THE COOPER UNION FOR THE ADVANCEMENT OF SCIENCE AND ART
Group #2260
SCHEDULE OF BENEFITS
Effective July 2010
Medical Benefits:
Maximum Benefit Per Covered Person Per Lifetime While Covered By
This Plan For:
Medical $2,000,000
Hair Wig (in the event of cancer treatment) $350
Temporomandibular Joint (TMJ) and Myofascial Pain $1,000
Dysfunction (MPD) Treatment
Hospice Care
Family Counseling $500
Bereavement Counseling $200
Notwithstanding any provision of this Plan to the contrary, all benefits received by an individual under any benefit option,
package or coverage under the Plan shall be applied toward the maximum benefit paid by this Plan for any one covered
person during the entire time he is covered by this Plan for such option, package or coverage under the Plan, and also toward
the maximum benefit under any other options, packages or coverages under the Plan in which the individual may participate
in the future.
Maximum Benefit Per Covered Person Per Calendar Year For:
Flu Shot One
Rehabilitation Facility 180 Days
Routine Mammograms One Mammogram
Routine Gynecological Examination $300
Well Child Care – Birth to age 6 Unlimited
Routine Physical Examination - age 6 and over $300
Extended Care Facility (Skilled Nursing Facility) 60 Days
Other Benefits Per Covered Person For:
Routine Colorectal Screening Beginning at age fifty (50)
Pre-Existing Conditions: No more than $1,000 toward
Limitation Time Period and dollar Limits eligible expenses unless no
treatment for 3 months prior to
enrollment date or covered under
the Plan for 12 consecutive
months
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Preferred Nonpreferred
Provider Provider
Deductible Per Calendar Year:
Individual (Per Person) None $2001
Family (Aggregate) None $4001
If two or more covered members of a family are injured in the same accident and, as a result of that accident,
incur covered expenses, only one individual deductible amount will be deducted from the total covered expenses
of all covered family members related to the accident for the remainder of the calendar year.
Out-of-Pocket Expense Limit Per Calendar Year: (includes deductible)
Individual (Per Person) $500 $7501
Family (Aggregate) $1,500 $2,0001
Refer to Medical Expense Benefit, Out-of-Pocket Expense Limit for a listing of charges not applicable to the out-
of-pocket expense limit.
Amounts applied toward satisfaction of the preferred provider out-of-pocket expense limit may also be applied
toward satisfaction of the nonpreferred provider out-of-pocket expense limit and vice versa.
Coinsurance:
The Plan pays the percentage listed on the following pages for covered expenses incurred by a covered person
during a calendar year after the individual or family deductible has been satisfied and until the individual or
family out-of-pocket has been reached. Thereafter, the Plan pays one hundred percent (100%) of covered
expenses for the remainder of the calendar year or until the maximum benefit has been reached. Refer to
Medical Expense Benefit, Out-of-Pocket Limit, for a listing of charges not applicable to the one hundred percent
(100%) coinsurance.
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Retirees under VSIP 1988 and 1992 – Calendar year Deductibles $100/person, $300 family. Out-of-Pocket
maximum $600/person, $1,800 family
Preferred Nonpreferred
Provider Provider
(% of negotiated (% of customary
BENEFIT DESCRIPTION rate, if applicable, and reasonable
otherwise amount after the
% of customary deductible)
and reasonable
amount)
Inpatient Hospital
Pre-certification is required and failure to obtain will result in a penalty of
$250, the penalty is waived if hospital charge is less than $1,000 (refer to
Health Care Management)
(Penalty is waived for CUFCT covered persons who retired under the early
retirement program dated 1988 and 1992)
First $100,000 per confinement 100% 100%
Thereafter 80% 80%
Preadmission Testing 100% *100%
Outpatient Surgery/Ambulatory Surgical Facility 80% 80%
2
Preferred Nonpreferred
Provider Provider
(% of negotiated (% of customary
BENEFIT DESCRIPTION rate, if applicable, and reasonable
otherwise amount after the
% of customary deductible)
and reasonable
amount)
Emergency Room (Hospital/Physician/Diagnostic) 80% *80%
Non-Emergency Care 80% 80%
Out-of-Area Emergency Room Services 80% *80%
Urgent Care Facility 80% 80%
Accident Expense Benefit 100% *100%
Limitation: $300 maximum benefit per accident First $300; First $300;
80% 80% after
deductible
Ambulance Services 80% 80%
Physician Services
Inpatient Visit 80% 80%
Office Visit 100% 80%
(general practitioner, family practitioner, pediatrician, general internist, (after $12
gynecologist) (diagnostic services billed separately) copay per
visit)
Specialist Office Visit 100% 80%
(diagnostic services billed separately) (after $12
copay per
visit)
Surgery - Physician's Office** 80% 80%
Surgery – Inpatient/Outpatient (Hosptial/ASC)** 80% 80%
Injections and Allergy Injections 80% 80%
Allergy Testing/Serum 80% 80%
Pathology 80% 80%
Anesthesiology 80% 80%
Radiology 80% 80%
Infertility Diagnostic 80% 80%
Infertility/AI-IVF Not Covered Not Covered
Diagnostic Services and Supplies
Inpatient or Outpatient 80% 80%
* Deductible Waived
** Anesthesia is paid at the same level as surgery
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Preferred Nonpreferred
Provider Provider
(% of negotiated (% of customary
BENEFIT DESCRIPTION rate, if applicable, and reasonable
otherwise amount after the
% of customary deductible)
and reasonable
amount)
Second and Third Surgical Opinion 100% 80%
(after $12
copay per
visit)
Extended Care Facility 80% 80%
Home Health Care 80% 80%
Hospice Care 80% 80%
Durable Medical Equipment 80% 80%
Prostheses 80% 80%
Well Child Care 100% 80%
Limitation: Birth to age 6 (after $12
copay per
visit)
Immunization 100% 80%
Limitation: child-birth to age 6
Immunization 100% 80%
Limitation: adult-child-age 6 and older
Routine Preventive Care/Wellness Benefits 100% *80%
Limitation: $300 maximum benefit per person per calendar year (after $12
age 6 and older copay per
visit)
Routine Diagnostic Procedures (included in calendar maximum) 100%
100% 80%
Routine Mammograms 100% 80%
If sponsored by employer, covered at 100% (after $12
copay per
visit)
Routine Gynecological Examination 100% 80%
Limitation: $300 maximum benefit per calendar year (after $12
copay per
visit)
4
Preferred Nonpreferred
Provider Provider
(% of negotiated (% of customary
BENEFIT DESCRIPTION rate, if applicable, and reasonable
otherwise amount after the
% of customary deductible)
and reasonable
amount)
Routine Colorectal Screenings 100% 80%
Limitation: age 50 and over (after $12
(See Medical Expenses Benefit, Routine Colorectal Screenings for details) copay per
visit)
Flu Shots 100% *100%
Limitation: 1shot maximum benefit per calendar year
for all covered persons
Mental & Nervous Disorders and Chemical Dependency Care
Inpatient Services (including Rehab and Detox)
First $100,000 per confinement 100% 100%
Thereafter 80% 80%
Outpatient Services (including Rehab and Detox) 100% 80%
(after $12
copay per
visit)
Therapy Services (Cardiac Rehab, Chemotherapy/Radiation, Dialysis, 80% 80%
Physical, Occupational, Respiratory)
Speech Therapy 80% 80%
Limitation: For restorative purposes only
Birthing Center 80% 80%
Private Duty Nursing 80% 80%
Acupuncture 80% 80%
Limitation: Administered by a licensed provider
Chiropractic Care 80% 80%
Contraceptive Management 80% 80%
Limitation: Prescribed devices and injectables
Hair Wig (in the event of cancer treatment) *100% *100%
All Other Covered Expenses 80% 80%
Prescription Drugs
Pharmacy Option (% of customary and reasonable amount)
Generic 80% After Deductible
Brand Name 80% After Deductible
Limitation: 30 day supply
* Deductible Waived
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Prescription Drug Program:
Mail Order Option Includes Oral Contraceptives
Mail Order Option
Mail Order Prescription 100% after copay
Copay Generic: $10 copay Per Prescription
Brand Name: $10 copay Per Prescription
Limitation: 90 day supply
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Dental Benefits:
All benefits are available for full-time employees and proportional faculty employees only.
Deductible Per Calendar Year:
Individual (Per Person) $50
Family $150
The deductible is waived for diagnostic & preventive dental services.
Orthodontic Benefit:
Orthodontic services per individual lifetime while covered by this $1,500
Plan not subject to retroactive and $500 maximum benefit
Maximum Benefit Per Covered Person Per Calendar Year For:
Class I - Diagnostic & Preventive Dental Services 100% with no deductible
Class II - Basic Dental Services - Restorative 80% after deductible
Class III - Major Dental Services 60% after deductible
Class IV - Orthodontic services 50% after deductible
Preliminary Benefits for Class I, II, II combined** $500
services per calendar year (other than Orthodontics) Per Person
** Plus Retroactive amount, if applicable
** The Dental Plan is a Retroactive plan, which means you may receive an additional benefit at the end
of the calendar year. See “How the Dental and Vision Plans Work” for more information.
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Vision Benefits:
All benefits are available for full-time, retired and proportional faculty employees.
Maximum Benefit Per Covered Person Every Two Calendar Years For: $250**
Eye Examination
Conventional Lenses - Single Vision - Bi-focal - Tri-focal – Lenticular and/or
Contact lenses – Medically Necessary – All Other Corrective Contact Lenses
only for corrective vision
Frames (maximum to $250)
** The Vision Plan is a Retroactive plan, which means you may receive an additional benefit (except for
frames) at the end of every two (2) calendar years. See “How the Dental and Vision Plans Work” for
more information.
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