Important Update: The monthly employee contribution will remain unchanged effective 1/1/2024 at $309.21.
IMPORTANT UPDATE:
The monthly employee contribution will remain unchanged effective 1/1/2024 at $309.21.
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HOW THE PLAN WORKS: AT A GLANCE

The Railroad Employees National Health and Welfare Plan / The SMART-TD Health and Welfare Plan

Click here for the Managed Medical Care Program (MMCP) overview grid

Click here for the Comprehensive Health Care Benefit (CHCB) overview grid

1

Deductible

This is the amount you pay each year for eligible health care services before the Plan starts to pay.

NOTE: Certain preventive services are paid by the Plan at 100 percent without any deductible.

2

Coinsurance

Once you’ve reached your deductible, the Plan will pay a percentage of your eligible health care costs (for example, 90 percent), and you’ll pay the remaining percentage (for example, 10 percent) until you meet the coinsurance out-of-pocket maximum.

3

Copayment

In the meantime, you might have copayments. These are fixed costs you pay for certain in-network health care expenses, usually at the time of service (for example, paying $10 when you pick up a prescription). Copays do not count toward your deductible or out-of-pocket maximum.

4

Out-of-pocket maximum

Designed to protect you, this is the maximum amount you pay in coinsurance each year before the Plan starts paying 100 percent for eligible health care services (except for in-network copays).

RAILROAD HEALTH & WELLNESS BENEFITS SUMMARY1
The Railroad Employees National Health and Welfare Plan
The SMART-TD Health and Welfare Plan
MANAGED MEDICAL CARE PROGRAM (MMCP)
Medical (including behavioral health care and substance use disorders)
  
In-Network
Out-of-Network
1
 Annual Deductible
(Does not apply toward out-of-pocket maximum) 		$350 individual/$700 family $700 individual/$1,400 family
2
 Coinsurance
(Percentage member pays for eligible health care services, once deductible is met) 		10% 30%
3
 Copays
(Apply to in-network prescription drugs and in-network services listed below and do not apply to deductible or out-of-pocket maximum)
Telemedicine Visit Through Teladoc® Member pays $10 per visit Not applicable
Convenient Care Clinic Member pays $10 per visit Member pays 30% after deductible is met
Office Visit to a Primary Care Physician (PCP) Member pays $25 per visit Member pays 30% after deductible is met
Office Visit to a Behavioral Health Clinician Member pays $25 per visit Member pays 30% after deductible is met
Urgent Care Facility Member pays $25 per visit Member pays 30% after deductible is met
Office Visit to a Specialist Member pays $40 per visit Member pays 30% after deductible is met
Emergency Care Facility2 Member pays $100 per visit Member pays $100 per visit
4
 Annual Out-of-Pocket Maximum3 $2,000 individual/$4,000 family $4,000 individual/$8,000 family
Medical (Other Benefits Features)
Lifetime Benefits Maximum Unlimited Unlimited
Certain Preventive Services4 Certain services are covered by the Plan 100% Member pays 30% for limited scope of services
Skilled Nursing Facility Member pays 10% after deductible is met (up to 60 days per calendar year) Member pays 30% after deductible is met (up to 60 days per calendar year)
Home Health Care Member pays 10% after deductible is met Member pays 30% after deductible is met (up to 40 visits per calendar year)
Centers of Excellence5 Certain defined services are covered by the Plan 100% Not applicable
Hospice Care Member pays 10% after deductible is met (up to $3,000) Member pays 30% after deductible is met (up to $3,000)
Care Coordination/Medical Management6 Not applicable Notification requirements for certain services
Medical (Benefits Design Features7)
Retail — 21-Day Supply
Generic Member pays $10 per prescription Member pays 25% of R&C (reasonable and customary) costs9
Brand (Formulary)8 Member pays $30 per prescription
Brand (Non-formulary)8 Member pays $60 per prescription
Mail Order — Up to 90-Day Supply
Generic Member pays $10 per prescription Member pays 25% of R&C (reasonable and customary) costs9
Brand (Formulary) Member pays $60 per prescription
Brand (Non-formulary) Member pays $120 per prescription
  1. The benefits presented above apply only to those Railroads/Labor Unions that have reached new collective bargaining agreements effective on or after January 1, 2018.
  2. Does not apply if admitted to that hospital. The $100 copay applies to a true emergency as defined in the SPD.
  3. The out-of-pocket maximums apply solely to coinsurance amounts paid by the member and do not apply to deductibles or fixed-dollar copayments.
  4. Call the number on the back of your health plan ID card to determine which preventive care services are covered by your Plan.
  5. Certain defined complex conditions that are treated at various Centers of Excellence may qualify for this 100% benefit.
  6. Certain services require the member to provide advance notification to the company administering the medical benefits or the benefit payment will be reduced by 20% under the MMCP (out-of-network services only) or under the CHCB.
  7. Prescription drug in-network copayments and out-of-network member expenses do not apply to your deductible or out-of-pocket maximum. Certain drugs are subject to prior authorization rules, step therapy requirements and/or quantity/dose limits.
  8. Additional costs may apply when a generic alternative is available.
  9. Reasonable and customary costs are determined by the average cost of similar services in your geographic area.
 
RAILROAD HEALTH & WELLNESS BENEFITS SUMMARY1
The Railroad Employees National Health and Welfare Plan
The SMART-TD Health and Welfare Plan
Comprehensive Health Care Benefit (CHCB)
Medical (including behavioral health care and substance use disorders)
  
In-Network
Out-of-Network
1
 Annual Deductible
(Does not apply toward out-of-pocket maximum) 		$350 individual/$700 family
2
 Coinsurance (Percentage member pays for eligible health care services, once deductible is met) 20%
3
 Copays
(Apply to in-network prescription drugs and in-network services listed below and do not apply to deductible or out-of-pocket maximum)
4
 Annual Out-of-Pocket Maximum2 $3,000 individual/$6,000 family
Medical (Health Care Services)
Telemedicine Visit Through Teladoc® Member pays 20%; no deductible applies
Convenient Care Clinic Member pays 20% after deductible is met
Office Visit to a Primary Care Physician (PCP) Member pays 20% after deductible is met
Office Visit to a Behavioral Health Clinician Member pays 20% after deductible is met
Urgent Care Facility Member pays 20% after deductible is met
Office Visit to a Specialist Member pays 20% after deductible is met
Emergency Care Facility Member pays 20% after deductible is met
Medical (Other Benefits Features)
Lifetime Benefits Maximum Unlimited
Certain Preventive Services3 Certain services are covered by the Plan 100%
Skilled Nursing Facility Member pays 20% after deductible is met (up to 31 days per hospitalization)
Home Health Care Member pays 20% after deductible is met
Centers of Excellence4 Certain defined services are covered by the Plan 100%
Hospice Care Member pays 20% after deductible is met (up to $3,000)
Care Coordination/Medical Management6 Notification requirements for certain services
Prescription Drugs (Benefits Design Features7)
  
In-Network
Out-of-Network
Retail — 21-Day Supply
Generic Member pays $10 per prescription Member pays 25% of R&C (reasonable and customary) costs8
Brand (Formulary)7 Member pays $30 per prescription
Brand (Non-formulary)7 Member pays $60 per prescription
Mail Order — Up to 90-Day Supply
Generic Member pays $10 per prescription Member pays 25% of R&C (reasonable and customary) costs8
Brand (Formulary) Member pays $60 per prescription
Brand (Non-formulary) Member pays $120 per prescription
  1. The benefits presented above apply only to those Railroads/Labor Unions that have reached new collective bargaining agreements effective on or after January 1, 2018.
  2. The out-of-pocket maximums apply solely to coinsurance amounts paid by the member and do not apply to deductibles or fixed-dollar copayments.
  3. Call the number on the back of your health plan ID card to determine which preventive care services are covered by your Plan.
  4. Certain defined complex conditions that are treated at various Centers of Excellence may qualify for this 100% benefit.
  5. Certain services require the member to provide advance notification to the company administering the medical benefits or the benefit payment will be reduced by 20% under the MMCP (out-of-network services only) or under the CHCB.
  6. Prescription drug in-network copayments and out-of-network member expenses do not apply to your deductible or out-of-pocket maximum. Certain drugs are subject to prior authorization rules, step therapy requirements and/or quantity/dose limits.
  7. Additional costs may apply when a generic alternative is available.
  8. Reasonable and customary costs are determined by the average cost of similar services in your geographic area.
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