Opt-Out Option 1 Option 2 Option 3. Termination Age Retirement Retirement Retirement
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1 Medical Benefit Details Opt-Out Option Option Option 3 Lifetime (per person) Unlimited Unlimited Unlimited Retirement Retirement Retirement Annual Deductible Amount Reimbursed $500 for member $750 for member + $,000 for member + 90% until out of $75 for member + 80% until out of No deductible 90% until out of Out of Pocket Covered Expenses Prescription Drugs (legally requiring a prescription) 90% 80% 90% Dispensing Fee Cap $7 $7 $7 ManuScript Pay-direct Drug card Yes Yes Yes Prescription glasses/contacts or laser eye surgery: $50 per 4 Prescription glasses/contacts or laser eye surgery: $350 per 4 Vision Medically necessary contacts: $00 per 4 Medically necessary contacts: $00 per 4 Eye Exams: per 4 consecutive months for adults per consecutive months for children Eye Exams: per 4 consecutive months for adults per consecutive months for children Hospital 00% for private room up to $5 a day (including chronic care) Medical Supplies and Services Private Duty Nursing of $0,000 per calendar year Hearing Aids $300 every 4 calendar years of $5,000 per 3 calendar years $500 every 4 calendar years Paramedical Services
2 Physiotherapist Osteopath, Podiatrist / Chiropodist, Chiropractor, Massage Therapist, Speech Therapist, Naturopath, Psychologist, Acupuncturist $500 maximum per practitioner, per calendar year $600 maximum per practitioner, per calendar year Lutheran Church/ Dental Benefits Details Opt-Out Option Option Option 3 Deductible $00 for member + $75 for member + No deductible Retirement Retirement Retirement Dental Fee Guide Recall Examination Frequency Once every 9 months Once every 9 months Once every 6 months Basic Services 80% 90% 00% Services Periodontics and Endodontics 80% 90% 00% 80% 90% 00% Major Services 50% 60% Combined Annual s $,000 per calendar Basic and Services $,500 per calendar Basic and Services, Periodontics and Endodontics $,500 per calendar Major Services No maximum for Basic and Services, Periodontics and Endodontics $,500 per calendar Major Services Orthodontics 50% up to a lifetime maximum of $,000 per person 60% up to a lifetime maximum of $3,000 per person Lutheran Church/ Long Term Disability - Non taxable (member paid) Option Option Option 3
3 Benefit 50% of monthly 60% of monthly 60% of monthly Benefit $0,000 $0,000 $0,000 Qualifying Period 3 weeks 3 weeks 3 weeks Cost of Living Adjustment (COLA) No No Yes (%) Definition of Disability for years for years for years Age 65 or retirement Age 65 or retirement Age 65 or retirement Lutheran Church/ Basic Life Option Option Option 3 Option 4 Option 5 x annual x annual 3 x annual 4 x annual 5 x annual $500,000 $500,000 $500,000 $500,000 $500,000 Retirement Retirement Retirement Retirement Retirement Optional Life Options Available in units of $0,000 $50,000 (5 units) Earlier of age 70 or retirement Lutheran Church/ Dependant Life Spouse: 5% of employee s eligible annual Child:.5% of employee s eligible annual $50,000 Combined with Optional Spousal Life Member s Retirement
4 Optional Spouse Life Options Available in units of $0,000 $50,000 (5 units) Earlier of employee age 70, employee s retirement or spouse s age 70. Lutheran Church/ Dependant Life Spouse: 5% of employee s eligible annual Child:.5% of employee s eligible annual $50,000 combined with Optional Spousal Life Member s Retirement Optional Child Life Option Option $5,000 flat amount $0,000 flat amount $5,000 $0,000 Earlier of employee age 70, employee s retirement or maximum dependant child age. Earlier of employee age 70, employee s retirement or maximum dependant child age. Lutheran Church/ Out of Country Out of Country and ManuAssist $,000,000 Member s retirement
5 Optional Employee Accidental Death and Dismemberment (AD&D) Available in units of $0,000 Lutheran Church/ $00,000 (0 units) Earlier of age 70 or retirement Lutheran Church/
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