Medical Benefit Summary Plan Description (SPD)
Medical Summary of Benefits Coverage (SBC)
Medical Benefits Summary Material Modifications (SMM)
Summary Annual Report (SAR)
Notices/Letters
Eligibility
Effective January 1, 2017, employees are only required to accumulate 300 hours to earn Initial Eligibility and the Participant would become eligible for benefits on the 1st day of the following month after accumulating the 300 hours. The Participant would be eligible for the remainder of that Benefit Quarter, as well as the next Benefit Quarter. Afterwards, the Participant would need to work 250 hours in the Contribution Quarter in order to maintain eligibility under the corresponding Benefit Quarter.
For example, if a Member begins working in Covered Employment and works 300 hours by April 15, coverage will begin May 1 and run through the June, July and August 2017 Benefit Quarter. To continue coverage, the Participant will need 250 hours in the Contribution Quarter of April, May, and June to continue coverage in the Benefit Quarter of September, October and November.
*Please note that if hours in a month were used to gain
eligibility, those hours cannot be reused to maintain eligibility.
Deductible
There is a $200.00 per person calendar year deductible with a per family maximum of $600.00 as of June 1, 2011. Not all of the benefits are subject to this deductible. There is a $150.00 co-pay for emergency room visits.
Additional Limit on Non – PPO Providers
In addition to the limits noted above, the Fund will recognize only up to 70 percent of the reasonable and customary charges for covered expenses with doctors, hospitals, and other providers that are not part of the Blue Cross Blue Shield PPO networks. Charges above this amount will not be covered by the Fund and will be the responsibility of the Participant or Dependent. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Pre-Certification is required for all out-of-network services.
Dental Benefits
Dental benefits are subject to a separate $50.00 deductible with a maximum deductible of $150 per family unit. After the deductible is met, the Plan pays up to 100% of the reasonable cost of routine dental oral examinations and 80% of other covered dental services, up to an annual maximum benefit of $4,000 unless the patient is under the age of 19 then there is no limit. The Welfare Fund uses Delta Dental as the administrator of the dental benefits and both the Welfare Fund and Participants can receive savings as a result of using providers within the Delta Dental network. For further information about Delta Dental, please contact the Fund Office.
Orthodontic Benefits
The Welfare Fund pays 80% of reasonable charges up to a maximum lifetime limit of $4,500.
Vision Benefits
The Welfare Fund pays up to $40 for a general eye examination, $40 for contact lens fitting and follow-up exam and $350 for prescription glasses, frames, and lenses. The vision benefits are administered through EyeMed and Participants and dependents can receive discounts by using EyeMed providers. For further information about EyeMed providers please contact the Fund Office. You can use the Vision Center within our Wellness Center:
Or locate another provider by clicking on the link below:
Express Scripts - Prescription Drugs
100% of Reasonable and Customary cost for up to a 34 day retail supply less the applicable co-payments as
follows:
$10.00 - for covered generic drugs,
$20.00 - for covered brand name drugs on Express Scripts’ formulary, and
$40.00 - for covered brand name drugs not on Express Scripts’ formulary.
100% for Express Scripts’ Prescription Drug Mail Order Program (3 month supply), less the applicable copayments
as follows:
$ 0.00 - for covered generic drugs,
$10.00 - for covered brand name drugs on Express Scripts’ formulary, and
$20.00 - for covered brand name drugs not on Express Scripts’ formulary.
For prescribed specialty and self-administered injectable drugs (except insulin), 100% of Reasonable and
Customary cost less the applicable $20.00 co-payment but only if the drug is acquired from Accredo. There is no
coverage for specialty and self-administered drugs that are not acquired from Accredo.
Health Reimbursement Arrangement (HRA)
A Health Reimbursement Arrangement (HRA) is a supplemental way to help you pay for out of pocket medical expenses that you are required to pay under the terms of the Plumbers’ Welfare Fund, Local 130 U.A. (Plan) and the IRS Code 213(d).
Items you can reimburse through the HRA include:
- Annual deductibles per person
- Co-payments for medical expenses & prescription drugs
- Cobra and Self-Pay premiums.
- Menstrual care products, over the counter drugs and medications purchased without a prescription on or after January 1,2020
Debit cards available to use for HRA-eligible expenses.
Debit cards will be administered through Optum Financial. The amount available through your card will reflect the current unused credits to your HRA. You will not receive a card until you have earned initial eligibility under the Plan.
If you lose active eligibility and elect COBRA, you will continue to accrue additional credits to your HRA account and will have immediate access to those contributions. (Your rights, if any, to COBRA under the HRA will be explained in the COBRA Election Notice that is provided following a loss of eligibility.)
Effective September 18, 2024, if you no longer work in covered employment but you maintain a
balance in your HRA account, that account balance will not be subject to forfeiture and may be
used for reimbursement of eligible expenses subject to the terms of the Plan.
For more information, contact the Optum Financial customer care group at 877-292-4040.