The following medical plan, dental
plan, and vision plan summary data is for illustrative
purposes only and is NOT intended to be an all-inclusive
description of the Plan benefits or any limitations/exclusions
that may apply. It is not to be used for general distribution
purposes or in lieu of a Plan booklet. Every effort has
been made to insure that the following information is accurate
as of the date of issue, however, in all cases the applicable
Plan booklet (inclusive of all revisions or modifications
made subsequent to the latest printed editions) shall govern
the eligibility for the benefits payable under all Teamster
Construction Industry Welfare Trust programs. The Board
of Trustees retains the right of final determination in
questions of interpretation.
Please
click here to read the Privacy Notice. It describes
how medical information about you may be used and disclosed
and how you can get access to this information. Please
review it carefully. |
|
|
GENERAL
INFORMATION |
EMPLOYEE
CONTRIBUTION RATE |
$5.68 per compensable hour effective June 1, 2005 hours. |
|
All
hours remitted on your behalf are credited to your hour bank.
You may accumulate up to a maximum of 720 hours in your hour
bank. |
|
| New
Hires |
You will
become eligible for coverage on the first day of the month
following contributions of 200 hours to your hour bank, at
which time 120 hours are deducted from your hour bank. (For
example, if you work 100 hours in April and 100 hours in
May, your first day of eligibility will be June 1 and 120
hours will be deducted from your hour bank for coverage eligibility
in June.) |
| Continuing
Employees |
To maintain
eligibility you are required to have at least 120 hours in
your hour bank. 120 hours will be deducted from your hour
bank for each month of coverage. |
| Reinstatement |
If you
have 12 consecutive calendar months with less than 120 hours
in your hour bank, you will have to re-satisfy the initial
new hire eligibility requirement. |
LIFE
INSURANCE
Employee
Dependents |
$3,000
$1,000 (spouse); up to $1,000 for each child |
ACCIDENTAL
DEATH & DISMEMBERMENT
Employee Only |
$3,000 |
TIME
LOSS BENEFITS
Employee Only |
$200/week;
1-8-26 (1st day accident or hospital confinement; 8th day
illness; 26 weeks maximum) |
| DISABILITY
WAIVER OF CONTRIBUTIONS |
6
months |
| |
|
| MEDICAL
BENEFITS |
| PREFERRED
PROVIDER ORGANIZATION (PPO) |
The Trust utilizes a network of hospital, physician and
other medical providers that have agreed to discounted
fees for services. The network is the Beech Street Corporation
(First Choice Health in Washington). Use is voluntary but
can reduce out-of-pocket expenses. |
| HOSPITAL
PRECERTIFICATION AND UTILIZATION REVIEW |
Beech
Street Corp. also provides hospital precertification and
utilization review services. Hospital precertification is
required for inpatient stays. Failure to pre-certify an inpatient
admission results in the first $100 of hospital charges for
that admission not being covered. |
| LIFETIME
MAXIMUM BENEFITS |
$500,000
per person (Up to $10,000 is restored each January 1st.) |
| DEDUCTIBLES |
|
| Emergency
Room (ER) Care |
$75
deductible per visit. Waived if you are admitted as an inpatient
directly from the ER. |
Physician Services, Surgery, X-Ray, Lab & Other
Charges |
$200
per person, $600 per family per calendar year. Expenses incurred
in the last three months of a calendar year and used to satisfy
that year’s deductible will also be applied toward
the deductible for the next calendar year. |
| OUT-OF-POCKET
MAXIMUM |
$1,000
per person, $3,000 per family, per calendar year. |
| HOSPITAL |
80%/100%
of charges in excess of deductible. |
| Note: “80%/100%” in
this summary means payment is made at 80% until the out-of-pocket
maximum is reached during a calendar year, then at 100%
for the balance of the year. “Out of Pocket” excludes
the deductible, outpatient mental and nervous disorders,
home health care, hospice care, routine physical exams,
alcohol and drug facility charges and any penalties for
failing to precertify hospital inpatient admissions. |
|
| ALTERNATE
TREATMENT SETTINGS |
In
lieu of hospitalization, the plan pays covered charges in
alternate treatment settings, including skilled nursing facilities,
hospice, and home health care. Care must be certified by
Beech Street. No deductible unless otherwise noted. See limits
below. |
| Skilled
Nursing Facility |
80%/100%
of charges in excess of deductible. Limited to a lifetime
maximum of 365 days. Must follow within seven days of a discharge
from a hospital inpatient stay of at least three consecutive
days. Confinement must be for the same condition, must be
recommended by your physician, and may not be for custodial
care. |
Home Health Care |
100%
of charges, up to $100 per visit; maximum of 130 visits per
calendar year. |
| Hospice
Care |
100%
of charges. Outpatient maximum: $2,000. Inpatient maximum:
$150/day up to $3,000. |
| Alternate
Housing Facility |
100%
of charges, up to $40 per day; maximum of 70 days. |
| PHYSICIAN
SERVICES |
| Inpatient |
80%/100%
of charges in excess of deductible (well baby care excluded). |
| Outpatient |
80%/100%
of charges in excess of deductible. |
| Surgery |
80%/100%
of charges in excess of deductible. |
| Preventive
Care Outpatient: Physical Exams, Well Baby Care and Immunizations |
100% up to $100 (includes all x-ray and lab work). Limit of one examination
every 23 months (700 days). |
REHABILITATION
TREATMENT
Physical, Occupational and Vision Therapy |
80%/100% of charges in excess of deductible. $3,500 limit per condition. |
|
| SPINAL
TREATMENT BENEFIT |
80%/100%
of charges in excess of deductible. Limited to $500 per calendar
year. |
| ACUPUNCTURE
TREATMENT |
80%/100%
of charges in excess of deductible. Licensed Acupuncturists
(LAC) not covered. |
| DIAGNOSTIC
X-RAY/LAB |
80%/100%
of charges in excess of deductible. |
| DURABLE
MEDICAL EQUIPMENT |
80%/100%
of charges in excess of deductible. |
| SPECIAL
TREATMENT BENEFITS |
| Substance
Abuse Treatment |
80%
of charges to $3,500 per treatment series. Limited to 2 treatment
series |
Mental & Nervous
|
Inpatient: 80%/100%
of charges in excess of deductible.
Outpatient: 50% of charges
in excess of deductible. Maximum of 20 visits per calendar
year. |
| ORGAN
TRANSPLANTS |
80%/100%
of charges in excess of deductible. $150,000 lifetime maximum.
Special rules. |
| PRESCRIPTION
DRUGS |
Note: Plan deductibles do not apply to prescription drug benefits.
Prescription drug benefits must be obtained through NBN/Rx pharmacy network. |
| |
Generic |
|
Brand Non-Formulary |
RETAIL (limited to 34-day supply) |
| Plan Pays |
90% |
80% |
70$ |
| Participant pays |
10% to a $5 maximum copay |
20%to a $15 maximum copay |
30% to a $30 maximum copay |
|
MAIL ORDER (limited to 100-day supply |
| Plan Pays |
100% |
100% |
100% |
| Participant pays |
$10 copay |
$30 copay |
$40 copay |
| |
Note: The co-insurance percentages
listed in this summary for medical benefits refer to:
% of the UCR (usual, customary,
and reasonable) charges, if using a non-PPO (non-network)
provider
% of the PPO (network) providers’ discounted charges or the UCR
charges, whichever charges are less, if using a PPO (network) provider
|
|
| DENTAL
BENEFITS |
| MAXIMUM
ANNUAL BENEFIT |
$1,500 per eligible, per calendar year. |
| ORTHODONTIC
BENEFIT AND LIFETIME MAXIMUM |
Dependent
Children Coverage Only. Plan pays 70% of eligible expenses
not to exceed the $1,200 lifetime maximum. |
| CLASS I-
DIAGNOSTIC & PREVENTIVE |
80%
of Reasonable and Customary charges. Maximum of one oral
exam, one cleaning, and one set of full mouth x-rays per
person per calendar year. |
| CLASS II-
GENERAL & RESORATIVE |
80%
of Reasonable and Customary charges. |
| CLASS III
- PROSTHETIC & MAJOR |
80%
of Reasonable and Customary charges. |
| |
|
| VISION
BENEFITS |
| FIRST
PAIR OF GLASSES |
| |
NBN PANEL
PROVIDER |
NON-PANEL
PROVIDER |
| Examination |
Paid in Full |
$35.00 |
| Lenses
(per pair)—Every 365 days* |
| Single Vision |
Paid in Full** |
$30.00 |
| Bifocal |
Paid in Full** |
$40.00 |
| Trifocal |
Paid in Full** |
$45.00 |
| Lenticular |
Paid in Full** |
$90.00 |
| Frames—Every
730 days* |
Paid in Full*** |
$30.00 |
| Contact
Lenses |
| Subnormal—Every
730 days* |
Paid in Full |
$200.00 |
| Elective—Must
be eligible for exams & lenses. Is in lieu of all other
services for 365 days* |
$100.00 |
$90.00 |
|
| SECOND
PAIR OF GLASSES |
| |
NBN PANEL
PROVIDER |
NON-PANEL
PROVIDER |
| Deductible |
$10.00 |
None |
| Lenses (per
pair)—Every 365 days. If not obtained at time of
first pair, the 365 days are tracked from date second pair
was ordered.* |
| Single Vision |
Paid in Full** |
None |
| Bifocal |
Paid in Full** |
None |
| Trifocal |
Paid in Full** |
None |
| Lenticular |
Paid in Full** |
None |
| Frames—Every
730 days. If not obtained at time of first pair, the 730
days are tracked from date second frame was ordered.* |
Paid in
Full*** |
None |
| Contact Lenses (elective)—Every
730 days after second pair is ordered if a change in prescription
is indicated or lenses damaged and unusable.* |
$100.00
(employee only) |
None |
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* These time frames
are strictly enforced (i.e., to the day).
** Paid in full means the cost of basic lenses is covered in full.
Certain lens extras such as scratch coat, some tints, progressives,
UV filters, special lens edge treatments, etc., are not covered.
*** Paid in full for the frames selection covered by your Plan.
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