I.B.E.W LOCAL 701 BENEFIT FUNDS
ALWAYS AT YOUR SERVICE

28600 Bella Vista Parkway, Suite 1110
Warrenville, IL 60555-1500
Phone (630) 393-1701   Fax (630) 393-3615
info@ibew701fbo.com


The following is a summary of the Benefits available under the General Welfare Fund of IBEW Local 701 as of 6/1/05 for Active Employees:

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Comprehensive Major Medical Members Assistance Program (MAP)
Death Benefits Physical Examination Benefit
Dental Benefits Prescription Drug Program
Hearing Care Supplemental Accident Benefit
Life Insurance Vision Care
Medical Savings Allowance (MSA) Weekly Loss of Time
Other (includes COBRA information) 
ACTIVE EMPLOYEES ONLY, NO DEPENDENTS
WEEKLY LOSS OF TIME BENEFITS*
NON Occupational Weekly Benefit Amount 2.5% of the last 12 months earnings up to a $400 maximum per week
Maximum number of weeks Payable

26
Benefit starting date: Disability due to an accident:

First day
Disability due to an illness:

Fourth day
Occupational Benefit Amount: First Week

$ 45
Subsequent Weeks

$ 15
Maximum Weeks Payable

26
Benefit starting date: Disability due to an accident:

First day
Disability due to an illness:

Fourth day

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 Life Insurance
Active Employee*    $ 10,000
Spouse and eligible dependent children    $ 5,000
Accidental Death & Dismemberment*

$  10,000
* Items with an asterisk do not apply to Employees covered by the Maintenance D Collective Bargaining Agreement.  Also, please note that Maintenance D Benefits apply to Employees only and do not apply to their dependents
COMPREHENSIVE MAJOR MEDICAL BENEFITS
Lifetime Maximum

$ 1,000,000
Annual Deductible Per Person

$250
Per Family

$500
The benefits normally payable on your claim will be reduced by $100 if you do not pre-certify any inpatient or outpatient surgery, whether in or out of the PPO network.  Any other inpatient Hospital confinement outside the PPO network must also be pre-certified or the benefits normally payable on your claim will be reduced by $100.  The Plan will pay no benefits for inpatient treatment of Mental or Nervous Disorders, chemical dependency, or substance abuse if you do not pre-certify the treatment.  To pre-certify these types of treatment call Med-Care Management at (800) 423-7781.
Emergency Room Deductible:      $100 per incident. Waived if admitted as an inpatient directly          from the emergency room.
Co-Insurance Percentages:

PPO Providers:  90 %                 Non-PPO Providers: 70%

Out-of-Pocket Limits:

PPO Providers: $ 1,000         Non-PPO Providers: $ 2,000 

PPO and Non-PPO out of pocket limits are separate.                                                             Amounts that apply to one limit will not be applied to the other.
PPO Physician office visit $10 co-payment per visit; not subject to the deductible
Non-PPO surgical centers are not covered.

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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 for up to six months
Chiropractic care
Maximum Benefit $1,000 per Calendar Year
Voluntary Sterilization (Eligible Employee and spouse only)

Lifetime Maximum Benefit: 
Subject to Lifetime Benefit Only
Infertility treatment and procedures (Eligible Employee and spouse only)

Maximum Benefit: 
$10,000 per Lifetime
Weight control treatment (Eligible Employee and spouse only)

Maximum Benefit: 
$1,000 per Lifetime
Corrective refractive surgery

$750 per eye
per Lifetime
Temporomandibular joint syndrome (TMJ)  Benefit Calendar Year Maximum

$1,000
Lifetime Maximum                                                            $3,000
Smoking cessation, with Physicians approval

$500 Lifetime Maximum
Speech therapy: Speech and language therapy will no longer be covered by the plan, except for speech therapy to restore following a stroke, or for cleft palate.
Physical and occupational therapy: 

25 visits following a covered surgical procedure:          12 visits for a covered medical condition

If your therapy exceeds the applicable limit, you must call Med-Care Management @ 1-800-367-1934 for pre-certification of additional visits.
Podiatry Plan co-payment after the Calendar Year deductible has been satisfied
Tier 1- AFAS network

100%
Tier 2 - BCBS network

90%
Tier 3 - Non-Network

70%
Med Link (MRI, CT) - In -Network Not Subject to Deductible

100% 
The following item is not subject to the Comprehensive Major Medical Calendar Year deductible
PHYSICAL EXAMINATION EXPENSE BENEFIT Maximum Benefit per family

$2,000 per Calendar Year
Routine colonoscopies are covered under the comprehensive major medical benefit, not under the physical examination expense benefit
DENTAL CARE EXPENSE BENEFIT  (Calendar Year) Not Subject to Deductible
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
Orthodontia  (All eligible participants)

50% of covered charges
Individual Lifetime Maximum Orthodontia

$1,500
Per Person Calendar Yr. Maximum

Family Calendar Yr. Maximum      

$1,500

$5,000
Coverage for loss or removal of teeth begins on the date of initial eligibility.
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
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 (for 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
HEARING CARE EXPENSE BENEFIT
Maximum Benefit: Examination

$75 every two Calendar Years
Hearing aid instrument
per ear

$1,500 every five consecutive years
Artificial Stapes per ear

$4,500 every 15 consecutive years

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MEMBERS ASSISTANCE PROGRAM BENEFIT (MAP)

(No benefits will be payable if the treatment is not pre-certified or referred in accordance with the provisions on page 63 of the Summary Plan Description Booklet.)
Plan co-payment of covered charges, except prescription drugs

80%
Benefits will be reduced if you or your Dependent is receiving an inpatient or residential course of treatment or intensive outpatient program and you or your Dependent leaves against medical advice and MAP approval.  Even if the treatment has been pre-certified or referred.
PRESCRIPTION DRUG PROGRAM
Drug Card Program (for short-term [acute] prescription drugs up to 30-day supply):

Generic Drugs

 The greater of $10 or 20% of the cost (up to a maximum of $15)
Preferred Brand Drugs The greater of $15 or 20% of the cost (up to a maximum of $25)
Non- Preferred Brand Drugs The greater of $20 or 20% of the cost (up to a maximum of $40)

Mail Order Program (up to 90-day supply):

 Generic Drugs $20
Preferred Brand Drugs $35
Non- Preferred Brand Drugs $50

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OTHER INFORMATION
Dependents covered to age 19 if not full time student, to age 25 if full time student
COBRA (06/0l/05)
Regular Benefit Plan

Medical Only $759.83/month

 Medical/Dental/Vision
$838.23/month
COBRA (06/0l/05)
Security Plan

Medical Only $714.24/month

 Medical/Dental/Vision
$787.94/month
Hospitals / Physicians send medical claims to:
Blue Cross / Blue Shield
PO Box 805107
Chicago, IL 60680
Group No: P81221
BS Plan No: 621
BC Plan No: 121
Annual Claim Forms, 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 Telephone Inquiries 1-312- 938-7340 Providers ONLY
BCBS All Other Inquiries 1-800-571-1043 Members or Others
Med Care Management, Inc 1-800- 423-7781 In/Out Pt., Surgery and Emergency Pre-Cert.
Sav-RX (Prescription Drugs)  1-800- 233-4239 Group IBEW701-Active
IBEW701F-Factory Sign
Sav-RX ( Mail Order Pharmacy) 1-800- 233-4239 Group IBEW701-Active
IBEW701F-Factory Sign
Associated Foot & Ankle 1-800- 775-8829 Group No: IBEW Local 701
Med Link (MRI, CT) 1-888-558-0688 Group No: IBEW Local 701
MAP Phone Number 1-800- 540-0477

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To Launch the Summary Document into Microsoft Word, click here . 
To launch the document to a PDF file (recommended for printing) click here.  You must have Adobe Acrobat Reader in order to view a PDF file.  If you do not have this software, you can download it for free from  Adobe's Web Site.