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.
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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
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Benefits for Retired Employees Not Yet Eligible for Medicare
Death Benefit
Comprehensive Medical Expense Benefits
Employee Assistance Plan
Hearing Aid Benefits
Prescription Drug Benefits
Dental and Vision Benefits
Health Reimbursement Arrangement (HRA)
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Benefits for Retired Employees Eligible for Medicare
Death Benefit
Medicare Supplemental Medical Expense Benefits
Prescription Drug Benefits
Dental and Vision Benefits
Weight Watchers
Health Reimbursement Arrangement (HRA)
Retirees Not Working in the Industry
Rates Effective January 1, 2020
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Retiree not on Medicare, no dependents |
$228 per month |
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Retiree not on Medicare, with dependent not on Medicare |
$456 per month |
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Retiree not on Medicare, with two or more dependents not on Medicare |
$684 per month |
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Retiree not on Medicare, with dependent on Medicare |
$365 per month |
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Retiree not on Medicare, with dependent on Medicare and one or more dependents not on Medicare |
$593 per month |
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Retiree not on Medicare, with two dependents on Medicare |
$502 per month |
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Retiree on Medicare, no dependents |
$137 per month |
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Retiree on Medicare, with dependent on Medicare |
$274 per month |
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Retiree on Medicare, with dependent not on Medicare |
$365 per month |
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Retiree on Medicare, with two or more dependents not on Medicare |
$593 per month |
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Retiree on Medicare, with dependent on Medicare and one or more dependents not on Medicare |
$502 per month |
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Retiree on Medicare, with two dependents on Medicare |
$411 per month |
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Retiree Working in the Industry
Rates Effective January 1, 2020
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Retiree not on Medicare, no dependents, running out hour bank |
$228 per month |
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Retiree not on Medicare, with one or more dependents not on Medicare, running out hour bank |
$456 per month |
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Retiree not on Medicare, no dependents, after hour bank run out |
$456 per month |
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Retiree not on Medicare, with one or more dependents not on Medicare, after hour bank run out |
$912 per month |
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Retiree not on Medicare, with one or more dependents on Medicare, running out hour bank |
$365 per month |
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Retiree not on Medicare, with one or more dependents on Medicare, after hour bank run out |
$730 per month |
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Disability Retiree with Earnings above $24,000
Rates Effective January 1, 2020
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.
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Retiree not on Medicare, no dependents |
$380 per month |
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Retiree not on Medicare, with one dependent |
$760 per month |
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Retiree not on Medicare, with two or more dependents |
$1,140 per month |
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Death Benefits
Benefit
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Benefit Amount or Limitation
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Death Benefit for Retired Employee Only
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$10,000
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For additional information regarding Death Benefits refer to the Summary Plan Description (SPD) Section 4.
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Comprehensive Medical Expense Benefits - Not Yet Eligible for Medicare
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Benefit
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Benefit Amount or Limitation
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Medical Expense Benefits
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Calendar Year Deductible
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$500 per person - $1500 Family
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Maximum Benefit
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Spinal Manipulation Maximum
(including diagnostic tests)
(excluding lab tests)
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20 Visits per Calendar Year
(for covered individuals age 16 and older)
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Covered Expenses Payable by the Fund up to the Usual and Customary Fees
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PPO Charges
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Non PPO Charges
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Physician, Hospital/Facility
(inpatient and outpatient for Medical, Mental Health and Substance Abuse)
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85%
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75%
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Skilled Nursing Care
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60 days per confinement;
See Sec. 7.08 (A) (10)
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Out-of-Pocket Maximum per Calendar Year
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$1,950 per Person/$5,850 Family for
PPO expenses
$2,500 per Person for
Non-PPO expenses
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Out-of-Pocket Maximum Does Not Include:
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· Deductible Amount
· Prescription Drug
Co-payments
· Dental Expense Payments
· Vision Care Expense
Payments
Physical, Speech, Occupational Therapy Co-payment above 40 visit limit
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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.
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Note: Durable Medical Equipment and Local Ambulance Service for which PPO services are not available will be covered the same as PPO charges
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Outpatient Physical/Speech Therapy Maximum |
40 visits per Calendar Year* |
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Outpatient Occupational Therapy Maximum |
40 visits per Calendar Year* |
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* 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%. |
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
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Benefit
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Benefit Amount or Limitation
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Employee Assistance Plan (EAP) for Retired Employees and Dependents
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Initial Counseling with EAP Staff
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Up to Three Sessions Covered at No Charge
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For additional information regarding Employee Assistance Plan refer to the Summary Plan Description (SPD) Section 12.
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Hearing Aid Benefits
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Benefit
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Benefit Amount or Limitation
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Hearing Aid Benefit for Retired Employee and Dependents
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Hearing Aid and Exam
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100% Up to $900 per Ear
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Frequency Limit
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One per ear as medically necessary
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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
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Benefit
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Benefit Amount or Limitation
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Prescription Drug Benefit for Retired Employee and Dependents
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Minimum Co-Pay Amount
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Retail
(34 day supply)
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Mail
(90 day supply)
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Generic
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$10
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$20
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Brand Preferred
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20% ($25 minimum)
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20% ($50 minimum)
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Brand Non-Preferred
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30% ($45 minimum)
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30% ($90 minimum)
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Specialty Drug Co-Pay Percentage
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20%
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Annual Out-of-Pocket Maximum for Specialty and Prescription Drugs (Excludes Prescription Narcotics (narcotic agonists)
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$5,000 (Family)
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The participant co-payment for prescription narcotics (narcotic agonists) is always 20% and is not subject to any Out-of-Pocket Maximum
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For additional information regarding Prescription Drug Benefits refer to the Summary Plan Description (SPD) Section 9.
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Prescription Drug Benefits - Medicare
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Benefit
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Benefit Amount or Limitation
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Prescription Drug Benefit for Retired Employee and Dependents
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Co-Pay Percentage
(if greater than minimum co-pay amounts)
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20%
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Minimum Co-Pay Amount
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Retail
(31 day supply)
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Retail
(90 day supply)
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Mail
(90 day supply)
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Generic
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$5
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$15
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$10
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Brand Preferred
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$15
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$45
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$30
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Brand Non-Preferred
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$30
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$90
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$60
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Specialty Drug Co-Pay Percentage
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20%
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Annual Out-of-Pocket Maximum for Specialty and Prescription Drugs
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$2,500 (per person)
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For additional information regarding Prescription Drug Benefits refer to the Summary Plan Description (SPD) Section 9.
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Dental Benefit
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Dental Benefit
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Maximum Benefit
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$1,500 per Person per calendar year except for Diagnostic and Preventive services provided to Dependednts under the age of 19
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Co-payment Paid by the Fund for Diagnostic and Preventive Services
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100% up to the Usual and Customary Fees
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Co-payment Paid by the Fund for Al Other Covered Services |
80% up to the Usual and Customary Fees |
For additional information regarding Dental Care Discounts contact Dental Network of America (DNOA) at 1-800-367-1203
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Vision Benefit
If you wish to receive the Vision Benefit after your retirement, you must pay a separate monthly premium for such coverage. However, you may only receive the Vision Benefit after your retirement if you also pay the applicable retiree self-payment or premium to maintain your medical benefits under thePlan.
If you elect the Vision Benefit upon your retirement and pay the separate monthly premium, you will continue to receive the same coverage under the Plan as you did while you were an Active Employee.Accordingly, for claims incurred on or after January 1, 2018, the Schedules of Benefits for Retired Employees Not Yet Eligible for Medicare and Retired Employees Eligible for Medicare will change as follows:
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Vision Benefit
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Covered Expenses Payable by the Fund up to the Usual and Customary Fees Once Every
Calendar Year
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Your In-Network Cost
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Your Out-of-Network Cost
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Exam with Dilation as Necessary
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$0 Co-payment
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Balance over $40 for Participants andeligible
Dependents over age19
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Contact Lens Fit and Follow Up
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Standard Lenses
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$40 Co-payment, for fit and two follow up
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Not Covered
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visits
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Premium Lenses
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$40 Co-payment, then 10% off balance over
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Not Covered
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$40
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Contact Lenses (In Lieu of Glasses) Conventional
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$0 Co-payment, $150 Allowance, 15% off Balance over $150
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Balance over $110
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Disposable
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$0 Co-payment, $150 Allowance, 15% off Balance over $150
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Balance over $110
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Frames
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80% of Balance over
$150
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Balance over $110 for Frame, Lenses and Options
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Standard Plastic Lenses
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Single Vision Bifocal Trifocal
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$0Co-payment
$0Co-payment
$0Co-payment
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Not Covered
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Lens Options
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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
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$15Co-payment
$15Co-payment
$15Co-payment
$40Co-payment
$45Co-payment
$65 Co-payment 20% Off Retail Price
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Not Covered
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Medicare Supplemental Medical Expense Benefits
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Supplemental Medical Expense Benefit
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Amount Paid by Medicare in 2019
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Amount Paid by Participant in 2019
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Amount Paid by Plan in 2019
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Amounts Payable During any Hospital Confinement
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First 60 Days
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Amount over $1,364
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$712
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$652
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61st Day Through 90th Day
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Amounts over $341 per Day
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$103 per Day
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$238
per Day
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91st Day Until End of Lifetime Reserve
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Amounts over $682 per Day
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$206 per Day
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$476
per Day
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After Lifetime Reserve is Exhausted
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0%
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20%
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80%
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Pints of Blood
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First Three Pints
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$25 per pint
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More than Three Pints
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100%
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0%
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0%
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Medicare Part B Deductible
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0%
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0%
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100%
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Medicare Part B Expenses After Deductible
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80%
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0%
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20%
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Skilled Nursing Facility
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First 20 Days
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100%
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0%
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0%
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21st Day Through 100th Day
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Amounts over $170.50 per Day
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$51.50 per Day
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$119
per Day
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For additional information regarding Medicare Supplement Medical Expense Benefits refer to the Summary Plan Description (SPD) Section 8.
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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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Benefit
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Benefit Amount or Limitation
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Wellness Benefit for Active Employee and Spouse
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Physical Exam (and specified lab tests)
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100% - PPO Only
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Weight Watchers
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100% up to 6 months of a Monthly Pass or 12 months of an Online subscription per person per lifetime (Participant and eligible spouse)
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Benefit
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Benefit Amount or Limitation
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Wellness Benefit for Active Employee and Spouse
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Physical Exam (and specified lab tests)
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100% - PPO Only
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Weight Watchers
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100% up to 6 months of a Monthly Pass or 12 months of an Online subscription per person per lifetime (Participant and eligible spouse)
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