Summary Plan Description

TeamCare Plans U1/U3

Active Plan Benefit Booklet | Your Plan Benefits | Plan Year 2019
BOOKLET 1 OF 2

ABOUT THIS BENEFITS BOOKLET

Please read these Benefits Booklets in conjunction with one another as together they form the Summary
Plan Description for your benefit plan. “Benefits Booklet (1 of 2)” contains your Plan Benefit Profile, a
summary of any provisions unique to your Plan, and your Plan’s government-mandated Summary of
Benefits and Coverage form. “Benefits Booklet (2 of 2)” contains general benefits information and
provisions applicable to all plans.

TABLE OF CONTENTS
Plan Benefit Profile ......................................... 3
Additional Plan Provisions .............................. 7
Summary of Benefits and Coverage .............. 11

CCM GF 11/01/2018 Page | 1

 FROM THE BOARD OF TRUSTEES

Welcome. We are very pleased to have you as a Member in what we truly believe is an excellent
and comprehensive plan of benefits.

This is your Health Plan – a plan that we, as your Trustees, have been given the responsibility to
administer exclusively in your interests and the interests of nearly 500,000 other Members and their
dependents whom are entitled to share in its benefits. When the Health Fund was started in 1950, the
Trustees in place at that time had only one purpose in mind: To provide our Members, and their families,
with the highest level of benefits possible. Concern for the security and well-being of you and your family
has always been the cornerstone of our benefits philosophy. We pledge our efforts to continue providing
nothing less than the very best benefits your Plan can reasonably afford.

We are pleased to provide you with this Summary Plan Description (SPD) describing the comprehensive
benefit program available to you and your family members who qualify for coverage under your TeamCare
Health Plan. This SPD provides information about your eligibility for benefits, the covered services under
TeamCare, how to file a claim and your rights under the Health Plan. Please review this information
carefully and keep your SPD available for future reference. Whenever the benefits outlined in the SPD
materially change, information will be sent to you. You should keep these updates with your SPD so that
you will always have current information about your Health Plan. At any time you may also view the
current Health Plan SPD and all updated information at MyTeamCare.org.

Every effort has been made to ensure that this SPD is easy to understand and provides an accurate and
comprehensive information source regarding your Health Plan. All information in this SPD, however, is
subject to the terms of the actual Health Plan Document. The Health Plan Document will, at all times,
serve as the final written authority on all matters regarding this Plan. Only the Board of Trustees is
authorized to interpret the Health Plan and this SPD. No employer or union, or any representative of any
employer or union, is authorized to interpret this Plan.

We hope that learning about the benefits your Plan offers will bring you and your family comfort and peace
of mind. In addition, the “Plan Benefit Profile” section will provide you information about your specific
Plan. Please visit our website at MyTeamCare.org to download additional copies of your Plan Benefit
Profile.

If you have questions as you read through this SPD, please visit the Message Center found at
MyTeamCare.org or call our CustomerCare Center at 800-TEAMCARE (832-6227). Our CustomerCare
Center is open Monday through Friday, and our Benefits Specialist will make every effort to assist you.

Employee Trustees Employer Trustees

Charles A. Whobrey Arthur H. Bunte, Jr.
George J. Westley Gary F. Caldwell
Marvin Kropp Greg R. May
Gary Dunham Christopher J. Langan

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TeamCare Plans U1/U3
Plan Benefit Profile

Page | 3
      
UPS PACKAGE 
 

Plan U1 (Full‐Time) and Plan U3 (Part‐Time) Benefit Profile 
  Coverage Period:  Beginning on or after 01/01/2019 
 
   
PLAN BENEFIT LIMIT (ANNUAL)  PLAN DEDUCTIBLE (ANNUAL)  MEDICAL OUT‐OF‐POCKET EXPENSE LIMIT (ANNUAL)   
None    $100 per Individual    $1,000 per Individual   
$200 per Family   $2,000 per Family 
 
 
TEAMCARE PPO OFFICE VISIT  OUT‐OF‐NETWORK PENALTY   
$10 copayment for in‐network office visit    For non‐emergency medical care, your cost is 10% greater than an in‐network provider plus all charges above   
(Plan Deductible does not apply)  Reasonable and Customary and the loss of TeamCare Family Protection Benefit. 
 
MEDICAL PLAN BENEFITS  For further information, including a full Summary Plan Description (SPD), visit our website at MyTeamCare.org.   

TeamCare Wellness     Wellness benefits are payable at 100% of covered charges.  PPO office visit copayment does not apply.   
A TeamCare Physician must be used. 

CVS Minute Clinic    Minute Clinic locations can treat you and your covered family members for minor injuries, common illnesses   
(sore throat, colds, earaches, strep throat), and routine immunizations for a $0 copay. 

Hospital Expense Benefit    After Plan Deductible, 100% of covered charges.   

Surgical and Obstetrical Benefit    After Plan Deductible, 100% of covered charges.   

Ambulance Service Benefit    After Plan Deductible, 100% of covered charges subject to medical necessity review.   

Outpatient Accidental Bodily Injury Benefit      After Plan Deductible, 100% on the first day of treatment for accidental injury; 80% for all other services.   

TeamCare Lab Benefit    The TeamCare Lab Benefit is a voluntary program that covers lab testing at 100% (Plan Deductible does not   
  apply) provided the Physician submits the requisition through Quest Lab Card.  If a Physician does not submit 
  For more information call   specimens through Quest Lab Card, simply visit a Quest Diagnostics collection site.   
  800‐646‐7788 or visit  
  labcard.com  If you do not use the TeamCare Lab Benefit, after Plan Deductible the outpatient lab benefit is 80%; then 100% 
after Medical Out‐of‐Pocket Expense Limit is met. 

TeamCare Imaging Benefit    The  TeamCare  Imaging  Benefit  is  a  voluntary  program  that  covers  MRI,  CT,  and  PET  scans  at  100%  (Plan   
  Deductible does not apply) provided that the scans are scheduled directly through USIN.   
  To schedule a service call 
  877‐674‐0674   If you do not use the TeamCare Imaging Benefit, after Plan Deductible the outpatient imaging benefit (including 
x‐rays) is paid under Major Medical at 80%; then 100% after Medical Out‐of‐Pocket Expense Limit is met.   

Outpatient Cancer Treatment Benefit    After  Plan  Deductible,  100%  of  covered  charges  for  outpatient  nuclear  therapy,  radiation  therapy,   
chemotherapy, x‐ray and lab procedures for the treatment of cancer. If treatment is provided in a doctor’s 
office, a $10 TeamCare office visit copayment is due. 

Hearing Aid Benefit      After  Plan  Deductible,  100%  of  covered  charges  to  a  maximum  of  $1,000  per  ear  ($2,000  total)  every  36   
months. The Medical Out‐of‐Pocket Expense Limit does not apply. 

Chiropractic Benefit    After  Plan  Deductible,  80%  of  covered  charges  to  a  maximum  $1,000  per  person  per  calendar  year.    The   
Medical Out‐of‐Pocket Expense Limit does not apply. 

Behavioral Health Benefits  –  Inpatient    Facility:  After Plan Deductible, 100% of covered charges.   

 
Physician:  After Plan Deductible, 80% of covered charges; then 100% after Medical Out‐of‐Pocket Expense 
Limit is met. 

Behavioral Health Benefits  –  Outpatient    $10 copayment for in‐network office visit (Plan Deductible does not apply).  Otherwise, after Plan Deductible,   
80% of covered charges; then 100% after Medical Out‐of‐Pocket Expense Limit is met. 

Major Medical Benefit    After Plan Deductible, 80% of covered charges; then 100% after Medical Out‐of‐Pocket Expense Limit is met.   
     CCM GF – 10/15/2018   BASE PLAN U1 ‐ SPD ACT    
 
 
This group health plan believes this plan is a “grandfathered health plan” under the Patient Protection and Affordable Care Act (the Affordable Care Act, or PPACA). As permitted by the Affordable Care Act, a 
grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your plan may not include certain 
consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health 
plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits.  Questions regarding which protections apply and which 
protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the plan administrator at Research and Correspondence 
Department, TeamCare – A Central States Health Plan, 9377 West Higgins Road, Rosemont IL 60018‐4938 or call 800‐TEAMCARE. You may also contact the Employee Benefits Security Administration, U.S. 
Department of Labor at 866‐444‐3272 or www.dol.gov/ebsa/healthreform. This website has a table summarizing which protections do and do not apply to grandfathered health plans. 
   
      
UPS PACKAGE 
 

Plan U1 (Full‐Time) and Plan U3 (Part‐Time) Benefit Profile 
  Coverage Period:  Beginning on or after 01/01/2019 
 

TEAMCARE Rx PRESCRIPTION   RETAIL PHARMACY STORE:  MAINTENANCE CHOICE / MAIL SERVICE PHARMACY:    

DRUG BENEFIT   $5  copayment  for  short‐term  prescription  fills  $0  copayment  for  a  90‐day  supply  of  medication.  Under 
and non‐maintenance medications.  Maintenance  Choice,  Member  can  receive  a  90‐day  supply  of 
  medication at a local CVS pharmacy store. 
  For more information call  
  888‐483‐2650 or visit   After the second fill of the same prescription, long‐term maintenance medications must be filled through Maintenance   
  caremark.com  Choice or CVS/Caremark Mail Service Pharmacy or be subject to a 50% co‐payment if filled through the Retail Pharmacy 
  Program.  On both Retail and Mail Order, if a generic equivalent is available, the Member must take the generic or be 
    responsible for the cost difference plus any copayment.  The Medical Out‐of‐Pocket Expense Limit does not apply. 
  TeamCare does not cover drugs or medicines on a formulary exclusion list compiled by CVS/Caremark.  The formulary 
exclusion list is available at MyTeamCare.org or by contacting CVS/Caremark. 

   

DENTAL BENEFITS    Annual Dental Maximum  None  TeamCare offers a voluntary network through 

   

You may use any dental provider for services    Annual Dental Deductible  None  Humana Dental that provides negotiated   

without  an  out‐of‐network  penalty.     Preventive Services  100%  discounts and protection from balance billing.   

However, TeamCare does offer a voluntary    Diagnostic and Restorative  100%   

  Crown and Bridge Work  80%  To find a provider, call 800‐592‐3112 or    

dental network through TeamCareDental.  visit: h
humanadentalnetwork.com.   

    Dentures (Full and Partial)  100% 
 
 
  Orthodontic (Child/Adult Child)  50% 
 
  Orthodontic Maximum 
                          (Child/Adult Child)  No Lifetime Maximum 
 
 
 

VISION BENEFITS  TeamCareVision is a voluntary vision network offered through EyeMed Vision Care: 
 
  Routine Eye Exam  $10 copayment   
You can use any vision provider for services.   Frames  $0 copayment up to $150 allowance 
However, TeamCare does offer a voluntary  Lenses (per pair)  $0 copayment 
vision network through the TeamCareVision  Contacts (in lieu of glasses)  $0 copayment up to $120 allowance 
program.  For a directory of EyeMed providers in the Select network, call 866‐723‐0514 or visit eyemedvisioncare.com. 
   

Vision Plan Benefits do not have an out‐of‐ For non‐EyeMed providers, the maximum reimbursement for Vision Plan Benefits is: 
network  penalty  but  there  is  a  maximum    Routine Eye Exam  $50.00 *  *   Routine  Eye  Exam  charges  from  non‐
 

reimbursement per service as indicated.      Frames  $75.00  EyeMed providers for Covered Dependents 

 

    Lenses (per pair)  $50.00  under age 19 will be subject to Reasonable   

The  Vision  Plan  Benefits  are  payable  once    Bi‐Focal Lenses (per pair)  $50.00  and  Customary  allowances  and  paid  at   

every 12 months.    Tri‐Focal Lenses (per pair)  $50.00  80%.   

 
  Lenticular Lenses (per pair)  $60.00 
 
  Contacts (in lieu of glasses)  $80.00 
 

SHORT‐TERM DISABILITY BENEFITS  Benefit provides 60% of average weekly base pay up to $500 per week for a maximum of 26 weeks; and includes 
 (Member Only)  continued coverage while on Short‐Term Disability.   
  
 
 
 
 

LIFE INSURANCE BENEFITS    Member Death  Full‐time Plan U1:  2080 hours x hourly wage to max of $100,000 (minimum of $40,000) 

Part‐time Plan U3:  1040 hours x hourly wage to max of $100,000 (minimum of $40,000) 
 
    Accidental Death  Full‐time Plan U1:  2080 hours x hourly wage to max of $100,000 (minimum of $40,000) 
Part‐time Plan U3:  1040 hours x hourly wage to max of $100,000 (minimum of $40,000) 
 
  Spouse Death *    $5,000  *  Dependent Life Insurance Benefits are only 
payable on Covered Dependents.   
 
  Child/Adult Child Death *    $2,500 
 
  Total Permanent Disability   $16,000   
(Waiver of Premium) 
 
 

TEAMCARE FAMILY   In the event of a Member's death, the TeamCare Family Protection Benefit provides a maximum of five years of 
PROTECTION BENEFIT  free TeamCare PPO coverage for the Covered Spouse and Dependents provided that during the two‐year period 
  
  prior  to  death,  TeamCare  providers  were  used  exclusively  for  all  non‐emergency  care.  Please  refer  to  the   

 
  TeamCare Summary Plan Description for further information. 
  
 

MyTeamCare.org or 800‐TEAMCARE  For further benefit information, visit our website at MyTeamCare.org or call CustomerCare at 800‐TEAMCARE 
  (832‐6227).   

 
 
If there is a discrepancy between the Plan Benefit Profile and Plan Document, the Plan Document will be the controlling document in determining the benefit. 
 
This group health plan believes this plan is a “grandfathered health plan” under the Patient Protection and Affordable Care Act (the Affordable Care Act, or PPACA). As permitted by the Affordable Care Act, a 
grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your plan may not include certain 
consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health 
plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits.  Questions regarding which protections apply and which 
protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the plan administrator at Research and Correspondence 
Department, TeamCare – A Central States Health Plan, 9377 West Higgins Road, Rosemont IL 60018‐4938 or call 800‐TEAMCARE. You may also contact the Employee Benefits Security Administration, U.S. 
Department of Labor at 866‐444‐3272 or www.dol.gov/ebsa/healthreform. This website has a table summarizing which protections do and do not apply to grandfathered health plans. 
Page | 6
 TeamCare Plans U1/U3
Additional Plan Provisions

Page | 7
Page | 8
 ADDITIONAL PLAN PROVISIONS
GRANDFATHERED HEALTH PLAN

OUT-OF-POCKET EXPENSE LIMIT

The Out-of-Pocket Expense Limit is your portion of eligible covered medical expenses that you must pay after the Plan
has paid its required percentage. Once your eligible out-of-pocket expenses reach the maximum (see Plan Benefit
Profile), the Plan pays 100% of most covered charges for the rest of the calendar year.

The Out-of-Pocket Limit includes the balance of any Major Medical expenses that you must pay, including co-
insurance amounts and balances from the outpatient diagnostic x-ray and laboratory charges. However, it excludes
any non-covered expenses such as fees over the Reasonable and Customary limitation. The Out-of-Pocket Limit
applies only to covered medical expenses payable under the Major Medical Benefit and does not apply to the
Prescription Drug Benefit; the Hearing Aid Benefit; and Chiropractic, Dental or Vision Benefits.

PATIENT PROTECTION AND AFFORDABLE CARE ACT (PPACA)

This group health plan believes this plan is a “grandfathered health plan” under the Patient Protection and Affordable
Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve
certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan
means that your plan may not include certain consumer protections of the Affordable Care Act that apply to other
plans, for example, the requirement for the provision of preventive health services without any cost sharing. However,
grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for
example, the elimination of lifetime limits on benefits.

Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and
what might cause a plan to change from grandfathered health plan status can be directed to the plan administrator at
Research and Correspondence Department, TeamCare – A Central States Health Plan, 9377 West Higgins Road,
Rosemont IL 60018-4938 or call TeamCare at 800-TEAMCARE (832-6227). You may also contact the Employee
Benefits Security Administration, U.S. Department of Labor at 866-444-3272 or www.dol.gov/ebsa/healthreform. This
website has a table summarizing which protections do and do not apply to grandfathered health plans.

WOMEN’S HEALTH & CANCER RIGHTS

If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health
and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be
provided in a manner determined in consultation with the attending physician and the patient, for:

All stages of reconstruction of the breast on which the mastectomy was performed;
Surgery and reconstruction of the other breast to produce a symmetrical appearance;
Prostheses; and
Treatment of physical complications of the mastectomy, including lymphedema.

These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and
surgical benefits provided under this Plan. Therefore, the following deductibles and coinsurance apply:

Plan Deductible: $100 per Individual, $200 per Family

Medical Out-of-Pocket Expense Limit: $1,000 per Individual, $2,000 per Family
Coinsurance: 0% after Deductible.

If you would like more information on WHCRA benefits, call your Plan administrator at 800-TEAMCARE (832-6227) or
visit MyTeamCare.org.

Page | 9
Page | 10
 TeamCare Plans U1/U3
Summary of Benefits and Coverage

Page | 11
 Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services
Central States Health & Welfare Fund – UPS Package Plan U1 and Plan U3
Coverage Period: Beginning on or after 01/01/2019
Coverage for: You and Your Elected Dependents | Plan Type: PPO

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share
the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is
only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to MyTeamCare.org or call 800-TEAMCARE
(832-6227). For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms
see the Glossary. You can view the Glossary at healthcare.gov/sbc-glossary or call 800-TEAMCARE to request a copy.

Important Questions Answers Why this Matters:

You must pay all the costs up to the deductible amount before this plan begins to
$100 Per Individual, $200 Per Family. Does not apply to
What is the overall pay for most covered services you use. The annual deductible is based on a
in-network office visits and in-network prescription
deductible? calendar year from 1/1 through 12/31. See the chart starting on page 2 for how
benefits.
much you pay for covered services after you meet the deductible.
This plan covers some items and services even if you haven’t yet met the
Yes. Preventive care; lab services through Quest
Are there services deductible amount, but a copayment or coinsurance may apply. For example,
LabCard; advanced imaging services through USIN; and
covered before you meet this plan covers certain preventive services without cost-sharing and before you
services requiring a copayment are covered before you
your deductible? meet your deductible. See a list of covered preventive services at
meet your deductible.
healthcare.gov/coverage/preventive-care-benefits.
Are there other
deductibles for specific No.
services?
The out-of-pocket limit is the most you could pay during the calendar year for
What is the out-of-pocket
$1,000 Per Individual, $2,000 Per Family your share of the cost of covered services. This limit helps you plan for health
limit for this plan?
care expenses.
Deductibles; in-network copayments; out-of-network
penalty; chiropractic coinsurance; hearing aids;
What is not included in Even though you pay these expenses, they don’t count toward the out-of-pocket
prescription drugs; dental & vision benefits; premiums;
the out-of-pocket limit? limit.
health care services this plan doesn't cover; and
expenses not payable by the plan.
If you use an in-network doctor or other health care provider, this plan will pay
Will you pay less if you Yes. For a list of preferred providers in the TeamCare
some or all of the costs of covered services. For a list of preferred providers in
use a network provider? network visit MyTeamCare.org or call 800-TEAMCARE.
the TeamCare network, visit MyTeamCare.org or call 800-TEAMCARE.
Do you need a referral to
No. You can see the specialist you choose without permission from this plan.
see a specialist?
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146 Released on April 6, 2016

CCM GF 10/15/2018 For more information about limitations and exceptions, see the plan document at MyTeamCare.org. U3 1 of 8
 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

What You Will Pay

Common
Services You May Need
Medical Event
Primary care visit to treat
an injury or illness
If you visit a health
care provider’s office Specialist visit
or clinic
Preventive care/screening/
immunization
Network Provider
(You will pay the least)
$10 copayment per visit
$10 copayment per visit
$0
Out-of-Network Provider
(You will pay the most)
After Deductible, 30% plus any
charges determined to be
above Reasonable and
Customary.
Not Covered
Limitations, Exceptions & Other
Important Information
Additional costs may be owed for
medical services payable beyond the
office visit (e.g. x-rays, injections, lab
tests, etc.).
At recommended frequencies.

20% after Deductible, then 0% after

Diagnostic test (x-ray, blood
work)
If you have a test
Imaging (CT/PET scans,
MRIs)
Medical Out-of-Pocket Expense Limit is
met; or 0% for lab work if through
Quest LabCard benefit. For a Quest
10% greater than your cost for
LabCard provider, call LabCard Client
an in-network provider. You
Services at 800-646-7788 or visit
are also responsible for ---------------- None ----------------
labcard.com.
charges above Reasonable
and Customary.
20% after Deductible, then 0% after
Medical Out-of-Pocket Expense Limit is
met; or 0% if through USIN. To find a
USIN provider, call 877-674-0674.

CCM GF 10/15/2018 For more information about limitations and exceptions, see the plan document at MyTeamCare.org. U3 2 of 8
 What You Will Pay
Common Limitations, Exceptions & Other
Services You May Need Network Provider Out-of-Network Provider
Medical Event Important Information
(You will pay the least) (You will pay the most)
By the third fill, maintenance
medications must be filled through
Generic drugs the Caremark Mail Order Program /
If you need drugs to Maintenance Choice or be subject to
treat your illness or $5 Retail a 50% copay if filled through the
condition $0 Mail Order Retail Card program.
25% of Reasonable and There are some non-preferred brand
More information about
Customary charges and drugs that are excluded from
prescription drug Preferred brand drugs However, if you purchase a brand name
Mail Order is not available. coverage as determined by
coverage is available at prescription when a generic is available,
The per prescription maximum Caremark. For a list of these
MyTeamCare.org you are responsible for the cost
does not apply. excluded drugs, visit our website at
difference plus any copayment and the
MyTeamCare.org. If you continue
or per prescription maximum does not
using one of these drugs after this
apply.
date, you will be required to pay the
caremark.com
Non-preferred brand drugs full cost.
Walmart is not a participating
pharmacy.
If you use injectable medications, the
25% of Reasonable and plan provides a $1,000 per member
$5 Retail
Customary charges and per calendar year out-of-pocket
$0 Mail Order
Specialty drugs Mail Order is not available. maximum. Once the $1,000 out-of-
The per prescription maximum pocket maximum is met, all in-
does not apply. network injectable medications will
be paid by the Plan at 100%.
Facility fee (e.g., 10% greater than your cost for
0% after Deductible.
ambulatory surgery center) an in-network provider. You Additional costs may be owed for
If you have outpatient
are also responsible for medical services payable beyond the
surgery
Physician/surgeon fees 0% after Deductible. charges above Reasonable surgery (e.g. x-rays, lab tests).
and Customary.

CCM GF 10/15/2018 For more information about limitations and exceptions, see the plan document at MyTeamCare.org. U3 3 of 8

Common
Services You May Need
Medical Event
Emergency room care
If you need immediate Emergency medical
medical attention transportation
Urgent care
Facility fee (e.g., hospital
room)
If you have a hospital
stay
Physician/surgeon fee
Outpatient Services
If you need mental
health, behavioral
health, or substance
abuse services
Inpatient Services
Office Visits
Childbirth/delivery
If you are pregnant professional services
Childbirth/delivery
facility services
CCM GF 10/15/2018 For more information about limitations and exceptions, see the plan document at MyTeamCare.org.
What You Will Pay
Network Provider
(You will pay the least)
20% after Deductible, 0% after Medical
Out-of-Pocket Expense Limit is met.
0% after Deductible.
20% after Deductible, 0% after Medical
Out-of-Pocket Expense Limit is met.
0% after Deductible.
Physician fee is 20% after Deductible,
0% after the Major Medical Out-of-
Pocket Expense Limit is met. Surgeon
fee is 0% after Deductible.
$10 copayment for physician visit (Plan
Deductible does not apply). Otherwise,
20% after Deductible, 0% after Medical
Out-of-Pocket Expense Limit is met.
Facility fee is 0% after Deductible.
Physician fee is 20% after Deductible,
0% after Medical Out-of-Pocket
Expense Limit is met.
$10 copayment for initial visit
0% after Deductible
Limitations, Exceptions & Other
Out-of-Network Provider
Important Information
(You will pay the most)
Emergency care is paid the
same as if in-network. If admitted, the Emergency room
However, you are responsible services will be payable under the
for charges above Reasonable Hospital benefit. Additional costs
and Customary. may be owed for services payable
beyond the urgent care visit (e.g. x-
rays, lab).
10% greater than your cost for
an in-network provider. You
are also responsible for
charges above Reasonable ---------------- None ----------------
and Customary.
10% greater than your cost for ---------------- None ----------------
an in-network provider. You
are also responsible for
charges above Reasonable
and Customary. ---------------- None ----------------
10% greater than your cost for
an in-network provider. You Additional costs may be owed for
are also responsible for medical services payable beyond the
charges above Reasonable surgery (e.g. x-rays, lab tests).
and Customary.
U3 4 of 8
 What You Will Pay
Common Limitations, Exceptions & Other
Services You May Need Network Provider Out-of-Network Provider
Medical Event Important Information
(You will pay the least) (You will pay the most)
Home health care
Rehabilitation services 10% greater than your cost for Charges for services that are not
If you need help
Habilitation services an in-network provider. You considered Standard Medical Care,
recovering or have 20% after Deductible, 0% after Medical
are also responsible for Treatment, Services or Supplies are
other special health Skilled nursing care Out-of-Pocket Expense Limit is met.
charges above Reasonable not covered. In addition,
needs
Durable medical equipment and Customary. Maintenance Care is not covered.
Hospice services
Routine eye exam is 20% of If your plan provides Vision
$10 copayment under the TeamCare
Children’s eye exam Reasonable and Customary coverage, it is provided to covered
Vision program
allowance children through age 25 and only
$0 copayment for Lenses, and $0 TeamCare will pay a maximum once every 12 months. Also, in lieu
copayment for Frames. Standard of $75 for frames and $50 for of glasses, contact lenses are
lenses and frames up to $150 are standard lenses. Any charges covered to $120 maximum.
Children’s glasses
included in the copayment. The above these maximums paid For TeamCare Vision providers,
If your child needs member is responsible for any by TeamCare will be the contact EyeMed at 866-393-3401 or
dental or eye care difference in cost. responsibility of the member. eyemedvisioncare.com.
If your plan provides Dental
TeamCare will pay 100% of coverage, a Dental check-up is
Reasonable and Customary provided to covered children through
Children’s dental check-up 0% charges. You would be age 25 only once every six months.
responsible for charges above For TeamCare Dental providers call
Reasonable and Customary. 800-592-3112 or visit
humanadentalnetwork.com.

CCM GF 10/15/2018 For more information about limitations and exceptions, see the plan document at MyTeamCare.org. U3 5 of 8
Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
• Acupuncture
• Infertility Treatment: charges for services and
drugs related to the treatment of infertility,
including charges in connection with in-vitro
fertilization, artificial insemination and reversal of
prior sterilization
• Injury or illness that is work-related or covered by
Worker’s Compensation or an Occupational
Disease Law
• Long-Term Care
• Weight Loss Programs
• Private Duty Nursing
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
• Chiropractic Care
• Routine Foot Care
• Non-emergency care when traveling outside U.S.
• Emergency care when traveling outside the U.S.
CCM GF 10/15/2018 For more information about limitations and exceptions, see the plan document at MyTeamCare.org.
• Cosmetic Surgery: (except to the extent it’s • Charges for medical services that are not
required due to an accidental bodily injury). considered Standard Medical Care, Treatment,
Surgical procedures that are considered Cosmetic Services or Supplies.
unless they’re a result of an accidental injury • Reversal of sterilization procedures.
include but are not limited to: • Charges for stand-by surgeons.
▪ Augmentation mammoplasty (breast • Personal comfort items, state taxes or surcharges.
enlargement surgery), unless it is part of
reconstruction following breast surgery due to • Hospital confinements longer than accepted
cancer. standards of medical practice.
▪ Rhinoplasty (plastic surgery on the nose),
unless surgery is the result of an accident or
chronic nasal obstruction.
▪ Otoplasty (plastic surgery on ears), sometimes
referred to as “lop ears” or “cauliflower ears.”
▪ Blepharoplasty (repair of drooping eyelids),
unless the droop restricts the field of vision as
verified by an ophthalmologist.
▪ Keratectomy or keratotomy–for diagnosis of
myopia (nearsightedness) when the myopia is
correctable by lenses.
▪ Rhytidectomy (face lift), Dyschromia (tattoo
removal), Genioplasty (chin augmentation).
• Dental Care (Adult)
• Routine Eye Care (Adult)
• Hearing Aids
U3 6 of 8
Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. For more information on your rights to continue
coverage, contact the plan at 800-TEAMCARE (832-6227). You may also contact your state insurance department; the U.S. Department of Labor, Employee Benefits
Security Administration at 866-444-3272 or dol.gov/ebsa/healthreform; or the U.S. Department of Health and Human Services at 877-267-2323 x61565 or cciio.cms.gov.
Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information
about the Marketplace, visit HealthCare.gov or call 800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a
grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide
complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact the
Research and Correspondence Department, TeamCare – A Central States Health Plan, PO Box 5126, Des Plaines IL 60017-5126 or call 800-TEAMCARE (832-6227). In
addition, you can contact the Department of Labor’s Employee Benefits Security Administration at 866-444-EBSA (3272) or dol.gov/ebsa/healthreform.

Does this plan provide Minimum Essential Coverage? Yes

If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the
requirement that you have health coverage for that month.

Does this plan meet the Minimum Value Standards? Yes

If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services:

Español: Para obtener asistencia en Español, llame al 800-832-6227
Tagalog Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 800-832-6227

Chinese (中文): 如果需要中文的帮助，请拨打这个号码 800-832-6227

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 800-832-6227

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

CCM GF 10/15/2018 For more information about limitations and exceptions, see the plan document at MyTeamCare.org. U3 7 of 8
About these Coverage Examples:
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different
depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles,
copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under
different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby Managing Joe’s type 2 Diabetes Mia’s Simple Fracture
(9 months of in-network pre-natal care and (a year of routine in-network care of a (in-network emergency room visit and
a hospital delivery) well-controlled condition) follow up care)
 The plan’s overall deductible $100  The plan’s overall deductible $100  The plan’s overall deductible $100
 Specialist copayment $10  Specialist copayment $10  Specialist copayment $10
 Hospital (facility) coinsurance 0%  Hospital (facility) coinsurance 0%  Hospital (facility) coinsurance 0%
 Other coinsurance 0%  Other coinsurance 0%  Other coinsurance 0%

This EXAMPLE event includes services like:
Specialist office visits (prenatal care)
Childbirth/Delivery Professional Services
Childbirth/Delivery Facility Services
Diagnostic tests (ultrasounds and blood work)
Specialist visit (anesthesia)
This EXAMPLE event includes services like:
Primary care physician office visits (including
disease education)
Diagnostic tests (blood work)
Prescription drugs
Durable medical equipment (glucose meter)
This EXAMPLE event includes services like:
Emergency room care (including medical supplies)
Diagnostic test (x-ray)
Durable medical equipment (crutches)
Rehabilitation services (physical therapy)

Total Example Cost $12,800 Total Example Cost $7,400 Total Example Cost $1,900

In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:
Cost Sharing Cost Sharing Cost Sharing
Deductibles $200 Deductibles $0 Deductibles $100
Copayments $10 Copayments $60 Copayments $40
Coinsurance $100 Coinsurance $1,200 Coinsurance $100
What isn’t covered What isn’t covered What isn’t covered
Limits or exclusions $0 Limits or exclusions $30 Limits or exclusions $0
The total Peg would pay is $310 The total Joe would pay is $1,290 The total Mia would pay is $240
U1
The plan would be responsible for the other costs of these EXAMPLE covered services.

CCM GF 10/15/2018 For more information about limitations and exceptions, see the plan document at MyTeamCare.org. U3 8 of 8