Deductible Amount

In-Network

Individual Deductible Amount (every Plan Year)

$300

Family Maximum Deductible Amount (every Plan Year)

$600

Out-of-Network

Individual Deductible Amount (every Plan Year)

$600

This Plan has no Out-of-Network Family Deductible

Out-of-pocket limit

Individual

In-Network only (every Plan Year)

$3,000

Not including Deductible

Family

In-Network only (every Plan Year)

$6,000

Not including Deductible

Fund pays

In-Network

After Deductible

75%

Out-of Network

After Deductible

50%

Certain Out-of-Network emergency services, Out-of-Network services at an In-Network Facility and Air Ambulance Services are payable at In-Network rates. See Section 8.16 for more information

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Indiana Laborers Fringe Benefit Funds

413 Swan Street, Terre Haute, Indiana 47807, United States

812-238-2551

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