Detectives’ Endowment Association Health & Welfare Fund Coverage Period ...

Detectives¡¯ Endowment Association Health & Welfare Fund

Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Coverage Period: [1/01/2018-12/31/2018]

Coverage for: Family | Plan Type: Drugs Only

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the plan document

at or by calling 1-212-587-9120

Important Questions

Answers

Why this Matters:

What is the overall

deductible?

$0

See the chart starting on page 2 for your costs for services this plan covers.

Are there other

deductibles for specific

services?

No

You don¡¯t have to meet deductibles for specific services, but see the chart starting on page

2 for other costs for services this plan covers.

Is there an out¨Cof¨C

pocket limit on my

expenses?

Yes

PPACA defines the 2018 out-of-pocket limit to $7,350 (Individual) and $14,700 (Family).

What is not included in

the out¨Cof¨Cpocket

limit?

Fees for non-covered services

and ancillary cost fees.

Even though you pay these expenses, they don¡¯t count toward any out-of-pocket limit.

Is there an overall

annual limit on what

the plan pays?

Yes

The overall annual limit for the prescription drug benefits is $10,000 per calendar year per

each family unit.

Does this plan use a

network of providers?

Yes. For a list of preferred

providers, see

or call

1-888-DEA-NYPD.

If you use an in-network pharmacy, this plan will pay some or all of the costs of covered

prescriptions. Plans use the term in-network, preferred, or participating for providers in

their network. See the chart starting on page 2 for how this plan pays different kinds of

providers.

Do I need a referral to

see a specialist?

No

While you can see the specialist you choose without permission from this plan, this plan

reimburses for covered prescription drugs only.

Are there services this

plan doesn¡¯t cover?

Yes

Some of the prescriptions this plan doesn¡¯t cover are listed on page 6. See the

comprehensive benefits booklet for additional information about excluded services.

Questions: Call 1-888-DEA-NYPD or visit us at or .

If you aren¡¯t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary

at ebsa/healthreform or iio. or call 1-212-587-9120 to request a copy.

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Detectives¡¯ Endowment Association Health & Welfare Fund

Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Coverage Period: [1/01/2018-12/31/2018]

Coverage for: Family | Plan Type: Drugs Only

? Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.

? Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if

the plan¡¯s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if

you haven¡¯t met your deductible.

? The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the

allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and

the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)

? This plan may encourage you to use participating providers by charging you lower deductibles, copayments and coinsurance amounts.

Common

Medical Event

If you visit a health

care provider¡¯s office

or clinic

If you have a test

Your Cost If You

Use an

In-network

Provider

Your Cost If You Use an

Out-of-network Provider

Primary care visit to

treat an injury or

illness

Not covered

Not covered

Specialist visit

Not covered

Not covered

Not covered

Not covered

Not covered

Not covered

Not covered

Not covered

Not covered

Not covered

Services You

May Need

Other practitioner

office visit

Preventive

care/screening/imm

unization

Diagnostic test (xray, blood work)

Imaging (CT/PET

scans, MRIs)

Questions: Call 1-888-DEA-NYPD or visit us at or .

If you aren¡¯t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary

at ebsa/healthreform or iio. or call 1-212-587-9120 to request a copy.

Limitations & Exceptions

This plan is limited to prescription

drug coverage only.

This plan is limited to prescription

drug coverage only.

This plan is limited to prescription

drug coverage only.

This plan is limited to prescription

drug coverage only.

This plan is limited to prescription

drug coverage only.

This plan is limited to prescription

drug coverage only.

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Detectives¡¯ Endowment Association Health & Welfare Fund

Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Common

Medical Event

Services You

May Need

Generic drugs

If you need drugs to

treat your illness or

condition

More information

about prescription

drug coverage is

available at



.

Preferred (formulary)

brand drugs

Non-preferred brand

drugs

Your Cost If You

Use an

In-network

Provider

$0

For drug spend up to

$10,000 per calendar

year per family unit:

25% of the cost of the

medication PLUS the

difference between the

brand and the generic,

when one is available.

For drug spend up to

$10,000 per calendar

year per family unit:

50% of the cost of the

medication PLUS the

cost difference

between the brand

and the generic, when

one is available.

Coverage Period: [1/01/2018-12/31/2018]

Coverage for: Family | Plan Type: Drugs Only

Your Cost If You Use an

Out-of-network Provider

The applicable copayment plus the

difference in the cost of the drug

charged by the pharmacy and the

plan¡¯s contracted rate with network

pharmacies (calculated fee schedule).

The applicable copayment plus the

difference in the cost of the drug

charged by the pharmacy and the

plan¡¯s contracted rate with network

pharmacies (calculated fee schedule).

The applicable copayment plus the

difference in the cost of the drug

charged by the pharmacy and the

plan¡¯s contracted rate with network

pharmacies (calculated fee schedule).

Questions: Call 1-888-DEA-NYPD or visit us at or .

If you aren¡¯t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary

at ebsa/healthreform or iio. or call 1-212-587-9120 to request a copy.

Limitations & Exceptions

Some of the prescriptions this plan

doesn¡¯t cover are listed on page 6. See

the comprehensive benefits booklet

for additional information about

excluded services.

Some of the prescriptions this plan

doesn¡¯t cover are listed on page 6. See

the comprehensive benefits booklet

for additional information about

excluded services.

Some of the prescriptions this plan

doesn¡¯t cover are listed on page 6. See

the comprehensive benefits booklet

for additional information about

excluded services.

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Detectives¡¯ Endowment Association Health & Welfare Fund

Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Common

Medical Event

Services You

May Need

Psychotropic and

Asthma drugs

Specialty drugs

All drugs

If you have

outpatient surgery

If you need

immediate medical

attention

If you have a

hospital stay

Facility fee (e.g.,

ambulatory surgery

center)

Physician/surgeon

fees

Emergency room

services

Emergency medical

transportation

Your Cost If You

Use an

In-network

Provider

Generic - $0

For drug spend up to

$10,000 per calendar

year per family unit:

45% of the cost of all

brand name

medications PLUS the

difference between the

brand and the generic,

when one is available.

Not covered

For drug spend over

$10,000 per calendar

year per family unit:

50% for all

medications.

Coverage Period: [1/01/2018-12/31/2018]

Coverage for: Family | Plan Type: Drugs Only

Your Cost If You Use an

Out-of-network Provider

The applicable copayment plus the

difference in the cost of the drug

charged by the pharmacy and the

plan¡¯s contracted rate with network

pharmacies (calculated fee schedule).

Not covered

The applicable copayment plus the

difference in the cost of the drug

charged by the pharmacy and the

plan¡¯s contracted rate with network

pharmacies (calculated fee schedule).

Limitations & Exceptions

Some of the prescriptions this plan

doesn¡¯t cover are listed on page 6. See

the comprehensive benefits booklet

for additional information about

excluded services.

Not covered

Some of the prescriptions this plan

doesn¡¯t cover are listed on page 6. See

the comprehensive benefits booklet

for additional information about

excluded services.

Plan covers prescription drugs only.

Not covered

Not covered

Not covered

Not covered

Not covered

Not covered

Not covered

Not covered

Urgent care

Not covered

Not covered

Plan covers prescription drugs only.

Facility fee (e.g.,

hospital room)

Not covered

Not covered

Plan covers prescription drugs only.

Questions: Call 1-888-DEA-NYPD or visit us at or .

If you aren¡¯t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary

at ebsa/healthreform or iio. or call 1-212-587-9120 to request a copy.

Plan covers prescription drugs only.

Plan covers prescription drugs only.

Plan covers prescription drugs only.

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Detectives¡¯ Endowment Association Health & Welfare Fund

Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Common

Medical Event

If you have mental

health, behavioral

health, or substance

abuse needs

If you are pregnant

Services You

May Need

Physician/surgeon

fee

Mental/Behavioral

health outpatient

services

Mental/Behavioral

health inpatient

services

Substance use

disorder outpatient

services

Substance use

disorder inpatient

services

Prenatal and

postnatal care

Delivery and all

inpatient services

Coverage Period: [1/01/2018-12/31/2018]

Coverage for: Family | Plan Type: Drugs Only

Your Cost If You

Use an

In-network

Provider

Your Cost If You Use an

Out-of-network Provider

Not covered

Not covered

Not covered

Not covered

Not covered

Not covered

Plan covers prescription drugs only.

Not covered

Not covered

Plan covers prescription drugs only.

Not covered

Not covered

Not covered

Not covered

Not covered

Not covered

Questions: Call 1-888-DEA-NYPD or visit us at or .

If you aren¡¯t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary

at ebsa/healthreform or iio. or call 1-212-587-9120 to request a copy.

Limitations & Exceptions

Plan covers prescription drugs only.

Plan covers prescription drugs only.

Plan covers prescription drugs only.

Plan covers prescription drugs only.

Plan covers prescription drugs only.

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