| This is a summary of benefits
available under the Carpenters Health and Security Plan – For Employed
Carpenters. For benefit details and other plan provisions including limitations
and exclusions, please refer to the appropriate section of the plan booklet. If
there is a conflict between the “Benefit Summary” and the Employed
Plan booklet, the Employed Plan booklet governs. |
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Eligibility
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Rule
1. You must work a minimum of 275
hours (for which employer contributions were received by this plan) in a
three-month period, with at least one of those hours worked in the first month
of the three-month period. The fourth month is
the “lag month.” This is the time required for your employer to send
updated contribution records to the plan and the time required for the plan to
process those records. You are then eligible for a three-month period beginning
with the fifth month. Rule 1 must be used to establish initial eligibility.
After establishing inital eligibility, you may use Rule 1 or Rule 2 to continue
eligibility.
Rule
2. If you work a minimum of 1,250
hours (for which employer contributions were received by this plan) in the first
12 of the past 13 months, you are eligible for a three-month period, beginning
with the 14th month.
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Out-of-Pocket Expenses and
Maximums
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Annual
Deductible
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$200 per person per calendar
year.
$400 per family per calendar
year.
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Annual
Maximum |
$325,000 per person per
calendar year.
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Copayments
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$50
emergency room copayment. Waived if admitted as an inpatient directly following
treatment in the emergency room. $10
office visit copayment when a physician or mental health care provider bills an
office visit. An additional $10 when a nonpreferred provider bills an office
visit (for care received in Washington State only).
$200 inpatient hospital
copayment for inpatient hospital admissions at nonpreferred provider facilities.
Does not apply to inpatient hospital admissions when care is received outside
Washington State.
See also Prescriptions.
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Coinsurance
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10 percent for most services
and supplies. Paid at 100 percent for the remainder of the calendar year when an
individual’s coinsurance reaches $2,300. A family’s annual
coinsurance maximum is $4,600. 20 percent or 50 percent
depending on the type of service or supply received, the type of provider and
the out-of-pocket expenses satisfied. 20 percent and 50 percent coinsurance does
not apply toward the $2,300 annual coinsurance maximum (except orthognathic
surgery) and these services always require 20 percent or 50 percent
coinsurance.
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Physician
Services
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Physician
Services |
Paid at 90 percent. $10
office visit copayment when a physician or mental health care provider bills an
office visit. An additional $10 when a nonpreferred provider bills an
office visit (for care received in Washington State only). |
Second
Surgical Opinion
(if
required) |
Paid at 100 percent. Not
subject to the annual deductible. A second opinion must be obtained through the
medical review program.
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| Surgical Services – Surgeon, Assistant Surgeon and Anesthetist |
Paid
at 90 percent of the usual, customary and reasonable charge as determined by
this plan. If a second surgical opinion is required but not obtained, the
surgeon is paid at 50 percent for the covered surgery. |
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Preventive Care
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Participant
and Spouse |
Paid at 90 percent. $10
office visit copayment when a physician bills an office visit. An additional $10
when a nonpreferred provider bills an office visit (for care received in
Washington State only). $400 calendar year maximum benefit for the participant.
$300 calendar year maximum benefit for the spouse.
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Children |
Paid at 90 percent. $10
office visit copayment when a physician bills an office visit. An additional $10 when a nonpreferred provider bills an office visit (for
care received in Washington State only). $400 maximum during first year of life
(0 months through 11 months), $300 maximum during second year of life (12 months
through 23 months) and $200 maximum during third year through eighteenth year of
life (24 months through 18 years). |
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Pap
Smear and Mammogram |
Paid at 90 percent. One pap
smear per calendar year, one baseline mammogram and its interpretation (women
ages 35-39), and one mammogram and its interpretation each calendar year (women
age 40 and older).
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Hospital Services (Medical,
Surgical and Maternity)
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Inpatient
Hospital |
Paid at 90 percent. $200
inpatient hospital copayment for nonpreferred provider facilities. Preadmission
certification is required. If preadmission certification is not obtained, $50 is
deducted from the covered room and board expense for each day of inpatient
hospital care, up to a maximum of $250.
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Outpatient
Hospital |
Paid at 90 percent. $50
copayment for emergency room.
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Hospital
Alternatives
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Skilled Nursing
Facility
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Paid
at 90 percent. Calendar year maximum of $10,000. |
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Home
Health Care |
Paid at 100 percent. Calendar
year maximum of $5,000. Preauthorization is required.
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Hospice
Care |
Paid at 100 percent. Maximum
of 14 inpatient days during six-month period. Skilled care in the home is
limited to 60 visits. Respite care is limited to 120 hours per three-month
period. Preauthorization is required.
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Rehabilitative
Services |
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Inpatient
Rehabilitation |
Paid at 90 percent. Calendar
year maximum of $24,000. $200 inpatient hospital copayment for nonpreferred
provider facilities. Preadmission certification is required. If
preadmission certification is not obtained, $50 is deducted from the covered
room and board expense for each day of inpatient hospital care, up to a maximum
of $250. |
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Outpatient
Rehabilitation |
Paid at 90 percent. Calendar
year maximum of $2,000.
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Chiropractic
Care
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Chiropractor
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Paid at 80 percent. Calendar
year maximum of $750.
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Mental Health
Care
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Inpatient
Mental Health |
Paid at 80 percent. Calendar
year maximum of 15 inpatient days. $200 inpatient hospital copayment for
nonpreferred provider facilities. Preadmission certification is required. If
preadmission certification is not obtained, $50 is deducted from the covered
room and board expense for each day of inpatient hospital care, up to a maximum
of $250.
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Outpatient
Mental Health |
Paid at 80 percent. Calendar
year maximum of 30 outpatient visits. $10 office visit copayment when a
physician or mental health care provider bills an office visit. An additional
$10 when a nonpreferred provider bills an office visit (for care received in
Washington State only).
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Chemical
Dependency |
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Chemical
Dependency
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Paid at 80 percent. Maximum
of $5,000 paid in any 24-month period with a lifetime maximum of $10,000. $200
inpatient hospital copayment for nonpreferred provider facilities.
Preadmission certification is required. If preadmission certification is not
obtained, $50 is deducted from the covered room and board expense for each day
of inpatient hospital care, up to a maximum of $250. |
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Other Services
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Allergy Testing
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Paid
at 90 percent. Calendar year maximum of $600. |
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Ambulance
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Paid
at 90 percent. |
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Diagnostic
X-Ray and Laboratory |
Paid at 90
percent.
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Durable Medical Equipment and
Medical Supplies
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Paid
at 90 percent. Preauthorization is required. |
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Hearing
Aids |
Paid at 90 percent. $1,000
per ear maximum in any three consecutive year period.
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Neurodevelopmental
Therapy – Children Age Six and Under |
Paid at 90 percent. Calendar
year maximum of $1,500. Preauthorization is required.
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Neuropsychological
Assessments or Tests |
Paid at 80 percent. Calendar
year maximum of $600. Lifetime maximum of $1,200. Preauthorization is
required.
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Orthognathic
Surgery |
Paid at 50 percent. Lifetime
maximum of $5,000. Preauthorization is required.
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Orthotics – Foot Only |
Paid at 90 percent. $200
maximum in any three consecutive year period.
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Pregnancy
Care – Participant and Spouse Only |
Paid at 90
percent.
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TMJ/MPDS |
Paid at 50 percent. Lifetime
maximum of $2,500.
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Transplants |
Paid at 90 percent. Subject
to 12-month waiting period. Donor procurement maximum of
$25,000. |
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Prescriptions |
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Medco
Health Retail Pharmacy Program |
$7 copayment for each generic
prescription purchased from a participating retail pharmacy.
$15 copayment for each
brand-name prescription listed on the drug program formulary and purchased from
a participating retail pharmacy.
$30 copayment for each
brand-name prescription not listed on the drug program formulary and purchased
from a participating retail pharmacy.
Up to a 30-day maximum
supply.
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Medco
By Mail |
$10 copayment for each
generic prescription purchased through the home delivery pharmacy
service. $20 copayment for each
brand-name prescription listed on the drug program formulary and purchased
through the home delivery pharmacy service.
$35 copayment for each
brand-name prescription not listed on the drug program formulary and purchased
throughthe home delivery pharmacy service.
Up to a 90-day maximum
supply.
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Vision
Benefits |
Vision Benefits
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Paid based on Table of Covered Vision Care.
| Eye Examination – Per Calendar Year |
$80 |
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| Hardware – Per Calendar Year |
Single vision
Bifocal
Trifocal
Progressive
Lenticular
Contact lenses
Special lens treatment
Frames |
$60
$65
$95
$135
$135
$150
$20
$80 |
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Dental Benefits
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Dental Benefits
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Paid based on Dental Fee
Schedule. Calendar year maximum of $2,000
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Dental Implants
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Paid at 50 percent. Lifetime
maximum of $1,000.
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Orthodontic
Benefits |
Paid at 50 percent. Lifetime
maximum of $1,500.
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Time
Loss Benefits |
| Time Loss Benefits – Participant Only |
33 percent of journeyman pay
based on 40 hours at the prevailing journeyman rate specified in the Area Master
Agreement for a maximum of 26 weeks per disability. Physician certification is
required. Seven-day waiting period when disability is due to an
illness.
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Life
Insurance Benefits |
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Life
Insurance |
Participant – $30,000.
Dependents – $5,000. |
| Accidental Death and
Dismemberment – Participant Only |
Paid based on scheduled
amounts.
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