The following comparative data
is for illustrative purposes only. It 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 Washington Teamsters
Welfare Trust programs. The Board of Trustees retains the
right of final determination in questions of interpretation. |
|
WT - 100*
(*Employee Only) |
PLAN A |
PLAN B |
PLAN C |
CONTRIBUTION RATE |
$260.40 |
$770.50 |
$658.10 |
$491.00 |
| Employer contribution rates as of January 2006 based on December 2005 hours. Plans and rates may change periodically, so check with the Trust Administrative Office for the most current plan information and rates. |
|
COPAYS |
WT - 100*
(*Employee Only) |
PLAN A |
PLAN B |
PLAN C |
| •Physician |
None |
$15
co-pay per office visit. |
$20
co-pay per office visit. |
$30
co-pay per office visit. |
| •Hospitalization |
None
at PPO hospital. $100 per admission at Non-PPO |
None |
None |
None |
| •Emergency
Room Care |
None
at PPO hospital. $50 per visit at non-PPO. Waived if transported
by emergency vehicle. |
$75
per visit at PPO and Non-PPO hospitals. Waived if admitted. |
$75
per visit at PPO and Non-PPO hospitals. Waived if admitted. |
$75
per visit at PPO and Non-PPO hospitals. Waived if admitted. |
|
|
WT - 100*
(*Employee Only) |
PLAN A |
PLAN B |
PLAN C |
| DEDUCTIBLES |
$100
per employee, per calendar year, 3-month carryover. |
$100
per person, $300 maximum per family, per calendar year, 3-month carryover. |
$250
per person, $750 maximum per family, per calendar year, 3-month carryover. |
$500
per person, $1,500 maximum per family, per calendar year, 3-month
carryover. |
|
|
$1,000 per employee, per calendar year |
$500 per person; $1,000 maximum per family, per
calendar year |
$1,500 per person; $3,000 maximum per family, per
calendar year |
$3,000 per person; $6,000 maximum per family, per
calendar year |
| |
Includes deductible. |
Excludes
all co-pays and deductible. |
Excludes
all co-pays and deductible. |
Excludes
all co-pays and deductible. |
| |
"Out-of-Pocket
maximum" is the point each year most covered services
will be paid at 100%. 70%/100%, 80%/100%, and 90%/100% in
this summary means that benefits are paid at 70%, 80%, or
90% respectively until you are out-of-pocket the maximum
above and 100% thereafter for the rest of the year. Note:
Also excludes mental health and chemical dependency, prescription drugs, non-covered expenses, charges over usual
and customary charges (UCR), and any penalty for not precertifying
inpatient hospitalization. |
|
|
WT - 100*
(*Employee Only) |
PLAN A |
PLAN B |
PLAN C |
MEDICAL
BENEFITS
•Trust Lifetime Maximum |
$200,000
per employee |
$2,000,000
per person. |
$2,000,000
per person. |
$2,000,000
per person. |
| |
| |
WT - 100*
(*Employee Only) |
PLAN A |
PLAN B |
PLAN C |
| MANAGED
CARE AND PPO NETWORKS |
All of the plans have
access to the nationwide Beech Street hospital and physician
PPO network.In Washington State, Beech Street uses the First Choice Health Network. Utilization of the PPO network is voluntary
but will reduce out-of-pocket costs. The pharmacy network
is NBN/Rx. The mental health and chemical dependency network is HMC. Hospital Utilization Review and Case Management
is performed by Qualis Health, or--for mental health and chemical dependency--by HMC
|
|
| MATERNITY
MANAGEMENT PROGRAM |
The Trust will pay a $100 incentive benefit
if you call Evergreen Healthcare within 60 days of confirmation
of a pregnancy of you or your spouse and participate
in the program with the Evergreen Healthcare nurses throughout
the pregnancy. (Under WT-100 for the employee's pregnancy only.) |
| |
| |
WT - 100*
(*Employee Only) |
PLAN A |
PLAN B |
PLAN C |
HOSPITAL PRECERTIFICATION |
Hospital precertification by Qualis Health
required. $200 penalty when admission not preauthorized
10% coinsurance reduction for days not certified as medically necessary. |
Hospital precertification by Qualis Health
required. $200 penalty when admission not preauthorized.
No coverage for days not certified as medically necessary at a Non-PPO hospital or when admission not preauthorized at a PPO hospital. |
Hospital precertification by Qualis Health required. $200 penalty when admission not preauthorized. No coverage for days not certified as medically necessary at a Non-PPO hospital or when admission not preauthorized at a PPO hospital. |
Hospital precertification by Qualis Health required. $200 penalty when admission not preauthorized. No coverage for days not certified as medically necessary at a Non-PPO hospital or when admission not preauthorized at a PPO hospital. |
|
| |
WT - 100*
(*Employee Only) |
PLAN A |
PLAN B |
PLAN C |
| HOSPITAL |
80%/100%
of charges in excess of /deductible for days certified
by Qualis Health. |
90%/100%
of charges in excess of /deductible (and emergency room co-pay if any) for days certified
by Qualis Health. |
80%/100%
of charges in excess of deductible (and emergency room co-pay if any) for days certified
by Qualis Health. |
70%/100%
of charges in excess of deductible (and emergency room co-pay if any) for days certified
by Qualis Health. |
•Preadmission Testing |
Testing within four days of hospitalization
and related to the condition requiring hospitalization
will be paid at 100%. No deductible. |
Testing within four days of hospitalization
and related to the condition requiring hospitalization
will be paid at 90%/100%. No deductible. |
Testing within four days of hospitalization
and related to the condition requiring hospitalization
will be paid at 80%/100%. No deductible. |
Testing within four days of hospitalization
and related to the condition requiring hospitalization
will be paid at 70%/100%. No deductible. |
•2nd Surgical Opinions |
If required by Qualis Health paid at 100%.
No deductible. |
If required by Qualis Health paid at 100%.
No deductible. |
If required by Qualis Health paid at 100%.
No deductible. |
If required by Qualis Health paid at 100%.
No deductible. |
|
| |
WT - 100*
(*Employee Only) |
PLAN A |
PLAN B |
PLAN C |
ALTERNATE TREATMENT SETTINGS |
80%/100% of charges.
In lieu of hospitalization. Care must be certified by
Qualis Health. See limits below.
|
90%/100% of charges.
In lieu of hospitalization. Care must be certified by
Qualis Health. See limits below.
|
80%/100% of charges.
In lieu of hospitalization. Care must be certified by
Qualis Health. See limits below.
|
70%/100% of charges.
In lieu of hospitalization. Care must be certified by
Qualis Health. See limits below.
|
•Skilled Nursing Facility |
Up to $100 per day for 180 days. |
Up to $100 per day for 180 days. |
Up to $100 per day for 180 days. |
Up to $100 per day for 180 days. |
•Home Health Care |
Maximum 130 visits per calendar year. |
Maximum 130 visits per calendar year. |
Maximum 130 visits per calendar year. |
Maximum 130 visits per calendar year. |
| •Hospice
Care |
$10,000 lifetime limit. |
$10,000 lifetime limit. |
$10,000 lifetime limit. |
$10,000 lifetime limit. |
•Alternate Housing Facility |
$60 per day, maximum 70 days. |
$60 per day, maximum 70 days. |
$60 per day, maximum 70 days. |
$60 per day, maximum 70 days. |
|
| |
WT - 100*
(*Employee Only) |
PLAN A |
PLAN B |
PLAN C |
ORGAN TRANSPLANTS |
Special rules and limits. $200,000 maximum
per confinement. |
Special rules and limits. $200,000 maximum
per confinement. |
Special rules and limits. $200,000 maximum
per confinement. |
Special rules and limits. $200,000 maximum
per confinement. |
|
REHABILITATION |
WT - 100*
(*Employee Only) |
PLAN A |
PLAN B |
PLAN C |
•Inpatient |
80%/100% of charges in excess of deductible. |
90%/100% of charges in excess of deductible. |
80%/100% of charges in excess of deductible. |
70%/100% of charges in excess of deductible. |
•Outpatient
Physical Therapy, Occupational Therapy and Speech Therapy
|
80%/100% of charges in excess of deductible.
Maximum of 60 visits per employee per lifetime. |
100% after $15 co-pay per visit. No deductible.
Maximum of 24 visits each for physical and occupational
therapy per person per calendar year. Maximum of 60 visits
for speech therapy per person per lifetime. |
100% after $20 co-pay per visit. No deductible.
Maximum of 24 visits each for physical and occupational
therapy per person per calendar year. Maximum of 60 visits
for speech therapy per person per lifetime. |
100% after $30 co-pay per visit. No deductible.
Maximum of 24 visits each for physical and occupational
therapy per person per calendar year. Maximum of 60 visits
for speech therapy per person per lifetime. |
| |
| DURABLE
MEDICAL EQUIPMENT |
80%/100%
of charges in excess of deductible. |
90%/100%
of charges in excess of deductible. |
80%/100%
of charges in excess of deductible. |
70%/100%
of charges in excess of deductible. |
|
| |
WT - 100*
(*Employee Only)
|
PLAN A |
PLAN B |
PLAN C |
| PHYSICIAN
SERVICES |
|
| •Inpatient,
including 1st 72 hours well baby care |
80%/100%
of charges in excess of deductible. |
90%/100%
of charges in excess of deductible. |
80%/100%
of charges in excess of deductible. |
70%/100%
of charges in excess of deductible. |
| •Outpatient |
80%/100%
of charges in excess of deductible. |
100%
after $15 co-pay per office visit. No deductible. |
100%
after $20 co-pay per office visit. No deductible. |
100%
after $30 co-pay per office visit. No deductible. |
| •Surgery |
80%/100%
of charges in excess of deductible. |
90%/100%
of charges in excess of deductible. |
80%/100%
of charges in excess of deductible. |
70%/100%
of charges in excess of deductible. |
•Preventative
Care
Outpatient: physical exams, well baby care, immunizations
|
Physical
exams not covered. Immunizations paid at 80%/100% of charges
in excess of deductible. Does not include routine office
calls and associated lab. |
100%
after $15 co-pay per office visit. No deductible. $500 maximum per person per calendar year. Immunizations during newborn's 1st year are not subject to or applied to the maximum. |
100%
after $20 co-pay per office visit. No deductible. $500 maximum per person per calendar year. Immunizations during newborn's 1st year are not subject to or applied to the maximum. |
100%
after $30 co-pay per office visit. No deductible. $500 maximum per person per calendar year. Immunizations during newborn's 1st year are not subject to or applied to the maximum. |
|
|
WT - 100*
(*Employee Only) |
PLAN A |
PLAN B |
PLAN C |
| DIAGNOSTIC
X-RAY/LAB |
80%/100%
of charges in excess of deductible. |
90%/100%
of charges in excess of deductible. |
80%/100%
of charges in excess of deductible. |
70%/100%
of charges in excess of deductible. |
| |
| ACUPUNCTURE
TREATMENT |
80%/100%
of charges to an annual maximum of $500 per employee. Only
covered if a PPO provider is used. |
100%
after $15 co-pay per office visit. No deductible. Maximum
of 15 visits per person per calendar year. Only covered if a PPO provider
is used. |
100%
after $20 co-pay per office visit. No deductible. Maximum
of 15 visits per person per calendar year. Only covered if a PPO provider
is used. |
100%
after $30 co-pay per office visit. No deductible. Maximum
of 15 visits per person per calendar year. Only covered if a PPO provider
is used. |
Back
to top |
|
WT - 100*
(*Employee Only) |
PLAN A |
PLAN B |
PLAN C |
| SPINAL
TREATMENT BENEFIT |
80%/100%
of charges in excess of deductible. Maximum of 15 treatments
and $100 for diagnostic X-rays per person per calendar year. |
100%
after $15 co-pay per office visit. No deductible. Maximum
of 15 treatments and $100 for diagnostic X-rays per person per calendar
year. |
100%
after $20 co-pay per office visit. No deductible. Maximum
of 15 treatments and $100 for diagnostic X-rays per person per calendar
year. |
100%
after $30 co-pay per office visit. No deductible. Maximum
of 15 treatments and $100 for diagnostic X-rays per person per calendar
year. |
| |
| JAW
TREATMENT |
80%
up to $6,000 per lifetime. Regular benefits apply for accidents. |
90%
up to $6,000 per lifetime. Regular benefits apply for accidents. |
80%
up to $6,000 per lifetime. Regular benefits apply for accidents. |
70%
up to $6,000 per lifetime. Regular benefits apply for accidents. |
|
| |
WT - 100*
(*Employee Only) |
PLAN A |
PLAN B |
PLAN C |
| HEARING
AIDS |
Not
covered. |
90%/100%
of charges in excess of deductible up to $500 per person per 3 consecutive
calendar years. Cochlear implants covered under regular benefits
subject to special medical necessity criteria. |
80%/100%
of charges in excess of deductible up to $500 per person per 3 consecutive
calendar years. Cochlear implants covered under regular benefits
subject to special medical necessity criteria. |
70%/100%
of charges in excess of deductible up to $500 per person per 3 consecutive
calendar years. Cochlear implants covered under regular benefits
subject to special medical necessity criteria. |
|
| |
WT-100*
(*Employee Only) |
PLANS A, B &C |
PRESCRIPTION DRUGS |
Plan deductibles do not apply. Contraceptives
are not covered. |
Plan deductibles do not apply. Contraceptives
are covered. |
Retail Network Pharmacies |
Recommended Network |
Regular Network |
Recommended Network |
Regular Network |
•Generic |
90% |
80% |
100% after a co-pay equal to the greater of 10% or $5. |
100% after a co-pay equal to the greater of 10% or $10. |
•Brand |
75% |
65% |
100% after a co-pay equal to the greater of 30% or $15. |
100% after a co-pay equal to the greater of 30% or $20. |
| |
Notes: Participant
pays for prescriptions at pharmacy and is reimbursed according
to the percentage indicated. Retail prescriptions are limited
to a maximum 34-day supply. Prescriptions obtained from non-network
pharmacies are not covered except in a medical emergency. |
Notes: Participant
pays only the co-pay at the pharmacy.
Retail prescriptions are limited to a maximum 34-day supply.
Prescriptions obtained from non-network pharmacies are not
covered except in a medical emergency. |
Mail Order Network Pharmacies |
100% for up to a 100-day supply. $20 co-pay
per brand name prescription when a qualified generic is
available. |
100% after a $10
co-pay per generic and $35 co-pay per
brand name prescription. Limited to a 100-day supply. Participant pays only the co-pay.
|
|
| |
ALL PLANS — WT-100*, PLAN A, PLAN
and, PLAN C |
| |
HMC NETWORK |
NON-HMC NETWORK |
MENTAL HEALTH |
Mental Health and Chemical Dependency administered by Health Management Center (HMC) |
| •Inpatient |
100% of HMC authorized
network charges up to 45 days per person per calendar year.
Lifetime maximum of 90 days. |
50% of UCR charges for HMC authorized
treatment up to 45 combined days per person per calendar
year with a combined lifetime maximum of 90 days. |
| •Outpatient |
100% of HMC authorized
Individual/Group Outpatient Sessions after co-pay. Maximum
of 50 sessions per eligible per calendar year. |
50% of UCR charges for HMC authorized
treatment up to 50 combined days per person per calendar
year. |
| |
| >CHEMICAL
DEPENDENCY |
100% of HMC authorized
network charges up to $10,000 per episode with a 2-episodes
lifetime maximum. |
50% of HMC authorized
network charges up to a combined $10,000 per episode, and a 2-episodes
lifetime maximum. |
| |
Maximums are a combination of HMC network and non-network treatment. |
| |
| ASSISTANCE
PROGRAM |
100% up to 3 HMC Authorized
outpatient visits per person per calendar year for assessment
of personal, mental health and chemical dependency related
problems. |
None |
| |
| SUBSTANCE
ABUSE PROFESSIONAL (SAP) |
100% of HMC authorized
SAP services for eligible active employees who fail a DOT
alcohol or drug test. |
None |
| |
|
|
|
|
|
WT - 100*
(*Employee Only) |
PLAN A |
PLAN B |
PLAN C |
| LIFE
INSURANCE |
|
|
|
|
•Employee |
$2,000 1) |
Optional 5) |
Optional 5) |
Optional 5) |
| •Dependents |
Not available |
Optional 5) |
Optional 5) |
Optional 5) |
| |
AD&D
•Employee Only |
$2,000 1) |
Optional 5) |
Optional 5) |
Optional 5) |
| |
TIME LOSS BENEFITS
•Employee Only |
$80 per week;
1-8-26 3) |
Optional 6) |
Optional 6) |
Optional 6) |
| |
LONG TERM DISABILITY
•Employee Only |
Not available |
Optional 4) |
Optional 4) |
Optional 4) |
| |
| DISABILITY WAIVERS |
3 months |
3 months 7) |
3 months 7) |
3 months 7) |
| |
| COORDINATION OF BENEFITS |
Yes. Standard Coordination
of Benefits. |
Yes. Standard Coordination of Benefits for Plans A, B and C. |
*Employee Only Plan
|
Plan WT-100
- 1)Life and AD&D in increments of $2,500=$1.00 (Maximum $30,000)—May be used to increase or decreaseamounts.
- 3)Time Loss (1-8-26) ** in increments of $25/week=1.05 (Maximum $400/week)—May be used to increase or decrease amounts.
OVERALL SUMMARY NOTE: The hospital/physician PPO network, pharmacy PPO network, and mental health and chemical dependency HMC network in this summary apply to all Plans participants. The co-insurance percentages listed in this spreadsheet refer to:
—% of UCR (usual, customary, and reasonable) charges, if using a non-PPO (non-network) provider, and
—% of PPO (network) providers' discounted charges, if using a PPO (network) provider.
Use of a PPO provider will eliminate the potential for charges over UCR, which are non-covered expenses and, generally speaking, result in less out-of-pocket costs to the participant |
|
