Plan Highlights for Retired Employees

The Welfare Plan provides comprehensive medical expense benefits and prescription drug benefits for retired employees and their dependents.

The Plan also provides a death benefit for retired employees.

   

•       Eligibility for Retiree Medical Benefits

•       Self-Pay Requirements for Retiree Medical Benefits

Retiree Not Working in the Industry
Retiree Working in the Industry
Disability Retiree with Earnings Above $24,000

•       Benefits for Retired Employees Not Yet Eligible for Medicare

Death Benefit
Comprehensive Medical Expense Benefits
Wellness Benefit
Employee Assistance Plan
Hearing Aid Benefits
Prescription Drug Benefits
Dental Care Discounts
Health Reimbursement Arrangement (HRA)

•       Benefits for Retired Employees Eligible for Medicare

Death Benefit
Medicare Supplemental Medical Expense Benefits
Prescription Drug Benefits
Dental Care Discounts
Weight Watchers
Health Reimbursement Arrangement (HRA)

 

Retirees Not Working in the Industry

Rates Effective January 1, 2013

 

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Retiree Working in the Industry

Rates Effective January 1, 2013

 

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Disability Retiree with Earnings above $24,000

Rates Effective January 1, 2013

Disability Retirees under age 60 with Annual Social Security wages in excess of $24,000 in the year will pay higher rates in the following year.

Retiree not on Medicare, no dependents	$280 per month
Retiree not on Medicare, with one dependent	$560 per month
Retiree not on Medicare, with two or more dependents	$840 per month

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Death Benefits

 

Benefit	Benefit Amount or Limitation
Death Benefit for Retired Employee Only	$5,000

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

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Comprehensive Medical Expense Benefits - Not Yet Eligible for Medicare

Benefit	Benefit Amount or Limitation
Medical Expense Benefits
Calendar Year Deductible	$300 per person - $900 Family
Maximum Benefit
Maximum per Sickness           or Accident	$2,000,000 per Person
Spinal Manipulation Maximum           (including diagnostic tests)           (excluding lab tests)	$1,500 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. 7.08 (A) (10)
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	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	PPO Charges	Non PPO Charges
Outpatient	85%	75%
Inpatient	85%	75%
Chemical Dependency	PPO Charges	Non PPO Charges
Outpatient	85%	75%
Inpatient	85%	75%
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, then the Fund pays 75% and the Participant co-pay is 25%.

For additional information regarding Comprehensive Medical Expense Benefits  - Not Yet Eligible for Medicare refer to the Summary Plan Description (SPD)  Section 7.

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Employee Assistance Plan

Benefit	Benefit Amount or Limitation
Employee Assistance Plan (EAP) for Retired 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.

 

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Hearing Aid Benefits

Benefit	Benefit Amount or Limitation
Hearing Aid Benefit for Retired 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 Hearing Aid Benefits refer to the Summary Plan Description (SPD) Section 14.

 

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Prescription Drug Benefits - Not Yet on Medicare

Benefit	Benefit Amount or Limitation
Prescription Drug Benefit for Retired 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 (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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Prescription Drug Benefits - Medicare

Benefit	Benefit Amount or Limitation
Prescription Drug Benefit for Retired Employee and Dependents
Co-Pay Percentage (if greater than minimum co-pay amounts)	20%
Minimum Co-Pay Amount	Retail (31 day supply)	Retail (90 day supply)	Mail (90 day supply)
Generic	$5	$15	$10
Brand Preferred	$15	$45	$30
Brand Non-Preferred	$30	$90	$60
Specialty Drug Co-Pay Percentage	20%
Annual Out-of-Pocket Maximum for Specialty and Prescription Drugs	$2,500 (per person)

For additional information regarding Prescription Drug Benefits refer to the Summary Plan Description (SPD) Section 9.

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Dental Care Discounts

If you are eligible for Retired Employee Coverage, you now have access to the discounts under a dental PPO network.  The Fund does not pay for the services provided by your Dentist.  However, the Fund pays a fee so that you will have access to discounts under the dental PPO network.  The retiree pays the full cost of the discounted dental services directly to the provider.

 

 

For additional information regarding Dental Care Discounts contact Dental Network of America (DNOA) at 1-800-367-1203

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Medicare Supplemental Medical Expense Benefits

Supplemental Medical Expense Benefit	Amount Paid by Medicare in 2013	Amount Paid by Participant in 2013	Amount Paid by Plan in 2013
Amounts Payable During any Hospital Confinement
First 60 Days	Amount over $1,184	$532	$652
61st Day Through 90th Day	Amounts over $296 per Day	$58 per Day	$238 per Day
91st Day Until End of Lifetime Reserve	Amounts over $592 per Day	$116 per Day	$476 per Day
After Lifetime Reserve is Exhausted	0%	20%	80%
Pints of Blood
First Three Pints			$25 per pint
More than Three Pints	100%	0%	0%
Medicare Part B Deductible	0%	0%	100%
Medicare Part B Expenses After Deductible	80%	0%	20%
Medicare Part B (Mental Health)	60%	20%	20%
Skilled Nursing Facility
First 20 Days	100%	0%	0%
21st Day Through 100th Day	Amounts over $144.50 per Day	$29 per Day	$119 per Day
Maximum payable by the Plan per Sickness or Accident	$2,000,000

 

For additional information regarding Medicare Supplement Medical Expense Benefits refer to the Summary Plan Description (SPD) Section 8.

 

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Wellness Benefit

Covers Routine Physical Exams and Weight Watchers®.

The Plan provides for a 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: 

1. Routine physical examination by a licensed M.D. or D.O.

2. Wellness laboratory tests as follows:

   
   

   a- Comprehensive metabolic panel (organ function)

   b- Lipid panel and total cholesterol

   c- Occult blood over age 35 (gastrointestinal)

   d- Complete blood count with differential WBC (diseases)

   e- Complete urinalysis (infections, diseases)

   f- 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 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 100% up to 4 months of a Monthly Pass per person per lifetime (participant and eligible spouse) or will apply that amount towards whatever option you select, including Weight Watchers Online or Weight Watchers At Home. 

The Choice is Yours!
Weight Watchers Local Meeting:
Local Meeting 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.

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	100% up to 6 months of a Monthly Pass or 12 months of an Online subscription per person per lifetime (Participant and eligible spouse)

For additional information regarding Wellness Expense Benefits refer to the Summary Plan Description (SPD)  Section 13

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.

Weight Watchers

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 100% up to 4 months of a Monthly Pass per person per lifetime (participant and eligible spouse) or will apply that amount towards whatever option you select, including Weight Watchers Online or Weight Watchers At Home. 

The Choice is Yours!
Weight Watchers Local Meeting vouchers:
Local Meetings 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.

Call 1.866.204.1141 to start a program today or go online to Weight Watchers®.

 

Benefit	Benefit Amount or Limitation
Weight Watchers	100% up to a 4 months of a Monthly Pass per person per lifetime (Participant and eligible spouse)

 

 

 For additional information regarding Weight Watchers Benefits refer to the Summary Plan Description (SPD) Section 13.

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Health Reimbursement Arrangement (HRA)

If you are receiving a monthly pension benefit from the Pipe Fitters' Retirement Fund, Local 597 and you: (1) are eligible for Retired Employee Coverage under the Plan or (2) were previously an Employee eligible for benefits under this Plan, the Trustees have created an HRA account for you for the reimbursement of certain medical expenses you incur.
 

For additional information regarding Health Reimbursement Arrangement (HRA) refer to the Summary Plan Description (SPD) Section 3. 

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Retiree Medical Benefits Eligibility

     You are receiving a pension from the Pipe Fitters' Retirement Fund, Local 597

You were eligible for Welfare Plan benefits at the time you retired and for at least 12 of the preceding 20 benefit quarters

You pay the m     onthly premium to the Welfare Plan after the run-out of your Hour Bank

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