	60 days
Skilled Nursing	$5,000	$5,000	$5,000	$5,000	$5,000
DME/Prosthetics	$10,000	$10,000	$10,000	$10,000	$10,000
Rehabilitation
In patient	$10,000	$10,000	$10,000	$10,000	$10,000
Out patient	$3,000	$3,000	$3,000	$3,000	$3,000

Additional Benefits

	Plan A "Platinum"	Plan B "Gold"	Plan C "Silver"	Plan D "Bronze"	Plan E "Copper"
Alcohol/Drug Dependency
In patient (maximum)	45 days	45 days	45 days	45 days	45 days
Out patient (maximum)	60 visits	60 visits	60 visits	60 visits	60 visits
Mental/Nervous
In patient (maximum)	45 days	45 days	45 days	45 days	45 days
Out patient (maximum)	60 visits	60 visits	60 visits	60 visits	60 visits
Serious Mental Illness	Covered as any other illness	Covered as any other illness	Covered as any other illness	Covered as any other illness	Covered as any other illness
In Vitro Fertilization	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered

RX Plans(HealthSmartRX)

	Plan B "Gold"	Plan C "Silver"	Plan D "Bronze"	Plan E "Copper"
Retail Co-pays (30 day supply)
Generic	$10	$15	$20	Deductible: $150 per member Maximum: $5,000 annual benefit per member
Preferred Brand Name (formulary)	$20	$25	$35
Non-Preferred Brand Name (non-formulary)	$50	$60	$75
Mail Order Co-pays (90 Day Supply)
Generic	$15	$20	$25	Coinsurance: 90%/10%
Preferred Brand Name (formulary)	$30	$35	$45	Coinsurance: 75%/25%
Non-Preferred Brand Name (non-formulary)	$75	$90	$110	Coinsurance: 50%/50%
Diabetic Supply Program
Testing meter and all program supplies	$0.00 100% paid by plan (no co-pay)	$0.00 100% paid by plan (no co-pay)	$0.00 100% paid by plan (no co-pay)	$0.00 100% paid by plan (no co-pay, no deductible)

Vision Plans

Included with Medical Plan, in-network benefits listed below; see benefit flyer for details and for out-of-network benefits.
Exams	$10 co-pay per exam	One exam every 12 months
Materials	$25 co-pay per set of materials	One set (lenses and frames or contacts) every 12 months
Frame Allowance	$50 wholesale allowance at private practice providers OR $130 allowance at retail chain providers
Contact Lens Allowance	If covered in full contace lenses NOT elected, $150 reimbursement allowance (including fitting fee) (Materials co-pay does NOT apply)

Dental Plan

The Plan

Allows you to use the dentist of your choice and to obtain the service you and your dentist agree upon.
Has no waiting periods before certain procedures are covered.
Have no excluded procedures except cosmetic procedures as required by IRC 213.
Has no requirement for pre-approval of the procedure.
Has no maximum fee schedule for each procedure. The dentist’s normal fees are allowable expenses.
Allows orthodontic care to be covered the same as any other procedure. (Commencement of orthodontic treatment begins the date the braces are placed on the teeth. Orthodontists typically require a down payment and collect the balance of their fees over the duration of the treatment. For claims ¼ (25%) of the entire treatment plan charge will be reimbursed under the benefit formula. The balance of the charges ¾ (75%) will be reimbursed monthly by the plan over the period of treatment. Benefit checks will be sent monthly until the treatment plan is finished or coverage terminates.

How The Plan Works

Every year beginning January 1st, you and your covered dependents each have $2,000 coverage for dental care. The plan reimburses you:

0% of the first $50 of eligible dental expenses, then
100% of the next $100 of eligible expenses, then
80% of the next $500 of eligible expenses, then
50% of the next $3,000 of eligible expenses

to a maximum benefit of $2,000 per year.

Monthly Cost	Total Cost
Employee Coverage:	$ 22.90
Employee + Spouse Coverage:	$ 46.40
Employee + Children Coverage:	$ 52.50
Employee + Spouse & Children Coverage:	$ 68.38

How Direct Reimbursement is Used and How Reimbursements are Made:

1. The patient selects a dentist and agrees to a treatment plan.
2. The dentist mails an ADA claim form to Total Administrative Services Corporation“TASC”for payment.
3. The benefit check is mailed to the employee or to the dentist, if there is an assignment of benefits, within 10 days (including mail time).

To Enroll

Complete the dental enrollment form and return it to TACT. Your coverage election is irrevocable and will continue for the plan year unless there is a significant family status change, such as a marriage, divorce, death, birth or change in the employment status of your spouse.

Filing for Reimbursement

ADA claim forms should be mailed to:
Total Administrative Services Corp. (TASC)
2302 International Lane
Madison, WI 53704-3140
Fax : 608-663-2754
For claims service call: 1-800-422-4661

IMPORTANT NOTE: This “Benefit Summary” is intended as a reference only and should not be relied upon to fully determine coverage. If this summary conflicts with the Plan Document (or Certificate of Coverage, for fully insured benefits), the Plan Document (or Certificate of Coverage) will prevail. Please refer to the full benefit materials for an exact description of the benefits that are provided and for other terms and conditions of coverage.