HEALTH & WELFARE FUND SCHEDULE OF BENEFITS

           [Main Page]

EFFECTIVE 10/01/2006 

The following lists the policy benefits for the Bricklayers and Allied Craftworkers Local #74. This is not intended to be a complete statement of all the available plan provisions. 

Please note that the information presented is subject to change. Contact the Fund Office for verification of current benefits and regulations.  

To go directly to a specific topic, click on it from the list below.

LIFE INSURANCE HOSPITAL INPATIENT SECOND SURGICAL OPINION  PHYSICAL EXAM ALCOHOLISM & SUBSTANCE ABUSE   CHIROPRACTIC / PHYSICAL MEDICINE INFERTILITY DIABETES SELF MANAGEMENT COLORECTAL CANCER SCREENING DENTAL

WEEKLY DISABILITY WELL CHILD CARE ADDITIONAL ACCIDENT MAJOR MEDICAL MENTAL / NERVOUS DISORDERS ORGAN TRANSPLANT PRESCRIPTION DRUGS         OCCUPATIONAL / SPEECH THERAPY MAMMOGRAPHY PROSTATE CANCER SCREENING VISION

SCHEDULE OF BENEFITS    (the benefits shown on this schedule apply only to persons who are eligible for the applicable benefits and are subject to all limitations and exclusions)
BENEFITS		MEMBER	DEPENDENT
LIFE INSURANCE		$25,000.00	$0.00
WEEKLY DISABILITY Non-occupational benefit
Maximum Weekly benefit		$300.00	$0.00
Maximum Number of Weeks		26	0
Date Disability Starts:		Accident  -  1st day Illness     -  8th day
SECOND SURGICAL OPINION		Unlimited	Unlimited
ADDITIONAL ACCIDENT		$200.00	$200.00
WELL CHILD CARE  Maximum Amount		NONE	$2,000.00
WELL CHILD CARE (age limit)		NONE	To age 19
PHYSICAL EXAM OR HEALTH DYNAMICS EXAM (Pertains to You and Your spouse Only)		$300.00	$300.00
back to top
MAJOR MEDICAL BENEFITS
INPATIENT HOSPITAL
Maximum Daily Room & Board Rate Maximum Daily		Semi-Private Rate	Semi-Private Rate
Intensive Care Rate		2x’s Semi-Private	2x’s Semi-Private
Hospital Miscellaneous Charges		Unlimited	Unlimited
PHYSICAL MEDICINE / CHIROPRACTIC CARE
Office call & all services performed		Reasonable Charge	Reasonable Charge
Maximum per calendar year		$1,000.00	$1,000.00
Maximum Lifetime payment		$5,000.00	$5,000.00
Major Medical Cash Deductible		$250.00	$250..00
Maximum Family Cash Deductible		$500.00	$500.00
The $500.00 Maximum Family Cash Deductible must be reached by two covered family members each satisfying an Individual Cash Deductible in the same calendar year.
Accumulation Period		Calendar Year	Calendar Year
Maximum Lifetime Payment		$1,000,000.00	$1,000,000.00
However, the following benefit limits apply:
PSYCHIATRIC SERVICES
Maximum Lifetime - Subject to the overall Lifetime Maximum
Inpatient Care -
Maximum Days per Calendar Year		10	10
Maximum Days per Lifetime		20	20
Outpatient Care  -  50% co-insurance in or out of network
Maximum Days per Calendar Year		20	20
Maximum Days per Lifetime		40	40
Alcoholism and Narcotism *
Annual Maximum  -  $5,000.00
Lifetime Maximum  -  $15,000.00
Inpatient Care -
Maximum Days per Calendar Year		10	10
Maximum Days per Lifetime		20	20
Outpatient Care  -  50% co-insurance in or out of network
Maximum Days per Calendar Year		20	20
Maximum Days per Lifetime		40	40
* Plan Benefits for Alcoholism and Narcotism are limited to two confinements per lifetime and each course of treatment must be completed for benefits to be payable.
back to top
PRESCRIPTION DRUG
Maximum per person per calendar year (Experimental Drugs are not covered.)		$15,000.00	$15,000.00
MAIL ORDER PRESCRIPTIONS
Three month supply purchased through Express Scripts		80%	80%
OCCUPATIONAL AND SPEECH THERAPY
Maximum lifetime per person (Benefits for member only.)		$10,000.00	$0.00
HUMAN ORGAN TRANSPLANT
Maximum per transplant procedure Not to exceed the Major Medical Lifetime Limit.		$300,000.00	$300,000.00
COINSURANCE PERCENTAGE
1)  If a Preferred Provider is used  -  85% 2)  If a Non Preferred Provider is used  -  80% 3) 4) In regards to Outpatient Treatment for Psychiatric Services, Alcoholism and  Narcotism, whether or not a PPO Provider is used  -  50%  however, a)  the Coinsurance Percentage shall be 100% for a person in a calendar year after $1,500.00 of “Eligible Out-of-Pocket expense”, as defined, are incurred in connection with that person’s illness during that calendar year: and b)  for all members of a Family, the Coinsurance Percentage shall be 100% in a calendar year after $3,000.00 of “Eligible Out-of-Pocket Expense”, as defined, are incurred in connection with all the illnesses associated with the family during the remainder of that calendar year. At least two (2) members of the Family must meet &1,500.00 of “Eligible Out-of Pocket Expense” per calendar year.
“Eligible Out-Pocket Expenses” are those expenses that are Covered Charges in excess of the Cash Deductible which are not payable solely because of any payment percentage of less than 100%.
back to top
PREGNANCY Benefits for pregnancy, childbirth and related medical conditions are payable under the same terms and conditions as benefits are payable for any injury or disease.
MAMMOGRAPHY BENEFITS Notwithstanding anything to the contrary contained in the Certificate, benefits shall be provided for the screening, by low dose mammography, for the presence of occult breast cancer in women, ages 35 and older, once every calendar year. Such benefits will be payable to the same extent as for any other radiological examination and subject to the same dollar limits, deductibles and coinsurance factors under the Group Policy.  “Low-dose Mammography” means x-ray examination of the breast using  equipment dedicated specifically for mammography, including the x-ray tube, filter, compression device, screens, films and cassettes, with an average radiation exposure delivery of less than one radii mid-breast with two views for each breast.
INFERTILITY BENEFITS Notwithstanding anything to the contrary contained in the Certificate, benefits shall be payable for the diagnosis and treatment of infertility to the same extent as for any other injury or sickness, subject to all the definitions, terms, conditions, limitations, coinsurance provisions, deductibles and exceptions of the Policy not inconsistent herewith. Diagnosis and treatment of infertility shall include, but not limited to the following procedures:             1)  in vitro fertilization;             2)  uterine embryo lavage;             3)  embryo transfer;             4)  artificial insemination;             5)  gamete intrafallopian tube transfer;             6)  zygote intrafallopian tube transfer; and             7)  low tubal ovum transfer.  In addition, benefits for procedures for in vitro fertilization, gamete infrafallopian tube transfer or zygote infrafallopian tube transfer shall be payable only if:              1)  the covered individual has been unable to attain or sustain a successful             pregnancy through reasonable, less costly medically appropriate infertility                       2)  the covered individual has not undergone 4 completed ooctye retrievals, except            that if a live birth follows a completed ooctye retrieval, then 2 more completed             oocyte retrievals shall be covered; and  3)  the procedures are performed at medical facilities that conform to the American   College of Obstetric and Gynecology guidelines for in vitro fertilization clinics or to the American Fertility Society minimal standards for programs of in vitro  fertilization.  “Infertility” means the inability to conceive after one year of unprotected sexual intercourse or the inability to sustain a successful pregnancy, as certified by the covered individual’s physician.
back to top
DIABETES SELF-MANAGEMENT TRAINING AND EDUCATION The Group Policy will provide coverage for outpatient self-management training and education, equipment, and supplies, for the treatment of type I diabetes, type 2 diabetes, and gestational diabetes mellitus. Coverage for diabetes self-management training will be subject to the same deductible, co-payment, and coinsurance provisions that apply to coverage under the Group Policy for other services provided by the same type of provider. Coverage will be provided for the following equipment when medically necessary and prescribed by a physician licensed to practice medicine in all of its branches. Coverage for the following items will be subject to deductibles, co-payment and co-insurance provisions provided for under the group policy or a durable medical equipment rider to the Group Policy: 1)  blood glucose monitors; 2)  blood glucose monitors for the legally blind; 3)  cartridges for the legally blind; and 4)  lancets and lancing devices. This coverage does not apply to a Group Policy of accident and health insurance that does not provide a durable medical equipment benefit. Coverage will be provided for the following pharmaceuticals and supplies when medically necessary and prescribed by a physician licensed to practice medicine in all of its branches. Coverage for the following items will be subject to the same coverage, deductible, co-payment, and co-insurance provisions under the Group Policy or a drug rider to the Group Policy: 1)  insulin; 2)  syringes and needles; 3)  test strips for glucose monitors; 4)  FDA approved oral agents used to control blood sugar; and 5)  Glucagon emergency kits.  This coverage does not apply to a Group Policy of accident and health insurance that does not provide a drug benefit. Coverage will be provided for regular foot care exams by a physician or by a physician to whom a physician has referred the patient. Coverage for regular foot care exams will be subject to the same deductible, co-payment, and co-insurance provisions that apply under the Group Policy for other services provided by the same type of provider. If authorized by a physician, diabetes self-management training may be provided as a part of an office visit, group setting, or home visit. “Diabetes self-management training” means instruction in an outpatient setting which enables a diabetic patient to understand the diabetic management process and daily management of diabetic therapy as a means of avoiding frequent hospitalization and complications. Diabetes self-management training shall include the content areas listed in the National Standards for Diabetes Self-management Education Programs as published by the American Diabetes Association, including medical nutrition therapy. “Medical nutrition therapy” shall have the meaning ascribed to “medical nutrition care” in the Diabetic and Nutrition Services Practice Act. “Physician” means a physician licensed to practice medicine in all of its branches providing care to the individual. “Qualified provider” means (a) a physician licensed to practice medicine in all of its branches or (b) a certified, registered, or licensed health care professional with expertise in diabetes management to whom the individual has been referred by a physician. Coverage for diabetes, self-management training, including medical nutrition education, will be limited to the following: 1)  Up to 3 medically necessary visits to a qualified provider upon initial diagnosis of diabetes by the patient’s physician or, if diagnosis of diabetes was made within one year prior to August 13, 1998 where the insured was a covered individual, up to 3 medically necessary visits to a qualified provider within one year after the effective date.             2)  Up to 2 medically necessary visits to a qualified provider upon a determination by a                  patient’s physician that a significant change in the patient’s symptoms or medical                   condition has occurred. A “significant change” in condition means symptomatic                   hyperglycemia (greater than 250 mg/dl on repeated occasions), severe                   hypoglycemia (requiring the assistance of another person), onset or progression of                  diabetes, or a significant change in medical condition that would require a                  significantly different treatment regimen.   Payment by the Fund Office for the coverage required for diabetes self-management training is only required to be made for services provided. No coverage is required for additional visits beyond those.
back to top
COVERAGE FOR COLORECTAL CANCER SCREENING The Group Policy will provide coverage for colorectal cancer screening with sigmoidoscopy or fecal occult blood testing once every 3 years for Covered Persons who are at least 50 years old. For Covered Persons who may be classified as high risk for colorectal cancer because the person or a first degree family member of the Covered Person has a history of colorectal cancer, the coverage will apply to persons who have attained at least 30 years old.
PROSTATE CANCER SCREENING  The Group Policy will provide coverage for an annual digital rectal exam and a prostate-specific antigen test, for male members upon the recommendation of a physician licensed to practice medicine in all its branches:            1) asymptomatic men age 50 and over; 2) African-american men age 40 and over; and 3) Men age 40 and over with a family history of prostate cancer
back to top
DENTAL	MEMBER		DEPENDENT
Coinsurance Percentages:
Type I    -  Preventive Dental Services	100%		100%
Type II   -  Basic Dental Services	70%		70%
Type III  -  Major Dental Services	70%		70%
Type IV  -  Orthodontic Dental Services	50%		50%
Maximum Amount per Benefit Period* (Type I, II and III Combined)	$1,250.00		$1,250.00
Maximum Benefit While Insured (Type IV)            Applicable to Dependent Children Only	NONE		$2,000.00
Cash Deductible per Person	$75.00		$75.00
Maximum Family Cash Deductible	$225.00		$225.00
The deductible applies only to covered expenses under Type II and Type III and must be incurred within a Benefit Period * all family members will have satisfied the deductible.  * Benefit period shall refer to a continuous period commencing on the first day of January of each calendar year and ending on the thirty-first day of December next following. A new period begins each year on the first day of January.
VISION	MEMBER		DEPENDENT
Maximum Payment per Benefit Period *	$300.00		$300.00
* Benefit Period shall refer to a continuous period commencing on the first day of January of each calendar year and ending on the thirty-first day of December next following. A new benefit period begins each year on the first day of January
VISUAL CORRECTION SURGICAL BENEFIT	MEMBER		DEPENDENT
Maximum Lifetime Benefit  (Member and Spouse only)	$1,000.00		$1,000.00
ALL BENEFITS, OTHER THAN LIFE ARE NON-OCCUPATIONAL AND ARE NOT PAYABLE FOR SICKNESS COVERED BY WORKER’S COMPENSATION OR INJURIES ARISING OUT OF ANY EMPLOYMENT FOR WAGE OR PROFIT.

 

Local 74 of Illinois 
phone:   630-734-0074
fax:        630-734-1870         

last updated:  06/27/07

Created by: Westwind Concepts / BAC #74