These Plans may remain in effect under a collective bargaining agreement until it expires on or after December 31, 2002 at which time Medical Plans A, B, C or WT-100 must be negotiated. 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.
PLANS: JC-28XL l WT-PLUS l WT-450
BENEFITS: Deductibles l Hospital l Maternal l Physician Services l Prescriptions l Alternate Care
Optional coverage: Except for WT-Plus, Employee Life and AD & D, Dependent Life, and Time Loss/Accident & Sickness coverage may be added or subtracted from the base coverage. WT-Plus options are extra Time-Loss only.
BENEFITS/SERVICES
CONTRIBUTION RATE
$865.00
$942.35
$792.15
EMPLOYEE LIFE
AND AD&D
$.75 per $2,500
Limit $30,000
Includes $5,000
(Maximum additional coverage available is $25,000)
Includes $30,000
(No additional coverage or reductions allowed.)
Includes $2,000
(Maximum additional coverage allowed is $27,500)
DEPENDENT LIFE
$.25 per $500
Limit $2,000
Includes $500
(Maximum additional coverage allowed is $1,500)
Includes $2,000
(No additional coverage or reductions allowed)
Includes $500
(Maximum additional coverage allowed is $1,500)
TIME LOSS / ACCIDENT & SICKNESS (A&S)
$1.375 per $25/wk
Includes $100/wk
(Maximum additional coverage allowed is $300/wk)
Includes $200/wk
(Additional coverage amounts of $100/wk and $200/wk only. No reductions)
Includes $100/wk
(Maximum additional coverage allowed is $300/wk)
LONG TERM DISABILITY
$6.25
Not included
(Available for negotiation)
Included
(May not be negotiated out)
Not included
(Available for negotiation)
DISABILITY WAIVERS
$11.40
Includes 3 mos.
(Additional 9 mos. Medical only available)
Includes 3 mos.
(Additional 9 mos. Medical only available)
Includes 3 mos.
(Additional 9 mos. Medical only available)
MEDICAL BENEFIT
• Trust Lifetime Maximum
$2,000,000 per person.
$2,000,000 per person
$2,000,000 per person.
OUT-OF-POCKET MAXIMUM
$500 per family, per calendar year
PPO
NON-PPO
$500 per person; $1,000 maximum per family, per calendar year.
$1,000 per person; $1,500 maximum per family, per calendar year. Combined PPO and Non-PPO amounts.
$1,000 per person; $1,500 maximum per family, per calendar year.
"Out-of-Pocket maximum" is the point each year most covered services will be paid at 100%. 90%/100% in this summary means that benefits are paid at 90% until you are out-of-pocket the maximum above and 100% thereafter for the rest of the year. Note: excludes mental and nervous, organ transplant, alternative housing, alcohol/drug, TMJ/MPD benefits, other limited benefits, prescription drugs, non-covered expenses, charges over usual and customary charges (UCR), and penalty for not pre certifying hospitalization.
"Out-of-Pocket maximum" is the point each year most covered services will be paid at 100%. 80%/100% or 90%/100% in this summary means that benefits are paid at either 80% or 90% respectively until you are out-of-pocket the maximum above and 100% thereafter for the rest of the year. Note: excludes mental and nervous, organ transplant, alternative housing, alcohol/drug, TMJ/MPD benefits, other limited benefits, prescription drugs, non-covered expenses, charges over usual and customary charges (UCR), and penalty for not pre certifying hospitalization.
$1,000 per person; $1,500 maximum per family, per calendar year. "Out-of-Pocket maximum" is the point each year most covered services will be paid at 100%. 80%/100% in this summary means that benefits are paid at 80% until you are out-of-pocket the maximum above and 100% thereafter for the rest of the year. Note: excludes mental and nervous, organ transplant, alternative housing, alcohol/drug, TMJ/MPD benefits, other limited benefits, prescription drugs, non-covered expenses, charges over usual and customary charges (UCR), and penalty for not pre certifying hospitalization.
** $1,000,000 until first contract renewal January 1, 1999 or later then $2,000,000.
BENEFITS/SERVICES
JC-28XL
WT-PLUS
WT-450
PPO
NON-PPO
Hospitalization
None
None
$100 per admission
None at PPO hospital. $100 per admission at non-PPO hospital.
Emergency Room Care
None at PPO hospital. $25 per visit at non-PPO.
None
$50 per visit
None at PPO hospital. $50 per visit at non-PPO.
Note: ER deductible waived at non-PPO hospitals if patient is transported in an emergency by an ambulance, Medic One, etc.
Note: ER deductible waived at non-PPO hospitals if patient is transported in an emergency by an ambulance, Medic One, etc.
Note: ER deductible waived at non-PPO hospitals if patient is transported in an emergency by an ambulance, Medic One, etc.
Physician Services, Surgery, XRay, Lab & Other Charges
None for Physician Services, Surgery, X-Ray and Lab. $100 per family per year for durable medical equipment and supplies. 3month carryover.
$10 co-pay per office visit. (X-ray, lab, surgical charges paid at 90%/100% of discounted charges.)
$100 per person, $300 per family, per calendar year, 3month carryover.
$100 per person, $300 per family, per calendar year, 3month carryover.
MANAGED CARE PLAN
Yes
Yes
Yes
Hospital precertification required. 10% coinsurance reduction for days not certified by Qualis Health.
Hospital precertification required. $200 penalty when admission not preauthorized. 10% coinsurance reduction for days not certified byQualis Health.
Hospital precertification required. $200 penalty when admission not preauthorized. 10% coinsurance reduction for days not certified by Qualis Health.
HOSPITAL
100% of first $2,000 of charges; 90%/100% of the excess. 100% benefit at PPO hospital for days certified by Qualis Health.
90%/100% of discounted charges for days certified by Qualis Health.
80%/100% of UCR charges in excess of deductible for days certified by Qualis Health.
80%/100% of charges in excess of deductible for days certified by Qualis Health.
Pre-admission Testing
Testing done within four days of hospitalization and related to the condition requiring hospitalization will be paid at 100%. No deductible.
Testing done within four days of hospitalization and related to the condition requiring hospitalization will be paid at 100%. No deductible.
Testing done within four days of hospitalization and related to the condition requiring hospitalization will be paid at 100%. No deductible.
2nd Surgical Opinion
Optional. Paid at 100%. No deductible.
If required by PRO-West paid at 100% no deductible, otherwise paid at regular benefit level. If required by Qualis Health and not obtained, surgeon charges paid at regular benefit level less 10%.
If required by PRO-West paid at 100% no deductible, otherwise paid at regular benefit level. If required by Qualis Health and not obtained, surgeon charges paid at regular benefit level less 10%.
JC-28XL
WT-PLUS
WT-450
PPO
NON-PPO
MATERNITY MANAGEMENT PROGRAM
The Trust will pay a $100 incentive benefit if you call Evergreen Health-care within 60 days of confirmation of pregnancy of you or your spouse and participate in the Healthy Baby program with the Evergreen Health-care nurses through the pregnancy.
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 Healthy Baby program with the Evergreen Healthcare nurses throughout the pregnancy.
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 Healthy Baby program with the Evergreen Healthcare nurses throughout the pregnancy.
ALTERNATE TREATMENT SETTINGS
In lieu of hospitalization, the plan pays covered charges in alternate treatment settings, i.e. skilled nursing facilities, hospice, and home health care. Care must be certified by Qualis health. No deductible. See limits described below.
In lieu of hospitalization, the plan pays covered charges in alternate treatment settings, i.e. skilled nursing facilities, hospice, and home health care. Care must be certified by Qualis Health. No deductible. See limits described below.
In lieu of hospitalization, the plan pays covered charges in alternate treatment settings, i.e. skilled nursing facilities, hospice, and home health care. Care must be certified by Qualis Health. No deductible. See limits described below.
100% of first $2,000 combined charges for hospital and alternate treatment settings; 90%/100% of the excess.
90%/100% of discounted charges.
80%/100% of UCR charges.
80%/100% of charges.
Skilled Nursing Facility
Up to $110 per day for 180 days.
Up to $100 per day for 180 days. Combined PPO/Non-PPO benefit.
Up to $100 per day for 180 days.
Home Health Care
Maximum 130 visits per calendar year.
Maximum 130 visits per calendar year. Combined PPO/Non-PPO benefit.
Maximum 130 visits per calendar year.
Hospice Care
$10,000 lifetime limit.
$10,000 lifetime limit. Combined PPO/Non-PPO benefit.
$10,000 lifetime limit.
Alternate Housing Facility
$60 per day, maximum 70 days.
$60 per day, maximum 70 days. Combined PPO/Non-PPO benefit.
$60 per day, maximum 70 days.
WT-450
PPO
NON-PPO
Surgery
90%/100% of charges.
90%/100% of discounted charges.
0%/100% of UCR charges in excess of deductible.
80%/100% of charges in excess of deductible.
Preventive Care Outpatient:
Physical Exams,
Well Baby Care,
Immunizations
90%/100% of charges.
100% after $10 co-pay. $500 per person per calendar year. Immunizations during newborn's 1st year are not subject to or applied to the maximum.
80%/100% of UCR charges in excess of deductible. $500 per person/ calendar year. Immunizations during newborn's 1st year are not subject to or applied to the maximum.
80%/100% of charges in excess of deductible. $500 per person per calendar year. Immunizations during newborn's 1st year are not subject to or applied to the maximum.
$500 is a combined PPO/Non-PPO maximum.
SPINAL TREATMENT BENEFIT
90%/100% of charges. Maximum 15 treatments per calendar year. Maximum $100 per calendar year for diagnostic X-rays.
90%/100% of discounted charges. No copay. Maximums of 24 treatments and $100 diagnostic x-ray per calendar year, including non-PPO.
80%/100% of UCR charge in excess of deductible. Maximum 15 treatments per calendar year. Maximum $100 per calendar year for diagnostic x-rays.
80%/100% of charges in excess of deductible. Maximum 15 treatments per calendar year. Maximum $100 per calendar year for diagnostic X-rays.
$100 x-ray is combined PPO/Non-PPO maximum.
ACUPUNCTURE TREATMENT
90%/100% of charges to an annual maximum of $500 per person. Services are only covered if a PPO provider is used.
90%/100% of charges. Annual maximum of $500 per person. Covered only if PPO used.
None
80%/100% of charges to an annual maximum of $500 per person. Services are only covered if a PPO provider is used.
DIAGNOSTIC X-RAY/LAB
90%/100% of charges.
90%/100% of discounted charges.
80%/100% of UCR charges in excess of deductible.
80%/100% of charges in excess of deductible.
DURABLE MEDICAL EQUIPMENT
90%/100% of charges in excess of deductible.
90%/100% of discounted charges.
80%/100% of UCR charges in excess of deductible.
80%/100% of charges in excess of deductible.
HEARING AIDS
90% up to $500 in 3-year period.
Not covered
Not covered
Not covered
ORGAN TRANSPLANTS
Special rules and limits. $200,000 maximum per transplant.
Special rules and limits. $200,000 maximum per transplant (Combined PPO/Non-PPO).
Special rules and limits. $200,000 maximum per transplant.
JAW TREATMENT
Including TMU and MPD
80% of charges. $6,000 lifetime maximum. Regular benefits apply in cases of accident.
90% of discounted charges. No deductible.
80% of UCR charges. No deductible.
80% of charges. $6,000 lifetime maximum. Regular benefits apply in cases of accident.
JC-28XL
WT-PLUS
WT-450
PPO
NON-PPO
PPO Pharmacy
•Generic
100% at recommended PPO pharmacy. 90% at regular PPO pharmacy.
100%. $3 co-pay per Rx . at recommended PPO pharmacy. $5 co-pay at regular PPO pharmacy.
Not Covered except in a medical emergency
90% at recommended PPO pharmacy. 8 0% at regular PPO pharmacy.
•Brand
90% at recommended PPO pharmacy. 80% at regular PPO pharmacy.
100%. $10 co-pay per Rx at recommended PPO pharmacy. $15 co-pay at regular PPO pharmacy.
Not Covered except in a medical emergency
75% at recommended PPO pharmacy. 65% at regular PPO pharmacy.
Mail Order
100% for 100-day supply. $20 co-pay per prescription will be applied to a brand name drug when a qualified generic is available.
100% for 100-day supply. $20 co-pay per prescription will be applied to a brand name drug when a qualified generic is available.
100% for 100-day supply. $20 co-pay per prescription will be applied to a brand name drug when a qualified generic is available.
Non-PPO Pharmacy
• Generic
Not Covered except in medical emergency.
N/A
Not Covered except in medical emergency.
Not Covered except in medical emergency.
• Brand
Not Covered except in medical emergency.
N/A
Not Covered except in medical emergency.
Not Covered except in medical emergency.
Note: Plan deductibles do not apply to prescription drug benefits. Retail prescriptions are limited to a maximum 34 day supply.
Note: Plan deductibles do not apply to prescription drug benefits. Retail prescriptions are limited to a maximum 34 -day supply.
Note: Plan deductibles do not apply to prescription drug benefits. Retail prescriptions are limited to a maximum 34-day supply.
OPTIONAL BENEFITS
*1) - Life and AD&D in increments of $2,500 = $.75** (Maximum $30,000) — (Options not available for WT-Plus.)
*2) - Dependents Life in increments of $500 = .25**— (Options not available for WT-Plus.) (Maximum $2,000)
*5) - Twelve month waiver of contributions available at an additional $11.40 per eligible employee, per month.
** Optional benefits above can be used for both increasing or decreasing benefits as listed on page 1 of this Summary except as noted for WT-Plus.
*** Time Loss is only available as 1-8-26; i.e., 1st day accident, 8th day illness and 26 weeks maximum. Increments of $25/week = $1.375 (Maximum $400/week)
CHANGE IN GROUP HEALTH COOPERATIVE BENEFITS
Due to a significant rate increase for Group Health Cooperative (GHC) coverage, the Trust elected to change the benefit levels of the GHC plan in 2006 for those who enroll in the GHC plan in lieu of any of the Trust’s Medical Plans. This was done to reduce the increase and keep the GHC plan option affordable for those employees and families. The new GHC plan will cover essentially the same services as before but will have a $200 annual deductible per person and 80% plan coverage for most covered services.