Pipe Fitters' Welfare Fund, Local 597


Plan Highlights for Active Employees

The Welfare Plan provides comprehensive medical expense benefits, dental benefits, vision benefits, member assistance program and prescription drug benefits for active employees and their dependents.

The Plan provides weekly disability benefits for employees that are unable to work due to a non-work related illness or injury.  The Plan also provides death and dismemberment benefits for employees.

Eligibility

Death Benefits

Weekly Accident and Sickness Disability Benefits

Comprehensive Medical Expense Benefits

Dental Expense Benefits

Vision Benefits

Employee Assistance Plan

Hearing Aid Benefits

Prescription Drug Benefits

RxSavings Solutions

HRA Benefits




 

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 six consecutive months, 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.  

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 2.

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Death Benefits

 

Benefit

Benefit Amount or Limitation

Death Benefit for Active Employee Only

$50,000

 

Accidental Dismemberment Benefit for Active Employees Only

For loss of:

Both hands, both feet, or sight of
both eyes

$10,000

One hand and one foot, one hand and
sight of one eye, or one foot and sight of
one eye

$10,000

One hand, one foot, or sight of one eye

$5,000

 

For additional information regarding Death Benefits and Death and Dismemberment Benefits refer to the Summary Plan Description (SPD) Section 4 and Section 5.

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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

Benefits are paid for a maximum of 26 weeks for any one period of disability. Benefits will be paid for no more than two periods of disability during any 60-month period. Your disability is considered a separate and distinct disability period if you return to full-time work for at least one continuous week between periods of disability

 

 

For additional information regarding Weekly Accident and Sickness Disability Benefits refer to the Summary Plan Description (SPD) Section 6

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Comprehensive Medical Expense Benefits

 

Benefit

Benefit Amount or Limitation

 Medical Expense Benefits for Active Employees and Dependents

 Calendar Year Deductible

$500 per person - $1500 Family

  Maximum Benefit

          Spinal Manipulation Maximum
          (including diagnostic tests)
          (excluding lab tests)

20 Visits 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 for Medical, Mental Health and Substance Abuse)

85%

75%

         Skilled Nursing Care  60 days per confinement; See Sec. 708(A)(10)

  Out-of-Pocket Maximum per
  Calendar Year

$1,950 per Person/$5,850 Family for PPO expenses

$5,000 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

Physical, Speech, Occupational Therapy - Co-payments above 40 visit limit

 

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

 Outpatient Physical/Speech Therapy Maximum  40 visits per Calendar Year*
 Outpatient Occupational Therapy Maximum  40 visits per Calendar Year*
 *  After the 40 visits outpatient maximum is reached, no other payment is made under the Plan with the following exceptions: if 40 visits 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 significant or multiple injuries and/or illnesses, then the Fund pays 75% and the Participant co-pay is 25%.

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  • Dental Expense Benefits
     

    Benefit

    Benefit Amount or Limitation

     Dental Expense Benefit for Active Employees and Dependents

              Dental Benefits Other than Orthodontia Care

                   Maximum Benefit

    $2,500 per Person per Calendar Year

                   Co-payment Paid by the Plan

    80%

    Co-payment Paid by the Plan for Diagnostic
    and Preventitive Services
    100%

              Orthodontia Treatment

    $2,000 per Person per Lifetime

     

    For additional information regarding Dental Expense Benefits refer to the Summary Plan Description (SPD)   Section 10.

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    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 maximum allowance

     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.

     

    For additional information regarding Vision Benefits refer to the Summary Plan Description (SPD)  Section 11.

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    Employee Assistance Plan

     

    Benefit

    Benefit Amount or Limitation

      Employee Assistance Plan (EAP) for Active Employees and Dependents

       Initial Counseling with EAP Staff

    Up to Five Sessions Covered at
    No Charge

     

    For additional information regarding Employee Assistance Plan refer to the Summary Plan Description (SPD) Section 12. 

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    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 as medically necessary

     

    For additional information regarding Employee Assistance Plan refer to the Summary Plan Description (SPD) Section 14.

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    Prescription Drug Benefits

     

    Benefit

    Benefit Amount or Limitation

     Prescription Drug Benefit for Active Employee and Dependents

     

     

     Minimum Co-Pay Amount

    Retail (34 day supply)

    Mail (90 day supply)

     Generic

    $10

    $20

     Brand Preferred

    20% ($25 minimum)

    20% ($50 minimum)

     Brand Non-Preferred

    30% ($45 minimum)

    30% ($90 minimum)

     Specialty Drug Co-Pay Percentage

    20%

     Annual Out-of-Pocket Maximum  for Specialty and  Prescription Drugs (Excludes Prescription Narcotics (narcotic agonists)

    $5,000 per family

     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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