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Summary Plan Description

Benefit Summary

This is a summary of benefits available under the Carpenters Health and Security Plan of Western Washington—For Employed Carpenters (the Employee Health Plan). For benefit details and other plan provisions including the eligibility requirements for eligible dependents, enrollment requirements, and limitations and exclusions, please refer to the appropriate section of the Employee Health Plan booklet. If there is a conflict between the Benefit Summary and the Employee Health Plan booklet, the Employee Health Plan booklet governs.
Eligibility

Monthly Dollar Bank Deduction

Effective October 1, 2009, the monthly dollar bank deduction is $725 for the A07 benefit package and $675 for the B07 benefit package.

Initial Eligibility

You must accumulate a minimum amount equal to three months of eligibility in your dollar bank account to start the eligibility system ($2,175 at October 2009 rates). At least $1.00 of contributions must be earned 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 benefits on the first day of the fifth month for a three month period.

If your current dollar bank deduction is $675, click here.

Continuing Eligibility

After your initial eligibility, you must continue to accumulate sufficient contributions in you dollar bank account to fund each monthly dollar bank deduction. When the amount in your dollar bank equals or exceeds the monthly dollar bank deduction, you will be eligible on the first day of the second month after your dollar bank balance exceeds the monthly deduction amount.
Out-of-Pocket Expenses and Maximums
Annual Deductible $200 per person per calendar year. $400 per family per calendar year.
Annual Maximum $750,000 per person per calendar year. View previous policy.
Copayments

$50 emergency room copayment. Waived if admitted as an inpatient directly following treatment in the emergency room. $10 office visit copayment if an office visit is billed by a physician or mental health care provider.

Additional $10 office visit copayment if an office visit is billed by a nonpreferred provider. Does not apply to office visits billed outside the preferred provider network.

$200 inpatient hospital copayment for inpatient hospital admissions at nonpreferred provider facilities. Does not apply to inpatient admissions billed outside the preferred provider network. See also Prescriptions.

Coinsurance

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.

20 percent or 50 percent depending on the type of service or supply received, and the type of provider used. These services always require 20 or 50 percent coinsurance and the 20 or 50 percent coinsurance does not apply toward the $2,300 annual coinsurance maximum.
Physical Examinations
Physical Examinations

Participant, spouse and domestic partners—Paid at 100 percent. Subject to the Preventive Health Benefit Schedule.

Children—Paid at 90 percent. Subject to the Preventive Health Benefit Schedule. $10 office visit copayment if an office visit is billed. An additional $10 office visit copayment if an office visit is billed by a nonpreferred provider.
Screening Tests
Screening Tests

Paid at 100 percent for participants, spouses and domestic partners. Subject to the Preventive Health Benefit Schedule.

Paid at 90 percent for children. Subject to the Preventive Health Benefit Schedule. Not subject to the annual deductible. $10 office visit copayment if an office visit is billed. An additional $10 visit copayment if an office visit is billed by a non-preferred provider.
Routine Immunizations
Routine Immunizations

Paid at 100 percent for participants, spouses and domestic partners. Subject to the Preventive Health Benefit Schedule.

Paid at 90 percent for children. Subject to the Preventive Health Benefit Schedule. Not subject to the annual deductible. $10 office visit copayment if an office visit is billed. An additional $10 visit copayment if an office visit is billed by a non-preferred provider.
Physician Services
Physician Services Paid at 90 percent. $10 office visit copayment if an office visit is billed. An additional $10 office visit copayment if an office visit is billed by a nonpreferred provider.
Second Surgical Opinion Paid at 100 percent. Not subject to the annual deductible. A second opinion (if required) must be obtained through the medical review program.
Surgical Services—Surgeon, Assistant Surgeon and Anesthetist Paid at 90 percent of the usual, customary and reasonable charge as determined by this plan.
Hospital Services (Medical, Surgical and Maternity)
Inpatient Hospital Paid at 90 percent. $200 inpatient hospital copayment for nonpreferred provider facilities. Preadmission certification is required.
Outpatient Hospital Paid at 90 percent.
Emergency Room Paid at 90 percent. $50 copayment for emergency room.
Hospital Alternatives
Skilled Nursing Facility Paid at 90 percent. Calendar year maximum of 25 inpatient days.
Home Health Care Paid at 100 percent. Calendar year maximum of 30 visits. Preauthorization is required.
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.
Rehabilitative Care
Inpatient Rehabilitation Paid at 90 percent. Calendar year maximum of 15 inpatient days. $200 inpatient hospital copayment for nonpreferred provider facilities. Preadmission certification is required.
Outpatient Rehabilitation Paid at 90 percent. Calendar year maximum of 30 visits.
Chiropractic Care
Chiropractor Paid at 80 percent. Calendar year maximum of 24 spinal manipulations.
Mental Health Care
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.
Outpatient Mental Health Paid at 80 percent. Calendar year maximum of 30 visits.
Chemical Dependency
Chemical Dependency Paid at 80 percent. Inpatient treatment not to exceed 28 days in a 24-month period. Outpatient treatment not to exceed 36 visits in a 24-month period. Lifetime maximum of three episodes of treatment. $200 inpatient hospital copayment for nonpreferred provider facilities. Preadmission certification is required.
Other Services
Allergy Testing Paid at 90 percent. Calendar year maximum as follows: blood testing for allergies is limited to 12 allergens; skin testing for allergies is limited to 60 allergens.
Ambulance Paid at 90 percent.
Autism Spectrum Disorders Paid at 90 percent. Calendar year maximum of 15 visits. Preauthorization is required. For children age 12 and under.
Diagnostic X-Ray and Laboratory Paid at 90 percent.
Durable Medical Equipment and Medical Supplies Paid at 90 percent. Preauthorization is required.
Neurodevelopmental Therapy Paid at 90 percent. Calendar year maximum of 15 visits. Preauthorization is required. For children age six and under.
Neuropsychological or Psychological Assessments or Tests Paid at 80 percent. Lifetime maximum of $1,200. Preauthorization is required.
Pregnancy Care Paid at 90 percent. For the participant, spouse and domestic partner only.
Transplants Paid at 90 percent. Subject to a 12-month waiting period. Donor procurement maximum of $25,000.
Prescriptions
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.
Medco By Mail

$14 copayment for each generic prescription purchased through the home delivery pharmacy service.

$30 copayment for each brand-name prescription listed on the drug program formulary and purchased through the home delivery pharmacy service.

$60 copayment for each brand-name prescription not listed on the drug program formulary and purchased through the home delivery pharmacy service.

Up to a 90-day maximum supply.
Vision Benefits
Eye Examination Annual maximum of $100
Hardware

Single vision—$75

Bifocal—$105

Trifocal—$150

Progressive—$150

Lenticular—$150

Special lens treatment—$40

Frames—$90

Contact lenses—$125
Dental Benefits
Dental Paid based on Dental Fee Schedule with annual maximum of $2,000 for participants and dependents with a $725 dollar bank deduction and $1,500 for those with a $675 dollar bank deduction.
Dental Implants Paid at 50 percent. Lifetime maximum of $1,000 for participants and dependents with a $725 dollar bank deduction. No benefit for those with a $675 dollar bank deduction.
Orthodontic Paid at 50 percent. Lifetime maximum of $1,500 for participants and dependents with a $725 dollar bank deduction and $1,000 for eligible children with a $675 dollar bank deduction.
Time Loss Benefits
Time Loss The weekly time loss benefit for participants with a $725 dollar bank deduction is equal to 33 percent of journeyman pay based on a 40-hour week at the prevailing journeyman's rate specified in the Area Master Agreement signed by your most recent contributing employer. This benefit is paid for a maximum of 26 weeks. Physician certification is required. Seven-day waiting period when disability is due to an illness. For the participant only. The weekly time loss benefit for participants with a $675 dollar bank deduction is $100 per week for a maximum of 26 weeks.
Life Insurance Benefits
Life Insurance

Participant—$30,000.

Dependents—$5,000.
Accidental Death and Dismemberment Paid based on schedule amounts. For the participant only.