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Pipe Fitters' Welfare Fund, Local 597

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.

   

  •       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 and Vision Benefits
Health Reimbursement Arrangement (HRA)

  •       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, 2019

 

Retiree not on Medicare, no dependents $222 per month
Retiree not on Medicare, with dependent not on Medicare $444 per month
Retiree not on Medicare, with two or more dependents not on Medicare $666 per month
Retiree not on Medicare, with dependent on Medicare $355 per month
Retiree not on Medicare, with dependent on Medicare and one or more dependents not on Medicare $577 per month
Retiree not on Medicare, with two dependents on Medicare $488 per month
Retiree on Medicare, no dependents $133 per month
Retiree on Medicare, with dependent on Medicare $266 per month
Retiree on Medicare, with dependent not on Medicare $355 per month
Retiree on Medicare, with two or more dependents not on Medicare $577 per month
Retiree on Medicare, with dependent on Medicare and one or more dependents not on Medicare $488 per month
Retiree on Medicare, with two dependents on Medicare $399 per month

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Retiree Working in the Industry

Rates Effective January 1, 2019

 

Retiree not on Medicare, no dependents, running out hour bank $222 per month
Retiree not on Medicare, with one or more dependents not on Medicare, running out hour bank $444 per month
Retiree not on Medicare, no dependents, after hour bank run out $444 per month
Retiree not on Medicare, with one or more dependents not on Medicare, after hour bank run out $888 per month
Retiree not on Medicare, with one or more dependents on Medicare, running out hour bank $355 per month
Retiree not on Medicare, with one or more dependents on Medicare, after hour bank run out $710 per month

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Disability Retiree with Earnings above $24,000

Rates Effective January 1, 2018

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 $369 per month
Retiree not on Medicare, with one dependent $738 per month
Retiree not on Medicare, with two or more dependents $1,107 per month

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Death Benefits

 

Benefit

Benefit Amount or Limitation

Death Benefit for Retired Employee Only

$10,000

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

Benefit

Benefit Amount or Limitation

 Medical Expense Benefits

  Calendar Year Deductible

$300 per person - $900 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. 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

Physical, Speech, Occupational Therapy Co-payment 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%.
 

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 Benefit

 Dental Benefit

 

Maximum Benefit

$1,500 per Person per calendar year except for Diagnostic and Preventive services provided to Dependednts under the age of 19

Co-payment Paid by the Fund for Diagnostic and Preventive Services

100% up to the Usual and Customary Fees
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:

Vision Benefit

 

 

Covered Expenses Payable by the Fund up to the Usual and Customary Fees Once Every

Calendar Year

 

Your In-Network Cost

 

Your Out-of-Network Cost

 

Exam with Dilation as Necessary

 

$0 Co-payment

 

Balance over $40 for Participants andeligible

Dependents over age19

 

 

Contact Lens Fit and Follow Up

 

 

Standard Lenses

$40 Co-payment, for fit and two follow up

Not Covered

 

visits

 

Premium Lenses

$40 Co-payment, then 10% off balance over

Not Covered

 

$40

 

 

Contact Lenses (In Lieu of Glasses) Conventional

 

$0 Co-payment, $150 Allowance, 15% off Balance over $150

 

Balance over $110

 

 

Disposable

$0 Co-payment, $150 Allowance, 15% off Balance over $150

Balance over $110

 

Frames

 

80% of Balance over

$150

 

Balance over $110 for Frame, Lenses and Options

 

Standard Plastic Lenses

 

 

Single Vision Bifocal Trifocal

$0Co-payment

$0Co-payment

$0Co-payment

Not Covered

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

$15Co-payment

$15Co-payment

$15Co-payment

$40Co-payment

$45Co-payment

$65 Co-payment 20% Off Retail Price

Not Covered

 

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Medicare Supplemental Medical Expense Benefits

Supplemental Medical Expense Benefit

Amount Paid by Medicare in 2019

Amount Paid by Participant in 2019

Amount Paid by Plan in 2019

Amounts Payable During any Hospital Confinement

          First 60 Days

Amount over $1,364

$712

$652

          61st Day Through 90th Day

Amounts over $341 per Day

$103 per Day

$238
per Day

          91st Day Until End of Lifetime Reserve

Amounts over $682 per Day

$206 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%

Skilled Nursing Facility

          First 20 Days

100%

0%

0%

          21st Day Through 100th Day

Amounts over $170.50 per Day

$51.50 per Day

$119
per Day
 

 

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 100% of PPO Usual and Customary Fee for the covered service.  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 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 6 months of a Monthly Pass or  12 months of an online membership per person per lifetime (participant and eligible spouse).

    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 1.866.204.2885 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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    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 monthly premium to the Welfare Plan after the run-out of your Hour Bank

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    • 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)

     

     

    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)