Welfare Fund

Schedule of Benefits for Active Employees
(Except for Class 11*)

Welfare Fund Home

 

Comprehensive Major Medical	Members Assistance Program (MAP)
Death Benefits	Physical Examination Benefit
Dental Benefits	Prescription Drug Program
Hearing Care	Vision Care
Life Insurance	Weekly Loss of Time
COBRA	Other Information  (including where to send claims, etc)
* The benefits provided to eligible Class 11 employees and their eligible dependents are described  in an insert to the Plan Booklet

Weekly Loss Of Time Benefits  (Active Employees Only, No Dependents)
Non Occupational Weekly Benefit
Non Occupational Weekly Benefit Amount		2.5% of the last 12 months earnings up to a $400 maximum per week
Non Occupational Benefit starting date for Disability due to an accident:			First Day
Non Occupational Benefit starting date for Disability due to an illness:			Fourth Day
Non Occupational Maximum Weeks Payable:			26
Occupational Weekly Benefit
Occupational Benefit Amount First Week:			$45.00
Occupational Benefit Amount Subsequent Weeks:			$15.00
Occupational Benefit starting date for Disability due to an accident:			First Day
Occupational Benefit starting date for Disability due to an illness:			Eighth Day
Occupational Maximum Weeks Payable:			26
back to top
Life Insurance
Active Employee			$ 10,000
Eligible dependent of an active participant			$ 5,000
Accidental Death & Dismemberment			$10,000
back to top
Comprehensive Major Medical Benefits
Lifetime Maximum		$ 1,000,000
Annual Deductible		$250 Per Person
		$500 Per Family
Utilization review non-compliance deductible Applies to inpatient hospitalizations and surgeries (in or outpatient) that are not pre-certified		$100
Emergency room deductible (waived if omitted from ER) Separate from calendar year deductible and does not apply to the maximum out-of-pocket limit		$100 per incident
Plan co-payment for covered charges per Calendar Year after the satisfaction of the Calendar Year deductible and before the applicable out-of-pocket limit has been reached:		PPO Provider	90%
		Non-PPO Provider	70%
See Special Benefits and Limitations starting of page 3 of the Plan Booklet for some exceptions to these coinsurance percentages
Plan payment for covered charges after the applicable out-of-pocket limit has been met			100%
Out of Pocket limits per calendar year		PPO Provider	$1,000
		Non-PPO Provider	$2,000
Special Benefits and Limitations
PPO Physician office visit		$10 co-payment per visit;  not subject to the deductible or out-of-pocket limit
Non-PPO surgical center		not covered
Mental or nervous disorders and substance abuse (combined)
Maximum days of inpatient/intensive outpatient treatment:		Per calendar year	30 days
		Per lifetime	60 days
Inpatient/intensive outpatient  Percentage PPO:			90%
Inpatient/intensive outpatient  Percentage Non-PPO:			70%
Office/outpatient Percentage:			50%
No benefits are payable if the treatment is not pre-certified and approved in accordance with Plan rules. The calendar year deductible applies. Your coinsurance shares for mental or nervous disorders and substance abuse do not apply to the out-of-pocket limits and will not be paid at 100% if your applicable out-of-pocket limit has been met. Benefits for substance abuse will be reached to 50% if a patient terminates a MAP approved treatment and aftercare program against medical advise
Skilled Nursing Facility		Maximum number of days per confinement	45 Days
Home Health Care		Maximum Number of visits per Calendar Year	100
Hospice Care		Maximum benefits	$135 per day up to six months
Physical/occupational therapy
Maximum visits per disability		Post-surgical	25 visits
		Medical (no surgery)	12 visits
Pre-certification through Med-care Management is required if visits will exceed 12 for medical and 25 for Post-surgical.
back to top
Chiropractic care
Maximum benefit		$1,000 per calendar year
Infertility treatment and procedures (Eligible Employee and spouse only)		Maximum Lifetime Benefit:	$10,000
Non-surgical obesity treatment (Eligible Employee and spouse only)		Maximum Lifetime Benefit:	$1,000
Corrective refractive surgery		Maximum Lifetime Benefit:	$750 per eye
Transplant donor benefits
Maximum benefit for potential donor testing		$1,000
Maximum benefit for actual donor's  expenses		$50,000
Temporomandibular Joint Syndrome (TMJ)		Calendar Year Maximum	$1,000
		Lifetime Maximum	$3,000
Smoking cessation, with Physicians approval		Lifetime Maximum	$500
back to top
MRI's and CT and PET Scans
Tier 1		Med-Link network (no deductible)	100%
Tier 2		BCBS network (deductible applies)	90%
Tier 3		Non- network (deductible applies)	70%
The following items are not subject to the Comprehensive Major Medical Calendar Year deductible.
Wellness Benefit
Maximum Benefit per family for PPO providers			$2,000 per calendar year
Maximum Benefit per family for all services rendered by non-PPO providers			$350 per calendar year
Prescription Drug Program (Through Sav-Rx)
Generic Drugs		20%; minimum $10  maximum $15
Preferred Brand Drugs		20%; minimum $15 maximum $25
Non- Preferred Brand Drugs		20%; minimum $20  maximum $40
Mail Order Program (up to 90-day supply)
Generic Drugs		$20
Preferred Brand Drugs		$35
Non- Preferred Brand Drugs		$50
Use of Retail Pharmacy is mandatory for first two fills of  a long-term or maintenance modification. Mail order is mandatory for the fourth and all subsequent fills.
back to top
Dental Care Expense Benefit (Calendar Year) Not Subject to Deductible
Coverage for loss or removal of teeth begins on the date of initial eligibility.
Coverage A (routine oral examination)		100%   of covered charges
Coverage B (basic dental care)		80%  of covered charges
Coverage C (gold restorations, crowns, prosthetics)		50%  of covered charges
Calendar Year Maximum		$1,500 per individual/ $5,000 per Family
Orthodontia  (dependent children under age 19 only)		50%  of covered charges
Orthodontia Lifetime Maximum		$1,500 per Individual
back to top
Vision Care Expense Benefit
Indemnity Schedule		Maximum Benefit
Examination		$50
Single  Lens (pair) or Contacts		$65
Bi-Focal or Tri-Focal Lens (pair)		$75
Frames		$125
Contact Lenses following  cataract surgery		$100
Safety Glasses		$100
back to top
Vision Schedule		Maximum Benefit
Eye examination once per Calendar Year		Provided
Uncoated plastic lenses once per Calendar Year		Provided
Frames once every two Calendar Years		Provided up to $75
Contact lenses		Up to $100
Safety glasses (Employees only) once per Calendar Year		Up to $100
Please call NVA at (800) 672-7723 for the location of a provider near you, or visit their Web Site
back to top
Hearing Care Expense Benefit
Examination		$75 every two Calendar Years
Hearing aid instrument per ear		$1,500 every three consecutive years
back to top
Dependents covered to age 19 if not full time student, to age 25 if full time student
COBRA Regular Benefit Plan June 1, 2008		COBRA Security Benefit Plan  June 1, 2008
Medical Only	$805.60	Medical Only	$757.26
Medical, Dental, Vision	$894.32	Medical, Dental, Vision	$840.66
11 Month extension Medical only	$1,184.71	11 Month extension Medical only	$1,113.62
11 month extension  Medical, Dental, Vision	$1,315.18	11 month extension  Medical, Dental, Vision	$1,236.26
back to top
OTHER INFORMATION
Hospitals / Physicians send medical claims to: Blue Cross / Blue Shield PO Box 805107 Chicago, IL 60680-4112 Group No: P81221 BS Plan No: 621 BC Plan No: 121
Annual Claim Forms and ALL Dental Claim Forms should be sent to: IBEW Local 701 Benefit Funds 28600 Bella Vista Parkway, Suite 1110 Warrenville, IL 60555-1600
ALL Vision Claims should be sent to: National Vision Administration PO Box 2187 Clifton, NJ 07015 Sponsor No. 1090 800-672-7723
BCBS Provider Only Telephone Inquiries		1-312- 938-7340
BCBS All Other Inquiries (Members and others)		1-800-571-1043
Med Care Management, Inc In/Out Pt., Surgery and Emergency Pre-Cert.		1-800- 423-7781
Sav-RX (Prescription Drugs)  Group IBEW701-Active IBEW701F-Factory Sign		1-800- 233-4239
Sav-RX ( Mail Order Pharmacy) Group IBEW701-Active IBEW701F-Factory Sign		1-800- 233-4239
Med Link (MRI, CT) Group No: IBEW Local 701		1-888-558-0688
MAP Phone Number		1-800- 540-0477
Healthy Together		1-888-323-1472
back to top