Schedule of Benefits 2026
(Benefit Coverage Plans A and B)
This summary of benefits is an outline of the health benefits provided for Benefits Fund participants. These details are informational in nature and are not intended to imply coverage for a specific individual under the provisions of the Fund. Fund participants, their covered dependents, or participating providers can call the Benefits Fund toll-free at 518-869-9501 or send an email to benefit@rnbenefits.org with any questions.
Download a PDF Copy| Benefit | Benefit Coverage Plan A | Benefit Coverage Plan B | |||
|---|---|---|---|---|---|
| In-Network | Out-of-Network | In-Network | Out-of-Network | ||
| Financial | Deductible | None | $250 Individual; $500 Family | None | $300 Individual; $600 Family |
| Maximum out-of-pocket cost (does not include charges in excess of allowed amount or noncovered benefits) | $1,000 Individual; $2,000 Family copayment/coinsurance maximum | None | $1,000 Individual; $2,000 Family copayment/coinsurance maximum | None | |
| Coinsurance | None | 70%/30% | None | 70%/30% | |
| Reimbursement rate | None | 70th percentile | None | 70th percentile | |
| Preventive care | Well-child and well-adult visits | No cost | Paid at 70% of the allowed amount after deductible is met | No cost | Paid at 70% of the allowed amount after deductible is met |
| Well-woman visits | No cost | Paid at 70% of the allowed amount after deductible is met | No cost | Paid at 70% of the allowed amount after deductible is met | |
| Immunizations | No cost | Paid at 70% of the allowed amount after deductible is met | No cost | Paid at 70% of the allowed amount after deductible is met | |
| Benefit | Benefit Coverage Plan A | Benefit Coverage Plan B | |||
|---|---|---|---|---|---|
| In-Network | Out-of-Network | In-Network | Out-of-Network | ||
| Maternity Care | Routine obstetrical, prenatal care, delivery, and postnatal care for mother* | $10 copayment for initial visit only | Paid at 70% of the allowed amount after deductible is met | $10 copayment for initial visit only | Paid at 70% of the allowed amount after deductible is met |
| Inpatient Care | Room and board * | No cost | $500 copay/admission up to $1,000 max per individual or up to $2,000 max per family (deductible does not apply) Paid at 70% | No cost | $500 copay/admission up to $1,500 max per individual (deductible does not apply) Paid at 70% |
| Physician’s services* | No cost | Paid at 70% of the allowed amount after deductible is met | No cost | Paid at 70% of the allowed amount after deductible is met | |
| Surgery (Physician’s services)* | No cost | Paid at 70% of the allowed amount after deductible is met | No cost | Paid at 70% of the allowed amount after deductible is met | |
| Restorative physical and occupational therapy* | No cost | $500 copay/admission up to $1,000 max per individual or up to $2,000 max per family (deductible does not apply) Paid at 70% | No cost | $500 copay/admission up to $1,500 max per individual (deductible does not apply) Paid at 70% | |
| Skilled nursing facility (for up to 60 days per calendar year)* | No cost | $500 copay/admission up to $1,000 max per individual or up to $2,000 max per family (deductible does not apply) Paid at 70% | No cost | $500 copay/admission up to $1,500 max per individual (deductible does not apply) Paid at 70% | |
| Benefit | Benefit Coverage Plan A | Benefit Coverage Plan B | |||
|---|---|---|---|---|---|
| In-Network | Out-of-Network | In-Network | Out-of-Network | ||
| Outpatient Care | Office visits | $10 copay/visit PCP; $25 copay/visit specialist | Paid at 70% of the allowed amount after deductible is met | $10 copay/visit PCP; $30 copay/visit specialist | Paid at 70% of the allowed amount after deductible is met |
| Chiropractic care* | $10 copayment per visit | Paid at 70% of the allowed amount after deductible is met | $30 copayment per visit | Paid at 70% of the allowed amount after deductible is met | |
| Acupuncture | $25 copayment per visit | Paid at 70% of the allowed amount after deductible is met | $30 copayment per visit | Paid at 70% of the allowed amount after deductible is met | |
| Allergy treatment | $25 copayment per visit | Paid at 70% of the allowed amount after deductible is met | $30 copayment per visit | Paid at 70% of the allowed amount after deductible is met | |
| Restorative physical and occupational therapy* | $10 copayment per visit | Paid at 70% of the allowed amount after deductible is met | $30 copayment per visit | Paid at 70% of the allowed amount after deductible is met | |
| Cardiac rehabilitation* | $10 copayment per visit | Paid at 70% of the allowed amount after deductible is met | $30 copayment per visit | Paid at 70% of the allowed amount after deductible is met | |
| Radiology/imaging* | No cost | Paid at 70% of the allowed amount after deductible is met | $25 copayment | Paid at 70% of the allowed amount after deductible is met | |
| Laboratory tests* | No cost | Paid at 70% of the allowed amount after deductible is met | No cost | Paid at 70% of the allowed amount after deductible is met | |
| Restorative speech therapy for up to 30 visits per calendar year | $10 copayment per visit | Paid at 70% of the allowed amount after deductible is met | $30 copayment per visit | Paid at 70% of the allowed amount after deductible is met | |
| Surgery (physician’s services)* | No cost | Paid at 70% of the allowed amount after deductible is met | No cost | Paid at 70% of the allowed amount after deductible is met | |
| Surgery (facility charges)* | No cost | Paid at 70% after deductible is met | No cost | Paid at 70% after deductible is met | |
| Benefit | Benefit Coverage Plan A | Benefit Coverage Plan B | |||
|---|---|---|---|---|---|
| In-Network | Out-of-Network | In-Network | Out-of-Network | ||
| Other Services | Physician house calls | No cost | Paid at 70% of the allowed amount after deductible is met | No cost | Paid at 70% of the allowed amount after deductible is met |
| Home health care services (up to 140 visits per calendar year) | No cost | Paid at 70% (deductible does not apply) | No cost | Paid at 70% (deductible does not apply) | |
| Home hospice care (up to 210 days max combined with inpatient hospice care)* | No cost | Paid at 70% (deductible does not apply) | No cost | Paid at 70% (deductible does not apply) | |
| Inpatient hospice care (up to 210 days max combined with home hospice care)* | No cost | $500 copay/admission up to $1,000 max per individual or up to $2,000 max per family (deductible does not apply) Paid at 70% | No cost | $500 copay/admission up to $1,500 max per individual (deductible does not apply) Paid at 70% | |
| Durable medical equipment and supplies* | Paid at 80% of contracted amount | Paid at 70% of the cost of the covered item (deductible does not apply) | Paid at 80% of contracted amount | Paid at 70% of the cost of the covered item (deductible does not apply) | |
| In vitro fertilization services or covered fertility drugs+ (up to a $5,000 lifetime maximum benefit. May elect to use the $5,000 max for prescriptions, if desired.)*+ | No cost for IVF services; prescription copays may apply | Paid at 70% of the allowed amount after deductible is met | No cost for IVF services; prescription copays may apply | Paid at 70% of the allowed amount after deductible is met | |
| ER | At hospital emergency room (waived if admitted) | $75 copayment per visit | $100 copayment per visit | ||
| Benefit | Benefit Coverage Plan A | Benefit Coverage Plan B | |||
|---|---|---|---|---|---|
| In-Network | Out-of-Network | In-Network | Out-of-Network | ||
| Behavioral Health | Outpatient behavioral health | $10 copayment per visit | Paid at 70% of the allowed amount after deductible is met | $10 copayment per visit | Paid at 70% of the allowed amount after deductible is met |
| Inpatient behavioral health* | No cost | $500 copay/admission up to $1,000 max per individual or up to $2,000 max per family (deductible does not apply) Paid at 70% | No cost | $500 copay/admission up to $1,500 max per individual (deductible does not apply) Paid at 70% | |
| Substance Abuse | Outpatient medical rehabilitative care for substance abuse/alcohol addiction | $10 copayment per visit | Paid at 70% of the allowed amount after deductible is met | $10 copayment per visit | Paid at 70% of the allowed amount after deductible is met |
| Inpatient medical rehabilitative care for substance abuse/alcohol addiction* | No cost | $500 copay/admission up to $1,000 max per individual or up to $2,000 max per family (deductible does not apply) Paid at 70% | No cost | $500 copay/admission up to $1,500 max per individual (deductible does not apply) Paid at 70% | |
| Applied Behavior Analysis (ABA) | Outpatient ABA office visits* | $10 copayment per visit | Paid at 70% of the allowed amount after deductible is met | $10 copayment per visit | Paid at 70% of the allowed amount after deductible is met |
| Outpatient facility care for ABA* | No cost | Paid at 70% of the allowed amount after deductible is met | No cost | Paid at 70% of the allowed amount after deductible is met | |
| Benefit | Benefit Coverage Plan A | Benefit Coverage Plan B | |||
|---|---|---|---|---|---|
| In-Network | Out-of-Network | In-Network | Out-of-Network | ||
| Dental Care | Yearly deductible | None | $50/individual;$150/family | None | $50/individual;$150/family |
| Maximum yearly benefit | $1,200 | $1,200 | $1,200 | $1,200 | |
| Orthodontia maximum | $1,000 per course of treatment separated by two years | $1,000 per course of treatment separated by two years | $1,000 per course of treatment separated by two years | $1,000 per course of treatment separated by two years | |
| Diagnostic and preventive services | No cost | Paid at 80% of usual and prevailing fee | No cost | Paid at 80% of usual and prevailing fee | |
| Basic restorative services, endodontics, periodontics, maintenance of prosthodontics, and oral surgery | Paid at 80% of fee schedule | Paid at 80% of usual and prevailing fee | Paid at 80% of fee schedule | Paid at 80% of usual and prevailing fee | |
| Major restorative services, installation of prosthodontics, and orthodontics | Paid at 50% of fee schedule | Paid at 50% of usual and prevailing fee | Paid at 50% of fee schedule | Paid at 50% of usual and prevailing fee | |
| Benefit | Benefit Coverage Plan A | Benefit Coverage Plan B | |||
|---|---|---|---|---|---|
| In-Network | Out-of-Network | In-Network | Out-of-Network | ||
| Prescription Drugs | Yearly deductible | None | None | None | None |
| Maximum network out-of-pocket cost (doesn’t include clinical pharmacy program penalties) | $9,600 Individual; $19,200 Family | None | $9,600 Individual; $19,200 Family | None | |
| Prescription drugs at retail pharmacy (up to a 34-day supply) | Tier 1: $0 Generic Tier 2: $10 Preferred Tier 3: $20 Non-preferred | Reimbursed at contracted amount minus applicable in-network copayment | Tier 1: $7 Generic Tier 2: $20 Preferred Tier 3: $35 Non-preferred | Reimbursed at contracted amount minus applicable in-network copayment |
|
| Mail-order prescription drug program (mandatory for all maintenance prescription medications for up to a 90-day supply) | Tier 1: $0 Generic Tier 2: $20 Preferred Tier 3: $40 Non-preferred | Not applicable | Tier 1: $15 Generic Tier 2: $40 Preferred Tier 3: $70 Non-preferred | Not applicable | |
| Routine vaccinations (influenza, pneumococcal disease, zoster/ shingles, and COVID-19) administered at the pharmacy | No cost | Not covered | No cost | Not covered | |
| Prescription Drug Programs | Mandatory generics | Applies to all drugs filled at a retail pharmacy or by mail-order. If brandname is selected instead of generic, participant pays applicable copay and cost difference between generic and brand-name. This applies even if the physician writes “DAW.” | Applies to all drugs filled at a retail pharmacy or by mail-order. If brandname is selected instead of generic, participant pays applicable copay and cost difference between generic and brand-name. This applies even if the physician writes “DAW.” |
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| Preferred specialty drugs | Same copays as non-specialty drugs (retail and mail-order) | Same copays as non-specialty drugs (retail and mail-order) |
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| High performance step therapy (The practice of beginning drug therapy for a medical condition with the most cost-effective and safest drug therapy and progressing to other more costly therapy, only if necessary.) | Four therapeutic classes of drugs applies. Copay applies if step therapy guidelines are not followed: Retail copay – 25% or $50 max; Mail-order copay – 50% or $100 max (Automatic override will be applied for first or subsequent steps if the physician determines medical necessity; participant will pay only the copay associated with the prescribed drug, not the amount cited above for failing to follow step therapy guidelines.) | Four therapeutic classes of drugs applies. Copay applies if step therapy guidelines are not followed: Retail copay – 25% or $50 max; Mail-order copay – 50% or $100 max (Automatic override will be applied for first or subsequent steps if the physician determines medical necessity; participant will pay only the copay associated with the prescribed drug, not the amount cited above for failing to follow step therapy guidelines.) |
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| Preferred specialty pharmacy program | For growth hormone deficiency and rheumatoid arthritis class. Preferred specialty copay is standard specialty copay; non-preferred specialty copay is 10% of drug cost ($200 max) | For growth hormone deficiency and rheumatoid arthritis class. Preferred specialty copay is standard specialty copay; non-preferred specialty copay is 10% of drug cost ($200 max) |
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| Benefit | Benefit Coverage Plan A In-network Plan | Benefit Coverage Plan B Out-of-network Plan |
|
|---|---|---|---|
| Vision Care | Routine eye exam every two years (every year for children up to age 18) | $10 copayment per visit | Paid at up to $75 for exam and glasses or contact lenses (every two years) |
| Eyeglasses or contact lenses every 2 years (through Davis Vision) | $30 copay for lenses and/or frames within the Davis Frame Collection, or $150 credit toward non-plan frames, or $25 copay for disposable/planned replacement lenses |
| Benefit | Benefit Coverage Plans A and B | |
|---|---|---|
| Disability | Short-term, nonoccupational disability | Paid at two-thirds of regular, weekly compensation, up to $215 per week for a maximum period of 26 weeks |
| Long-term disability that extends beyond the qualifying period of six consecutive months | Paid at 50% of monthly base compensation, up to $350 per month, less other disability payments, to age 65 (age 70 if disabled after age 60) | |
| Other Insurance | Life | Paid at a minimum of $20,000 and a maximum of $50,000, computed by taking 150% of current base compensation, to the maximum allowable. Benefit is reduced 35% at age 65, and 50% at age 70 |
| Accidental death and dismemberment and loss of sight | Paid at 100% or 50% of maximum benefit, according to specific loss | |
| Paid Family Leave | Job protected, partial wage replacement to bond with a new child, care for a loved one with a serious health condition, or to help relieve family pressures when someone is called to active military service | Coverage provides up to 12 weeks of leave at 67 percent of your average weekly wage, capped at 67 percent of the Statewide Average Weekly Wage (SAWW), which is currently $1,757.19. |
