The Comprehensive Medical Benefit covers a wide range of medical expenses and provides financial protection when you and your family need medical care.
Both the Active and Non-Medicare Retiree Plans of Benefits work similarly. Generally, after you pay an individual deductible (up to a family limit), the Plan and you share the cost of medical expenses. The Plan pays:
For more information, including your deductibles, the percentages the Plan pays and annual limits, refer to the section titled Your Medical Benefits of your Summary Plan Description (SPD).
Your Prescription Drug Benefit features a retail pharmacy program and a mail-order program. The retail pharmacy program is for short-term prescriptions (up to a 34-day supply). The mail-order program is for long-term prescriptions (up to a 90-day supply).
For more information on this benefit, see the section titled The Prescription Drug Benefit of your Summary Plan Description (SPD).
The Dental Expense Benefit will pay a percentage of covered expenses depending on the type of services you receive. The percentages are as follows:
|Preventative and Diagnostic||100%|
|Restorative and Prosthodontics||80%|
Benefits are paid each year up to the individual annual maximum of $1,000. This maximum does not apply to preventive services for children under the age of 19. Benefits for Orthodontic services are paid up to the lifetime orthodontic maximum of $1,000, and are only available to covered Dependents under age 19. See the section titled Dental Expense Benefit (if shown on your schedule of benefits) of your Summary Plan Description for more information.
When you use VSP providers (in-network), many of your services are provided at no cost to you. Even when you go to a non-VSP provider (out-of-network), you will continue to receive the $200 per person annual allowance.
See the section titled Vision Care Benefit (If Shown On Your Schedule of Benefits) of your Summary Plan Description (SPD) for more information.
You are provided with financial assistance to your family in the event of death through Employee Life Insurance and Dependent Life Insurance. Life Insurance Benefits are not available under the Retiree Plan of Benefits or Medicare plan. See the section titled Life Insurance Benefit—For Eligible Employees and Their Dependents of your Summary Plan Description (SPD) for more information.
In the event of your death, a Life Insurance Benefit of $10,000 will be paid to your beneficiary.
In the event of a covered Dependent’s death, a Dependent Life Insurance Benefit is payable, as follows:
You may designate more than one beneficiary and indicate the percent of the benefit to be paid to each person. To designate a beneficiary, or to change your beneficiary at any time, contact the Fund Office for the proper form. If you do not designate a beneficiary, or if your beneficiary does not survive you, payment is made in equal shares to the members in the first appropriate surviving class:
The Accidental Death and Dismemberment (AD&D) Insurance Benefit is payable if you sustain a loss as a result of an accident, with the loss occurring within 90 days. This benefit is in addition to any other benefits under this Plan. The AD&D Benefit is provided through an insurance carrier and is not available under the Retiree Plan of Benefits. For the loss of life, the AD&D Benefit will be paid to your named beneficiary; otherwise, the benefit is payable to you.
For more information, including the amount of the Principal Sum and when benefits become payable, see the section titled Accidental Death and Dismemberment (AD&D) Insurance Benefit—For Eligible Employees Only in your Summary Plan Description (SPD).
The Weekly Accident and Sickness Benefit provides benefits when you are unable to work due to non-occupational sickness or injury. This benefit is payable if you:
Benefits are payable only after you submit written proof of the sickness or injury to the Fund Office (taxes will be withheld). To learn more about this benefit, including when benefits become payable, see the section titled Weekly Accident and Sickness Benefit—For Eligible Active Employees Only for your Summary Plan Description (SPD).
Dave broke his leg and had to have a pin put in surgically. He was out on disability for 12 weeks. Then he came back to work for a week and found out that his wound from surgery had an infection and he had to have more surgery and was out on disability for another 16 weeks. Even though Dave came back to work, both disabilities are related and Dave didn’t work for at least 350 hours in three months. Therefore, Dave would only receive benefits for 26 of the 28 weeks that he was disabled.
When you are enrolled in the Active Plan, some covered medical expenses include:
To see other covered medical expenses, and medical expenses that are not covered by the Active Plan, see your Summary Plan Description.
Yes. The Utilization Review (UR) Company must pre-approve all hospital care, except in an emergency or for childbirth. The UR Company must be notified within two days (48 hours) of an emergency admission. If you do not receive pre-approval, you will have to pay an additional $200 deductible penalty for the hospital stay.
To learn more about pre-approval and other cost-saving features of the Plan, see your Summary Plan Description.
If your dentist recommends treatment that can be expected to cost $250 or more, you are encouraged to submit a description of the treatment and the dentist’s charges to the Fund Office before treatment begins. The Fund Office will estimate your share of the cost for the treatment and determine what benefits can be expected to be paid by the Fund.
To learn more about pre-determination of dental benefits, see your Summary Plan Description.
When you are enrolled in the Active Plan, your eligible dependents are covered for medical, prescription drug, dental and vision benefits if you currently have the same coverage. Please note that members of Local 380 and their dependents currently do not have dental or vision coverage.
Life Insurance benefits also apply to your eligible dependents .
Your eligible dependents are not covered under the Accidental Death & Dismemberment (AD&D) benefit nor the Weekly Accident and Sick benefits.
To learn more about dependent eligibility and coverage, see your Summary Plan Description.
Most providers will file claims for you electronically.
If your provider does not file claims for you, you can fill out a claim form and send it to the address shown on your ID card.
For vision claims for a non-VSP provider, your provider will guide you on how to file for reimbursement.
For all non-medical, prescription drug, dental or vision claims, you must submit a claim to the Fund Office at the following address:
Fund Administrator Iron Workers’ Tri-State Welfare Fund
c/o: Zenith American Solutions
18861 90th Avenue, Suite A
Mokena, IL 60448
Contact the Fund Office to request a:
If you’re an active employee eligible for coverage on the date of your death, your beneficiary will receive a Life Insurance Benefit or an Accidental Death & Dismemberment (AD&D) Insurance benefit (if applicable). Your beneficiary must contact the fund office and provide the required information to receive these benefits.
See your Summary Plan Description for more information.
If you need to change your beneficiary information, you must to fill out the Beneficiary Designation form and return it to the Fund Office.
Before the Plan pays benefits, you must first meet the Plan’s deductible. You pay for covered expenses out of your own pocket until you reach the deductible. Then, you and the Plan share the cost of treatment through copayments or coinsurance.
Please note that preventive care from a network provider is covered in full without you having to first meet the deductible.
© Iron Workers Tri-State Welfare Fund. The information on this Web site presents selected highlights of the Iron Workers Tri-State Welfare Fund. The actual Plan provisions of the Plan are in the Plan’s legal document. In the event of a conflict between the wording on the site and the legal documents, the legal documents will govern. The Trustees reserve the right to amend, modify, or discontinue all or part of the Plan at any time.