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Five River Carpenters Health & Welfare Benefits

Updated November 9th, 2018

A Summary of your Benefits under the Five River Carpenters Health & Welfare Fund

Eligibility Rules

For initial eligibility under the Five River Carpenters Health & Welfare Fund you must have $3,100.00 in your HRA account.

Once you achieve Initial Eligibility you will continue to be eligible if you maintain a minimum of $3,100.00 per coverage quarter. These quarters are as follows:

Work Quarter Eligibility Quarter
September - November January - March
December - February April - June
March - May July - September
June - August October - December

Health & Welfare Benefits

Effective January 1, 2017 your plan is administered by Wellmark. Please refer to your medical ID card for contact information.

Five Rivers Carpenters Health & Welfare Plan is a comprehensive major medical benefit, which also includes dental, vision and prescription benefits. The plan utilizes network providers belonging to the Wellmark Preferred Provider Organization for the Medical benefits. You have the option to use the providers “in network” or “out of network”. However, your benefits under the Fund’s Health plan are greater and your out-of-pocket cost is less when you use the Wellmark providers (in-network).

WELLMARK (PPO) BENEFITS

Individual Calendar Year Deductible: $200.00
Family Calendar Year Deductible: $400.00
Individual Out of Pocket Expense: $500.00
Family Out of Pocket Expense: $1,000.00

After the calendar year deductible has been satisfied the plan will pay at 90% to your individual/family out of pocket per calendar year and then will pay at 100% of covered charges.

NON NETWORK BENEFITS

Individual Calendar Year Deductible: $500.00
Family Calendar Year Deductible: $1,000.00
Individual Out of Pocket Expense: $2,000.00
Family Out of Pocket Expense: $3,500.00

After the calendar year deductible has been satisfied the plan will pay at 80% to your individual/family out of pocket per calendar year and then will pay at 100% of covered charges.

Prescription Benefit

Prescriptions are covered through Optum℞. You must use your prescription identification card at participating pharmacies for your prescription benefits. You will be responsible for the greater of $10 or 10% each new or refill of a generic prescription. All Brand prescriptions are subject to $20 or 20% whichever is greater. Prescriptions are never paid at 100%; they will always be subject to a copay. Mail Order or online Pharmacy 90-Day Supply: Generic prescriptions are subject to $0 copay and Brand prescriptions are the greater of $0 or 20%.

Dental Benefit

Each family member is entitled a $300.00 Dental Benefit. It is a basic benefit that means you can have up to $300.00 worth of Dental work done per year payable at 100%.

Mental Nervous & Alcohol Drug Benefits

Services are covered the same as any other sickness or illness. This also includes Prescription Drugs.

Vision Benefit

Each family member is entitled to $200 per a two year period Routine Vision Benefit. This covers routine services for eye exams and hardware. The current “two calendar year” period for this provision is January 1, 2018 through December 31, 2019.

Short Term Disability Benefit

Weekly Loss of Time (Bargaining Agreement Members Only) Non- Occupational Benefits:

Payment begins – for Injury 1st Day
Payment begins – for Sickness 8th Day
Weekly Benefit $300
Maximum Payment Period 26 Weeks

Wellness Benefit

The Fund will cover one Annual Physical Exam per year. This applies to the member, spouse and children. The service rendered for a standard physical exam, as specific under the government’s CPT Code (Current Procedural Technology Code), will be paid. The new law requires that you do not have to pay a co-pay or deductible for this physical.

The Fund will cover Preventative Health Services. This applies to the member, spouse and children as defined by government’s Health Care Act. This would include, as an example, Immunization Practices from the Center for Disease Control and Prevention,Screenings for infants, children and adolescents as defined by the Health Resources and Service Administration and Preventative Care and Screening for women as outlined by the Health Resources and Service Administration. Again, the new law says that you will not have to pay a co-pay or a deductible for Preventative Health Services. Until the government has clearly defined what this is, the Trustees have defined this as care or tests that are used to prevent diseases or illnesses, which include items like pap smears, mammograms, and routine blood work. Note: This definition will be modified once the government has issued their regulations.

Pediatric Preventative Care

For purposes of the benefits available under the plan, the term “Pediatric” means birth up to age 18. The following amendments to the plan pertain to preventative pediatric vision care and oral care. Expenses incurred or charges made must still be usual, customary and reasonable as defined in the plan of benefits.

Vision Care (pediatric preventative only) coverage:

One routine vision exam each calendar year and one pair of eyeglass lenses per calendar year, with no calendar year benefit maximum, is covered under the plan of benefits.

Oral Care (pediatric preventative only) coverage:

Coverage for the following dental services will be provided in accordance with the Plan’s current schedule of benefits, but will not be subject to the dental calendar year benefit maximum for eligible dependent children up to age 18.

  • Routine periodic examinations limited to two exams per Calendar Year. A re-evaluation is considered included in the primary procedure and is not payable separately.
  • Complete mouth x-rays (posterior bitewing films and 14 periapical films plus bitewings) are allowed once during any three-year period for members age 13-18, in lieu of panorex x-ray.
  • Full series bitewing x-rays (4) are allowed only twice in a Calendar Year.
  • A panorex is allowable once during any three-year period in lieu of complete mouth x-ray.
  • Vertical bitewings are payable up to eight films.
  • Dental prophylaxis (cleaning) allowed twice in a Calendar Year. A child Prophylaxis will be allowed through age 13. An adult Prophylaxis will be allowed for age 14-18.
  • Dental sealant application on permanent molars is allowed for eligible Dependent children under age 18 once during any five-year period. Permanent molars include teeth numbers 1, 2, 3, 14, 15, 16, 17, 18, 19, 30, 31, and 32. (Permanent molars with occlusal restoration are ineligible.

All Adult Dependent Children Eligible for Coverage

Coverage will be available to a participant’s eligible children up to the end of the month in which the child attains age 26, regardless of the child’s marital status, student status, employment status, eligibility for other health insurance coverage, financial dependency on the participant, or any other factor other than the relationship between the child and the participant.

This is a self insured/self-funded plan. There is no extra charge for covering dependents.

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