Welfare & Eligibility

Becoming an eligible participant

You need to meet certain work requirements to first become eligible and to continue to be eligible for coverage.

Initial Eligibility

To first become eligible, you must have at least 300 hours of contributions in a contribution quarter. This means that you have worked 300 hours and your employer has contributed to the Fund for your 300 hours of work. The following chart shows you when you are eligible:

Contribution Quarter

300 Hours of Contributions

Corresponding Benefit Quarter

November, December, January

Yes

You’re eligible in April, May, June

February, March, April

Yes

You’re eligible in July, August, September

May, June, July

Yes

You’re eligible in October, November, December

August, September, October

Yes

You’re eligible in January, February, March

Your coverage begins on the first day of the corresponding benefit quarter following the contribution quarter during which you worked 300 hours. For example, if you worked at least 300 hours in November, December, and January combined, your coverage would begin on the next April 1 and continue through June 30.

Welfare Plan at a glance

Schedule of Benefits

The following chart highlights key features of your Plan. These benefits are described in greater detail later in this booklet. Important: For benefits to be payable, you must submit a claim within 12 months from the date of service.

Comprehensive Medical Benefit For You and Your Dependents

Lifetime Maximum

$1,000,000 per person

Annual Cash Deductible
Per Person
Per Family


$175
$500

Percentage Paid
PPO Hospital
PPO Ambulatory Surgical Center
Non-PPO Hospital
Non-PPO Ambulatory
Surgical Centers
Most Other Covered Expenses


Plan pays 90%; you pay 10%
Plan pays 90%; you pay 10%
Plan pays 80%; you pay 20%
NOT COVERED

Plan pays 80%; you pay 20%

Annual Out-of-Pocket Maximum

$1,500 (excludes $175 deductible)

The following benefits are paid at 100% by the Plan
and are not subject to the deductible.

Diagnostic X-Ray and Lab

Plan pays first $200 per person (for expenses in excess of $200, Plan pays 80% after deductible)

Physical Exam for You and Your Spouse

Plan pays up to $100 per person per year

Additional Accident

Plan pays first $300 per accident (for expenses in excess of $300, Plan pays 80% after deductible)

The following benefits are paid by the Plan at 80%, 90% for PPO Hospital. Certain outpatient services are paid at 50%. All benefits are subject to the deductible and Lifetime Maximum.

Infertility Treatment

$10,000 per person per lifetime

Substance Abuse Treatment
(Alcoholism and Narcotism)
Calendar Year Maximum
Lifetime Maximum

Inpatient


Outpatient
Percentage paid
Maximum Visits Per Year
Maximum Visits Per Lifetime



$7,500 per person
$15,000 per person

Maximum of 10 days per person per year; 20 days per person per lifetime


Plan pays 50%; you pay 50%
20
40

Mental Health Treatment
Inpatient

Outpatient
Percentage Paid
Maximum Visits Per Year
Maximum Visits Per Lifetime


Maximum of 10 days per person per year; 20 days per person per lifetime

50%
20
40

Transplants

$250,000 per person per transplant

Inpatient Convalescent Care

30 days per calendar year (Plan pays 80%; you pay 20%)

Dental Care Benefit For You and Your Dependents

Annual Deductible per calendar year
(January 1 through December 31)
Per Person
Per Family
Applies only to Basic and Major Services



$50
$150

Percentage Paid
Preventive Services
Basic Services
Major Services
Orthodontic Services


Plan pays 70%; you pay 30%
Plan pays 70%; you pay 30%
Plan pays 70%; you pay 30%
Plan pays 50%; you pay 50%

Maximum Benefit
Orthodontic Services
All Other Dental Services


$1,000 per person per lifetime
$1,000 per person per calendar year

Prescription Drug Benefit For You and Your Dependents

Retail and Mail Order Programs

You pay: 10% generic/20% preferred brand/ 40% non-preferred brand

Mandatory Mail Order

For 3rd fill of maintenance or long-term drug

Vision Care Benefit For You and Your Dependents

Annual Deductible

None

Maximum Benefit

Plan pays $175 per calendar year: $50 for the exam and $125 for eyewear.

Family Supplemental Benefit For You and Your Dependents

Calendar Year Maximum

$500 per family, subject to all applicable Plan provisions and limitations. You must file a claim for this benefit no later than March 31st following the calendar year in which the expense was incurred.

Death Benefit

For You

$25,000

Accidental Death and Dismemberment Benefit (AD&D)

For You

Up to $25,000 determined by the severity of the injury.

Note: In the case of an eligible employee’s accidental death, the Plan will pay the $25,000 death benefit and the $25,000 AD&D Benefit — or a total of $50,000.

Weekly Disability Benefit for You

Maximum Benefit

$200 per week

Maximum Payment Period

26 weeks

Benefit Begins

1st day of disability due to accident; 8th day of disability due to illness