Pipe Fitters' Welfare Fund, Local 597
Plan Highlights for Active Employees

 

 

 

 

 

	Eligibility Requirements – Pipe Fitters Welfare Fund, Local 597
		Initial Eligibility Requirement. You will become eligible for Active Employee Benefits on the first day of the second month after your Accumulation Account is credited with 450 Eligibility Hours.  These 450 Eligibility Hours must be earned within a six consecutive month, or shorter period.  Once you become eligible, coverage will continue for the remainder of the current Benefit Quarter and for the entire next Benefit Quarter.  Three hundred and seventy five Eligibility Hours will be deducted from your Accumulation Account at the time you become eligible. Once you meet the Initial Eligibility Requirement, you will continue to be covered for subsequent Benefit Quarters if you have at least 375 Eligibility Hours credited to your Accumulation Account as of the quarterly Determination Date. The Determination Date is January 31, April 30, July 31 or October 31 for the corresponding Benefit Quarter shown in the chart below. On each Determination Date, 375 Eligibility Hours will be subtracted from your Accumulation Account.  If you have more than 375 Eligibility Hours in your Accumulation Account, the excess will be carried forward, up to a maximum of 1,500 hours. The Eligibility Hours subtracted from your Accumulation Account each Determination Date provide coverage as shown in the following chart: Determination Date You must have 375 Eligibility Hours in your Accumulation Account on: To Be Eligible for Coverage in the following Benefit Quarter:                   January 31st  April, May and June                   April 30th  July, August and September                    July 31st October, November and December                   October 31st January, February and March When Coverage Ends. Coverage for you and your Dependents will end on the March 31st, June 30th, September 30th, or December 31st that you do not have 375 hours in your Accumulation Account on the Determination Date to meet the Continued Eligibility Requirements.  When your Plan coverage ends, your Dependents’ coverage under the Plan also ends.  When coverage ends, the Plan will provide you and your Dependents with certification of the length of your coverage under this Plan.  This will help reduce or eliminate any pre-existing condition limitation under a new group medical plan. If your coverage under the Plan ends, you and/or your Dependents may be eligible to elect COBRA Continuation Coverage. For additional information regarding Eligibility refer to the Summary Plan Description (SPD) Section 3.
	Death Benefits
		Benefit Benefit Amount or Limitation   Death Benefit for Active Employee Only $10,000     Accidental Death and Dismemberment Benefit for Active Employees Only For loss of:        Life $10,000        Both hands, both feet, or sight of both eyes $10,000        One hand, one foot, or sight of one eye $5,000 For additional information regarding Death Benefits and Accidental Death and Dismemberment Benefits refer to the Summary Plan Description (SPD) Section 4 and Section 5.
	Weekly Accident and Sickness Disability Benefits
		Benefit Benefit Amount or Limitation  Weekly Accident and Sickness Disability Benefit for Active Employees Only   Weekly Benefit Amount $350 up to Maximum of 26 weeks
		For additional information regarding Weekly Accident and Sickness Disability Benefits refer to the Summary Plan Description (SPD) Section 6
	Comprehensive Medical Expense Benefits
		Benefit Benefit Amount or Limitation  Medical Expense Benefits for Active Employees and Dependents   Calendar Year Deductible $300 per person - $900 Family   Maximum Benefit           Maximum per Sickness or Accident $1,000,000 per Person           Spinal Manipulation Maximum           (including diagnostic tests) $1,000 per Calendar Year (for covered individuals age 16 and older)   Covered Expenses Payable by the Fund  up to the Usual and Customary Fees PPO Charges Non-PPO Charges          Physician, Hospital/Facility          (inpatient and outpatient) 85% 75%          Skilled Nursing Care 60 days per confinement; See Sec. 708(A)(11)   Out-of-Pocket Maximum per Calendar Year $1,000 per Person for PPO expenses $2,500 per Person for Non-PPO expenses    Out-of-Pocket Maximum Does Not Include:    ·   Deductible Amount ·   Prescription Drug Co-payments ·   Dental Expense Payments ·   Vision Care Expense Payments ·   Co-payments for Outpatient Treatment of Mental and Nervous Disorders or Chemical Dependency Once you reach the Out-of-Pocket Maximum, the Plan pays 100% of allowable expenses for the calendar year up to the Maximum Benefit listed above. Expenses that apply towards the Non-PPO out-of-pocket limits apply towards the PPO out-of-pocket limits and vice versa. Note:  Durable Medical Equipment and Local Ambulance Service for which PPO services are not available will be covered the same as PPO charges   Mental and Nervous Disorders for Active Employees and Dependents PPO Charges Non-PPO Charges           Outpatient 50% 50%           Inpatient 85% 75%   Chemical Dependency PPO Charges Non-PPO Charges           Outpatient 50% 50%           Inpatient $6,000 per Course of Treatment Limited to Two Courses of Treatment per Lifetime Benefit Benefit Amount or Limitation Outpatient Physical/Speech Therapy Maximum $3,500 per Calendar Year* Outpatient Occupational Therapy Maximum $3,500 per Calendar Year* *  After the $3,500 outpatient maximum is reached, no other payment is made under the Plan with the following exceptions: if $3,500 is reached for the outpatient treatment of cerebral palsy, cerebral vascular incident (stroke), intracranial bleed, other head traumas, spinal cord injuries, multiple or complicated fractures or other catastrophic diagnoses with neurological implications, then the Fund pays 75% and the Participant co-pay is 25%.
		For additional information regarding Comprehensive Medical Expense Benefits refer to the Summary Plan Description (SPD)  Section 7.
	Wellness Expense Benefit Covers Routine Physical Exams and Weight Watchers®.   The Plan provides for a new Wellness Benefit that consists of a Routine Physical Exam Benefit and a Weight-Loss Program. Routine Physical Exam Benefit.  The Routine Physical Exam Benefit applies to active and retired employees and their dependent spouses, except persons with Retired Employee coverage who are Medicare eligible.  Persons with Retired Employee coverage who are Medicare eligible are already covered by most of these services and lab tests through Medicare and the Fund’s Supplement to Medicare.  Under the Routine Physical Exam Benefit, the Fund will pay the full Usual and Customary Fee for the covered service.  If you go to an out of network provider, this amount may be substantially less than the amount charged by your provider.  Under the Routine Physical Exam Benefit you can receive the following services once per calendar year:  Routine physical examination by a licensed M.D. or D.O.   Wellness laboratory tests as follows: Comprehensive metabolic panel (organ function) Lipid panel and total cholesterol Occult blood over age 35 (gastrointestinal) Complete blood count with differential WBC (diseases) Complete urinalysis (infections, diseases) Blood glucose (diabetes)   PSA screen (prostrate) for men over 40 and Mammogram for women over 40. No deductible or co-payments will need to be paid for the above services.  Any other medically necessary tests and services ordered by the physician are covered under the Comprehensive Major Medical benefit and subject to deductible and co-payments.  To take full advantage of the new Wellness Benefit, download the postcard and present it at your Doctor’s office when scheduling or undergoing the exam. Weight-Loss Program  Pipe Fitters has joined forces with Weight Watchers®  to bring you convenient weight-loss solutions from the only commercial weight-loss plan with evidence it works!  The Fund pays for the full cost of the 13 weeks program or will apply that amount towards whatever option you select, including Weight Watchers Online or Weight Watchers At Home.  The benefit pays once per lifetime per employee and per spouse. The Choice is Yours! Weight Watchers Local Meeting vouchers: Local Meeting vouchers are a 13 weeks prepaid program that offers the flexibility of attending Weight Watchers meeting in your community when and where it suits you best. Weight Watchers Online subscription: With Online subscription you can follow Weight Watchers step-by-step online, with interactive tools and resources.  Weight Watcher messages sent directly to your email address, hundreds of recipes and meal ideas. Weight Watchers At Home kit: The At Home kit gives you information and resources by mail to follow the plan step-by-step at home.  The kit includes weight-loss tools and bonus products that are conveniently delivered to your home, along with access to a Toll-free Helpline with 26 weeks of progress reporting. Call 1.866.204.1141 to start a program today or go online to Weight Watchers® .   Benefit Benefit Amount or Limitation   Wellness Benefit for Active Employee and Spouse        Physical Exam (and specified lab tests) 100% - PPO Only        Weight Watchers 13 Week Session
	Dental Expense Benefits
	Benefit Benefit Amount or Limitation  Dental Expense Benefit for Active Employees and Dependents           Dental Benefits Other than Orthodontia Care                Maximum Benefit $1,250 per Person per Calendar Year                Co-payment Paid by the Plan 80%           Orthodontia Treatment $1,500 per Person per Lifetime           TMJ Treatment $2,000 per Person per Lifetime
	For additional information regarding Dental Expense Benefits refer to the Summary Plan Description (SPD) Section 10.
	Vision Benefits
		Effective January 1, 2007, vision care benefits are provided exclusively through a contract with EyeMed Vision Care.  By using the EyeMed network you can receive substantially greater benefits than previously.  Under the new contract, EyeMed handles both the In-Network and Out-of-Network benefits. This means that you will no longer send vision claims to the Fund Office.  We encourage you to get the most out of your new benefit by using the EyeMed network.  The In-Network Benefits described below are available for one set of contact lenses or one set of frames and lenses per person per calendar year:  Vision Care Services                      In-Network Participant Cost  Exam with Dilation as Necessary: $0 Copay Contact Lens Fit and Follow-Up:  Premium:(includes toric, multifocal) $40 Copay  $40 Copay, then 10% off balance over $40 Contact Lenses: (Contact lens allowance covers materials only)      Conventional Contact Lenses $0 Copay up to $150 allowance, 15% off balance over $150      Disposable Contact Lenses   $0 Copay up to $150 allowance, plus any balance over $150 Frames: Any available frame at provider location   $0 Copay up to $150 allowance, 20% off balance over $150  Standard Plastic Lenses:      Single Vision      Bifocal      Trifocal   $0 Copay $0 Copay $0 Copay Lens Options:     UV Coating     Tint (Solid and Gradient)     Standard Scratch-Resistance     Standard Polycarbonate     Standard Anti-Reflective Coating     Standard Progressive (Add-on to Bifocal)     Other Add-Ons and Services   $15 Copay $15 Copay $15 Copay $40 Copay $45 Copay $65 Copay 20% off retail price   If you don’t use the EyeMed network, the benefits provided are substantially less. If you don’t use the network, you should still submit your claims to EyeMed.   Under this benefit, you are reimbursed for Out-of-Network benefits according to a schedule. The Out-of-Network Benefit payable per person per calendar year is limited to the following:   Vision Care Services                      Out-of-Network Benefit  Exam $40 Frames and Lenses or Contact Lenses: $110 Each year you can receive the Out-of-Network benefit up to the stated amount. For instance, if you go out of network and are charged $70 for an eye examination, EyeMed will pay the Out-of-Network benefit of $40. No further benefit is payable for a vision examination for that person for the remainder of the calendar year.     Similarly, if you go Out-of-Network and are charged $200 for frames, EyeMed will pay the Out-of Network Benefit of $110. No further benefit is payable for the remainder of the calendar year for frames and lenses or contact lenses.
	Employee Assistance Plan
		Benefit Benefit Amount or Limitation   Employee Assistance Plan (EAP) for Active Employees and Dependents    Initial Counseling with EAP Staff Up to Three Sessions Covered at No Charge
		For additional information regarding Employee Assistance Plan refer to the Summary Plan Description (SPD) Section 12.
	Hearing Aid Benefits
		Benefit Benefit Amount or Limitation   Hearing Aid Benefit for Active Employee and Dependents           Hearing Aid and Exam 100% Up to $900 per Ear           Frequency Limit One per ear for any 36 consecutive month period
		For additional information regarding Employee Assistance Plan refer to the Summary Plan Description (SPD) Section 13.
	Prescription Drug Benefits
		Benefit Benefit Amount or Limitation Prescription Drug Benefit for Active Employee and Dependents Co-Pay Percentage (if greater than minimum co-pay amounts) 20% Minimum Co-Pay Amount Retail (34 day supply) Mail (90 day supply) Generic $5 $10 Brand Preferred $15 $30 Brand Non-Preferred $30 $60 Specialty Drug Co-Pay Percentage 20% Annual Out-of-Pocket Maximum  for Specialty and Prescription Drugs (Excludes Prescription Narcotics (narcotic agonists) $5,000 The participant co-payment for prescription narcotics (narcotic agonists) is always 20% and is not subject to any Out-of-Pocket Maximum
		For additional information regarding Prescription Drug Benefits refer to the Summary Plan Description (SPD) Section 9.
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