PLUMBERS LOCAL 75 HEALTH FUND BENEFIT HIGHLIGHTS SUMMARY

Transcription

1 PLUMBERS LOCAL 75 HEALTH FUND BENEFIT HIGHLIGHTS SUMMARY Prepared by: Lee Jost and Associates October, 2005

2 PLUMBERS LOCAL 75 HEALTH FUND Benefit Highlights Benefit Description Class A Employees and Dependents Death Benefits (Employees only) $1,000 Loss-of-Time Benefits weekly rate (Employees only) $400 Comprehensive Major Medical Benefits for hospital services, physicians services, certain prescription drugs, x-ray and lab services, and other covered items and services when medically necessary, subject to the following: Lifetime maximum per person $500,000 Calendar year deductible 1 In-network 2 Per person $250 Per family $750 Out-of-network Per person $300 Per family $900 Emergency room separate dollar copay per visit before applicable copayment percentage $ 50 Plan s copayment of covered expenses Inpatient 3 In-network and precertified 80% In-network, but not precertified 75% Out-of-network, but precertified 70% Out-of-network, but not precertified 65% Outpatient In-network 80% Out-of-network 70% Ambulance services 80% Out-of-network PEAR group charges incurred while hospitalized or receiving outpatient treatment in a network hospital 80% 1 If the eligible employee or dependent spouse participates in the Preferred Provider Preventive Care Program in 2005, such person s individual deductible for 2006 will be reduced by $50. If both the eligible employee and dependent spouse participate in the Preferred Provider Preventive Care Program in 2005, the family s deductible for 2006 will be reduced by $100. The same reductions shall apply for subsequent years, provided the eligible employee and/or dependent spouse participate AND achieve performance goals of either improving body composition or maintaining acceptable body composition. 2 In-network means services and/or supplies received from a provider participating in the Preferred Provider Network. In addition, both inpatient and outpatient claims from Mercy Hospital-Janesville are payable according to the in-network level of benefits. Also, all PEAR (for Pathologists, Emergency, Anesthesiologists, and Radiologists) group charges incurred while hospitalized or receiving outpatient treatment in a network hospital are payable subject to the in-network deductible. 3 The Plan will not pay the hospital room and board charge when the utilization review manager determines that days of hospital stay are not medically necessary. 1

3 Eligible person s copayment for physicians visits, podiatry visits, and urgent care In-network, per visit Out-of-network Class A Employees and Dependents $25 (no other copayment applies) 70% of reasonable expenses Out-of-pocket maximum per calendar year, not including deductible or specific dollar amount copays for emergency room visits, physicians visits, podiatry visits, and urgent care In-network (and ambulance services) Per person $2,500 Per family $4,000 Out-of-network Per person $4,000 Per family $6,000 Plan generally pays 100% of covered expenses in excess of such maximum for remainder of that calendar year. Second surgical opinions; pre-admission testing; well child care ($300 per calendar year from birth to age 2, $75 per calendar year from age 2 to age 19); routine immunizations ($50 per calendar year for employee and spouse, no maximum for dependent children); Hepatitis B vaccinations (for employees only, up to Health Dynamics maximum); hospice care; subject to Comprehensive Major Medical Benefits lifetime 100% of reasonable expenses; maximum not subject to deductible Routine physical exam (for employee and spouse only) 100% to calendar year maximum of $300 - OR - 100% of actual fee through Health Dynamics; not subject to deductible 2

4 Class A Employees and Dependents Treatment of nervous and mental disorders Inpatient (31 days total per person per calendar year) 1 Inpatient, partial hospitalization, residential, and intensive outpatient (IOP) 31 days at 80% 2 If FSP Provider is NOT used Inpatient Partial hospitalization, residential, and intensive outpatient (IOP) 31 days at 65% of FSP-authorized amount NO BENEFITS Outpatient (25 total visits per person per calendar year) 1 100% of first 8 visits; then 80% of next 17 visits If FPS Provider is NOT used 50% of 25 visits at FSP-authorized amount 3 Treatment of substance abuse and alcoholism (per lifetime) Inpatient 4 Inpatient 31 days at 80% Partial hospitalization, residential, and intensive outpatient (IOP) 4 80%, up to $5,000 maximum If FSP Provider is NOT used Inpatient Partial hospitalization, residential, and intensive outpatient (IOP) Outpatient ($3,000 aggregate maximum) If FSP Provider is NOT used 31 days at 65% of FSP-authorized amount NO BENEFITS $3,000 maximum (100% of first $1,500; then 80% of next $1,500) 50% of FSP-authorized amount up to lifetime maximum 3 1 Trustees may extend this maximum per person per calendar year up to an additional 15 days for inpatient treatment and up to an additional 10 visits for outpatient treatment on a case-by-case basis upon the recommendation of the FSP manager. 2 2 for 1 benefit 2 days of partial hospitalization, residential treatment or intensive treatment = 1 day of inpatient treatment. 3 50% copayment does not apply to out-of-pocket maximum. 4 Trustees may extend this maximum per person per lifetime an additional 15 days for inpatient treatment and up to a maximum of $2,500 payable at the applicable copayment for partial hospitalization on a case-by-case basis upon the recommendation of the FSP manager. 3

5 Class A Employees and Dependents Prescription drug benefits If preferred provider pharmacy is used Deductible amount per person per calendar year $50 Eligible person s copayment per prescription Retail network pharmacy, up to a 30-day supply Generic $8.00 Brand name drugs on formulary list 20% copayment minimum $10.00, maximum $ Brand name drugs not on formulary list 1 20% copayment; minimum $35.00, maximum $ Mail-order service, up to a 90-day supply Generic $ 8.00 Brand name drugs on formulary list $16.00 Brand name drugs not on formulary list $50.00 If preferred provider pharmacy is not used No benefits, except for certain specified prescription drugs Vision Benefits Exam (1 per calendar year) $50 Lenses (1 set each 2 calendar years) Single, each lens $45 Bifocal, each lens $60 Trifocal, each lens $75 Lenticular, each lens $120 Contact lenses, each lens (1 set each 2 calendar years, in lieu of conventional lenses and frames) 2 $120 Frames (1 set each 2 calendar years) $150 Safety glasses (1 set per active employee each calendar year, up to maximum per set) $120 1 If a physician specifies no substitutions and the eligible person must receive the drug prescribed, the physician will be required to provide a written letter to the PPRx for authorization prior to the medication being dispensed for the eligible person to obtain that particular brand name drug at the copayment for brand name drugs on the formulary list. 2 Or, disposable contact lenses, up to the maximum for one set of contacts each two calendar years. 4

6 Class A Employees and Dependents Delta Dental Plan Dental Benefits Delta PPO Non-PPO Deductible (excluding orthodontics and PPO diagnostic and preventive services) Per person per calendar year $ 50 $ 150 Per family per calendar year $ 150 $ 450 Maximum benefit per calendar year $1,500 $1,000 Maximum orthodontic benefit per lifetime $1,500 $1,500 Diagnostic and preventive services 1 100% 70% Regular restorative services 80% 70% Crowns, inlays, and onlays 80% 70% Bridges and dentures 80% 70% Orthodontic services 100% 100% This summary reflects a basic outline of the coverages that are provided under the Plan. It is not meant to be a Summary Plan Description or a Plan Document. It is to be used solely as a tool by the Union to present an overview of what is in the Plan. The benefits reflected in the summary are not guaranteed and are subject to change at any time. plm\for\benefit Highlight Summary October Diagnostic and preventive services are covered twice per calendar year (at six-month increments). 5