Medical Benefits

Plumbers’ Welfare Fund, Local 130, U.A.

Eligibility

An eligible Participant becomes covered under the Welfare Fund after completing 150 hours in Covered Employment with a Contributing Contractor within 3 months.

Deductible

There is a $200.00 per person calendar year deductible with a per family maximum of $600.00 as of June 1, 2011. Not all of the benefits listed below are subject to this deductible. There is also a $25.00 co-pay for office visits and a $150.00 co-pay for emergency room visits.

Schedule of Medical Benefits
Pre-Admission Hospital	Tests Paid in full
In-patient Hospital Room & Board per stay	100% of Reasonable and Customary
In-hospital services	100% of 1st $2,000.00 90% of remaining bills until $2,000.00 out-of-pocket is met
In-hospital doctor visits Normal	$150.00 for 1st visit $100.00 per additional visit
In-hospital doctor visits Intensive Care	$275.00 for 1st visit $150.00 per additional visit
In-hospital doctor visits Consulting Physician	$250.00 each visit for a total of 3 consults
Surgical Benefits	Paid in full if in network
Assistant Surgeon	20% of allowed surgical charge
Organ Transplants	Subject to Plan maximums applicable to a specific transplant. Advance Trustee approval required for transplants.
Hospice Care	Up to $400.00 per day
Wellness	100% of Reasonable and Customary
Immunizations	100% of reasonable & customary charges for vaccinations including Hepatitis B.
Eye Care	$40 for general eye exam $40 for contact lens fitting and follow-up exam $200 for vision materials (Glasses/Contacts) Once per year unless patient is under the age of 18
Out-patient	100% of 1st $1,000.00 Then 80% of remaining bills until $2,000.00 out-of-pocket is met
Hearing Aids	$1,500.00 per aid once every 5 years
Hearing Exams	$125.00 per exam once every 2 years
Prescription Drugs	RETAIL: Generic drugs with a co-payment of $10.00. Name brand drugs a co-payment of either $10.00 or $20.00. MAIL ORDER: Generic drugs with a co-payment of $0.00. Name brand drugs a co-payment of either $5.00 or $10.00.

Additional Limit on Non – PPO Providers

In addition to the limits noted above, the Fund will recognize only up to 70 percent of the reasonable and customary charges for covered expenses with doctors, hospitals, and other providers that are not part of the Blue Cross Blue Shield PPO networks. Charges above this amount will not be covered by the Fund and will be the responsibility of the Participant or Dependent.

Dental Benefits

Dental benefits are subject to a separate $50.00 deductible with a maximum deductible of $150 per family unit. After the deductible is met, the Plan pays up to 100% of the reasonable cost of routine dental oral examinations and 80% of other covered dental services, up to an annual maximum benefit of $2,500 unless the patient is under the age of 18 then there is no limit. The Welfare Fund uses Delta Dental as the administrator of the dental benefits and both the Welfare Fund and Participants can receive savings as a result of using providers within the Delta Dental network. For further information about Delta Dental, please contact the Fund Office.

Orthodontic Benefits

The Welfare Fund pays 80% of reasonable charges up to a maximum lifetime limit of $3,500.

Vision Benefits

The Welfare Fund pays up to $40 for a general eye examination, $40 for contact lens fitting and follow-up exam and $200 for prescription glasses, frames, and lenses. The vision benefits are administered through EyeMed and Participants and dependents can receive discounts by using EyeMed providers. For further information about EyeMed providers please contact the Fund Office.

Health Reimbursement Arrangement (HRA)

A Health Reimbursement Arrangement (HRA) is a supplemental way to help you pay for out of pocket medical expenses that you are required to pay under the terms of the Plumbers’ Welfare Fund, Local 130 U.A. (Plan).

Items you can reimburse through the HRA include:

Annual deductibles per person
Co-payments for medical expenses & prescription drugs
Cobra and Self-Pay premiums.

HRA Reimbursement Claim filing instructions:

A signed, dated and completed claim form (below) plus all necessary explanation of benefits & proof of payment must be attached to the form.

Plumbers Welfare HRA Form
You cannot submit a claim on yourself or any of your dependents unless you or your dependents are eligible for benefits under the Plumbers’ Welfare Fund, Local 130 U.A. Plan.

Important Notice: This website provides only a brief explanation of the Health and Welfare Plan under the Plumbers’ Welfare Fund, Local 130, U.A. and is not a summary plan description. If there are any inconsistencies between this explanation and the Plan document, the Plan document shall control. Also, please refer to the Summary Plan Description for additional information about the benefits available and procedures of the Plumbers’ Welfare Fund, Local 130, U.A. or contact the Plumbers Welfare Fund Office .