Teamsters Local 170 Health and Welfare Fund

Health Benefits

Health Benefits

 
Medical Benefits and Pharmacy Benefits

The Benefits set forth hereinafter describe summarily the medical and pharmacy benefits to be provided to Participants and their Dependents. The Fund shall pay for the medical benefits and Pharmacy benefits described in a Participant’s Schedule of Benefits and applicable Benefit Description documentation (including Riders) as provided by Blue Cross Blue Shield and for the medical and pharmacy benefits described in a Participant’s Schedule of Benefits and applicable handbook as provided by Fallon Health Plan, subject to all of the limitations contained therein, including deductibles, co-payments, co-insurance, benefit limitations, pre-authorization requirements, referral requirements, other utilization management requirements, referral requirements, advance notice requirements and the limitations imposed in Article 4 (“General Limitations”). Further the Fund shall pay for vision benefits to be provided to Participants and their Dependents as described by Davis Vision Plan documents including the Vision Care Plan Benefit Description. See attachment #9.

Pharmacy benefits are provided as part of all Fallon plans choices for participants and their dependents who enroll in a Fallon Health Plan. Pharmacy benefits are provided as part of all Blue Cross Blue Shield plans for participants and their dependents who enroll in a Blue Cross Blue Shield Plan. Blue Cross Blue Shield partners with Express Scripts as the Pharmacy Benefit Manager for its Pharmacy Plans. Blue Cross Blue Shield/Express Scripts and the Fallon Health Plan are responsible for all aspects of the prescription drug plan including formulary development, claims processing and customer service. In general, the benefits are substantially similar although there may be differences in the list of drugs covered, the drug tier levels etc.

Coverage Tiers
The Plan establishes two tiers or levels of coverage, Tier 1 and Tier 2. Your Collective Bargaining Agreement establishes your tier of coverage and all employees eligible for coverage will be allowed to elect coverage from that tier/level. Retired Employees (ages 57-65) will be eligible for Tier 1 coverage.

Plan Choices and Types
The Plan provides medical plan choices from which active employees, COBRA participants, retired Employees (ages 57–65) and eligible spouses can choose.

Through Teamsters Local 170 Health and Welfare Fund, you have a choice of health plans administered for the Fund by different carriers (Blue Cross Blue Shield of MA and Fallon Health Plan). These plans all have networks of providers or providers that participate in their plans. For some of these plans (HMOs), you must see a participating in-network provider or no coverage is allowed. Other plans (PPO and POS plans) allow you to have services performed by non-participating providers but the amount you pay out of your pocket (deductibles, co-pays and/or co-insurance) will be higher.

Plans may also have different levels of coverage depending on the specific participating provider you see within the network, with higher copayments for services you receive from different levels/categories of providers. In addition, plans may require you to choose a primary care provider (PCP), who is responsible for coordinating your health care and providing referrals to specialists. For some plans, if a referral is not received from your primary care provider, no coverage is allowed at all while with other plans you may be required to pay a higher copay if you don’t receive a referral from your designated PCP.

Provider Networks
All of the Plans offered use a provider network or a group of physicians, hospitals and/or other health care providers who agree to accept a negotiated payment or fees (allowable charge) for services provided to Plan members. Network providers also agree to file the claims on behalf of Plan members. Blue Cross Blue Shield and Fallon Health are responsible for recruiting, credentialing, and communicating with providers.

Participants are encouraged to check the network status of their physician and hospital prior to, and each time they obtain a covered service. Hospitals and physicians may from time to time, change their status under the Plan. Consultation should be made to the most current version of the Blue Cross Blue Shield and Fallon provider directories. Participants are encouraged to call the Blue Cross Blue Shield Customer Service line at 1-800-821-1388 or use the online physician directory at www.bluecrossma.com to determine the status of their provider or to find a network provider. Participants can access the Fallon network by calling 1-800-868-5200 or going online to www.fallonhealth.org.

Member Costs
For all plans, you will pay a copay for office visits to in-network providers. For some specific and limited preventive services, you will not have a copay. You may also have a co-payment for in-patient and out-patient hospital services and other types of services such as x-rays, MRIs and other diagnostic imaging or laboratory tests. The amount you pay for a copayment in-network may depend on the category level of in-network provider you receive services from.

If you visit an out-of network provider, some plans will not allow coverage at all while others will require co-insurance or a percentage dollar amount that you will be responsible for if you choose to visit an out-of network provider.

Plans may have deductibles. This is a dollar amount that you will be required to pay before coverage begins. In addition, a plan may limit the amount you pay out of pocket.

Prior- Authorization and Utilization Management
In order to ensure that care is medically necessary, Plans may require prior-authorization or pre-approval for some services and may implement individual case management or other utilization management procedures for certain conditions/treatment. In certain cases, no payment will be provided if the appropriate process is not followed or if the treatment is not considered to be medically necessary. In addition, plans may limit the number of days or the frequency of certain procedures if the care is not found to be medically necessary.

Plans may also implement disease management programs for members with specific risk factors and/or disease states. Plans may contact you via mail, phone or electronic means regarding your condition and/or gaps in care, appropriateness of care and/or other issues related to your care. In addition, plans may limit the use of experimental or investigational services/care. In general, plans have committees that meet periodically to review new or investigational services/drugs etc. to determine the safety, efficacy and comparative effectiveness of treatments. You should discuss all treatments with your provider who can help you to determine whether a particular service is covered by the plan. You can also call the plan directly.

For specific plan requirements for pre-service review like for a hospitalization or surgery that is not an emergency, you should check with your health care provider or call Blue Cross Blue Shield and/or Fallon member services by phone or check-online for a listing of those services that may require authorization.

Medical Plans Offered
Blue Cross Blue Shield

Tier 1

Blue Choice New England Plan 2
This is a Point of Service Plan (POS) that uses a network of providers. In this Plan, you must have a referral from your PCP to see specialists or you will have a deductible and/or higher out-of pocket costs. You are allowed to have services from out-of network providers but if you do, your out-of-pocket costs will be much higher. You will be required to pay 20% of the cost of care for out-of-network or non-participating providers.

Blue Care Elect Preferred PPO – This is a Preferred Provider Organization (PPO) type plan, which uses a network of providers. With this plan, you are not required to have a PCP referral in order to seek specialty care. This Plan has higher out-of-pocket costs than other plans available. This plan is designed for use by early retirees who live out of state and choose it because there is out-of state coverage.

Tier 2

Network Blue New England Options
The Network Blue Plan is a Health Maintenance Organization (HMO). In this Plan, you must choose a PCP, you must receive a referral to see specialists and must always use participating providers or no coverage is provided.

You are afforded the ability to choose, at any time, to utilize Enhanced level of in-network providers (lowest costs to members); Standard level of in-network providers or Basic level of in-network providers (greatest cost to participants and dependents). Cost sharing arrangements vary, depending on the utilization and provider choices made by you.

Additional information regarding the medical benefits can be found in the Attachments to this SPD (#4-#6) which include the Participant’s Schedule of Benefits for Blue Cross Blue Shield. Other materials that describe your benefits in more detail are incorporated by reference in the BCBSMA Benefit Description and its associated riders. Benefits are subject to all of the limitations contained therein, including benefit limitations, pre-authorization requirements and other utilization management requirements, referral requirements, and advance notice requirements.

Copies of all of these materials can be found on the Fund’s website, at the Fund office or can be obtained upon request by calling the Fund office at (800)-447-7730.

Fallon

Tier 1

Fallon Health- Select Care Supreme Plan
The Select Care Supreme Plan is a Health Maintenance Organization (HMO) type plan. In this Plan, you must choose a PCP, you must receive a referral to see specialists and must always use participating providers or no coverage is provided.

Tier 2
Fallon Health- Select Care Premium Value

The Select Care Premium Value Plan is a Health Maintenance Organization (HMO) type plan. In this Plan, you must choose a PCP, you must receive a referral to see specialists and must always use participating providers or no coverage is provided.

This plan has the same network as the Supreme Plan mentioned above but has less generous benefits than the Supreme Plan (i.e. higher co-pays, deductibles, etc.).

Fallon Health- Direct Care Premium Value
The Direct Care Premium Value Plan is a Health Maintenance Organization (HMO) type plan. In this Plan, you must choose a PCP, you must receive a referral to see specialists and must always use participating providers or no coverage is provided.

The cost sharing arrangements under the Direct Plan are more favorable to the participant than the Select plan, but the network is smaller. Deductibles, co-pays, etc. are generally the same or less.

Additional information regarding the medical benefits can be found in the Attachments to this SPD (#1-#3) which include the Participant’s Schedule of Benefits for Fallon. Other materials that describe your benefits in more detail are incorporated by reference and include the Member Handbook, as provided by Fallon Health Plan. Benefits are subject to all of the limitations contained therein, including benefit limitations, pre-authorization requirements and other utilization management requirements, referral requirements, and advance notice requirements.

Copies of all of these materials can be found on the Fund’s website, at the Fund office or can be obtained upon request by calling the Fund office at (800)-447-7730.

Prescription Drug (Rx) Expense Benefit

The Fund provides coverage for prescription drugs either through Fallon Health or Blue Cross Blue Shield. Each plan has a network of pharmacies. Fallon has a drug formulary (a list of covered drugs).

Blue Cross Blue Shield has an open formulary. In addition, plans may impose other utilization management techniques such as prior-authorization or step-therapy.

Copayments are generally structured in three tiers with Tier 1 being the least expensive for the Participant or Dependent such as generic drugs; Preferred Brand drugs on Tier 2 and Non-Preferred Brand drugs on Tier 3.

Drugs can be purchased at retail or by mail. In general, purchasing drugs by mail provides a savings to the member.

Fallon Rx Program

Fallon Health Plan is the Fund’s Pharmacy Benefit Manager for the Plan’s prescription drug program for Participants and dependents enrolled in a Fallon Plan. 

Participants and dependents enrolled in a Fallon Health Plan have access to prescription drugs via the Fallon Health Pharmacy Network at www.fallonhealth.org/members/Pharmacy/pharmacy-network.aspx or you may view the Fallon Health drug formulary at www.fallonhealth.org/members/Pharmacy/online-drug-formulary.aspx.

Mail order prescriptions are administered by CVS Caremark may be obtained by calling 1-800-237-2767 or at www.fallonhealth.org/members/Pharmacy/mail-order-prescriptions.aspx.

Specialty drugs are administered by CVS Caremark.  Please contact Customer Service at 1-800-237-2767 or at www.fallonhealth.org/members/Pharmacy/specialty-pharmacy.aspx.

For additional information, please refer to the Fallon Health Plan Schedule of Benefits, found in Attachment #1, #2 and #3 of this Summary Plan Description, and/or the Member Handbook as provided by Fallon Health Plan.

Blue Cross Blue Shield MA Rx Program
Blue Cross Blue Shield MA and Express Scripts partner as the Fund’s Pharmacy Benefit Manager for the Plan’s prescription drug program for Participants and dependents enrolled in a Blue Cross Blue Shield Plan.

Blue Cross Blue Shield and Express Scripts are responsible for:

  • Developing and maintain a network of participating pharmacies;
  • Negotiating with pharmaceutical manufacturers;
  • Managing the prescription drug mail order program/specialty program
  • Processing prescription claims from participating pharmacies;
  • Processing prescription claims. Establishing and updating which Tier a Drug will be assigned. Blue Cross Blue Shield shall periodically update its pharmacy program;
  • Developing and implementing fill requirements, step therapies and prior authorization requirements.

Participants and dependents are provided access to the Blue Cross Blue Shield website at www.bluecrossma.com/medications to get the most current coverage information about a specific medication.

Retail pharmacy access includes most chain and many independent pharmacies.  The network is updated regularly.  Participants can visit www.bluecrossma.com or www.express-scripts.com or call Blue Cross Blue Shield of MA member services number at 1-800-217-7878.

The mail order drug program is provided by Express Scripts Home Delivery Service.  On-line enrollment can be made at www.starthomedelivery.com.  Click on REGISTER NOW and fill in the requested information to create a new profile. Make sure you include the member identification number on your BCBSMA I.D. card.  Or you can call Express Scripts at 1-800-892-5119 to speak to a representative.

The specialty mail order drug program is provided by a number of Pharmacies depending upon the specific specialty drug to be administered.  A list of specialty medications can be found on the BCBSMA website.  Visit the BCBSMA website www.bluecrossma.com select the “Member” option followed by “Using my Plan”, then “Pharmacy Coverage” and then select the “Specialty Networks” option for a current list.  Or, contact BCBSMA Member Services at 1-800-217-7878 for additional information.

If you are taking a specialty medication, the BCBSMA pharmacy benefit plan requires that your specialty medication must be filled through one of the specialty pharmacies in the BCBSMA Specialty Pharmacy Network.  Contact one of the specialty pharmacies listed below to arrange for dispensing of your specialty medication and patient education/counseling services.

AcariaHealth
www.acariahealth.com
1-866-892-1202

Accredo 
www.accredo.com
1-877-988-0058

CVS Caremark, Specialty Pharmacy
www.cvscaremarkspecialtyrx.com
1-866-846-3096

Onco360, Oncology Pharmacy Solutions
www.onco360.com
1-877-662-6633

Walgreens Specialty Pharmacy
www.walgreens.com/specialty
1-800-649-2872

*On-call, after hours’ service may also be available by calling the specialty pharmacy customer services toll free number.

Please note that some manufacturers of select specialty medications will only permit certain specialty pharmacies to dispense their specialty products. This is called a “limited distribution drug” (also referred to as “LDD”).  If your specialty medication is a limited distribution drug, your doctor should be able to assist you in identifying the specialty pharmacy which can dispense your limited distribution drug.  Otherwise, make sure to ask our selected specialty pharmacy if they can dispense your limited distribution drug.

Fertility Pharmacy Network

A list of fertility medications can be found on the BCBSMA website. Visit the BCBSMA website, www.bluecrossmas.com select the “Member” option, followed by “Using my Plan”, then “Pharmacy” Coverage”, and then select the “Specialty Pharmacy Networks” option for a current list. Or, contact BCBSMA Member Services at 1-800-217-7878 for additional information.

If you are taking a fertility medication, the BCBSMA pharmacy benefit plan requires that your fertility medication be filled through one of the pharmacies in the BCBSMA Fertility Pharmacy Network.   Contact one of the fertility pharmacies listed below to arrange for dispensing of your fertility medication and patient education/counseling services:

BriovaRx
www.briovarx.com
1-800-850-9122

Freedom Fertility Pharmacy
www.freedomfertility.com
1-866-297-9452

Metro Drugs
www.metrodrugs.com
1-888-258-0106

Village Fertility Pharmacy
www.villagefertilitypharmacy.com
1-877-334-1610

Walgreens
www.walgreens.com/specialty
1-800-424-9002

*On-call, after-hours service may also be available by calling the fertility pharmacy customer service toll free number.

Benefits Covered

The following is a list of many of the types of services covered by the medical, pharmacy, dental and vision plans to be provided to Participants and their Dependents and paid for by the Fund. Please note that this list is not exhaustive and for a complete list you should review the schedule of benefits, benefit descriptions, riders, handbooks and other plan documents provided by each of the plans. In addition, the documents provided by the plans will also provide you a full list of limitations and exclusions. You may call the Fund office or the plans to request the most updated version of any and all documents or go to the Fund website.  These include the following documents:

  • Fallon Community Health Plan (FCHP) Member Handbook and Associated Riders and the Schedule of Benefits
  • BCBSMA Benefit Description and Associated Riders and the BCBSMA Schedule of Benefits
  • Pharmacy Benefit Handbook and Associated Riders for the EnvisionRxOptions pharmacy benefit
  • Dental Blue Freedom or Dental Blue POS Summary of Benefits, Benefit Description and Associated Riders
  • Davis Vision’s Vision Care Plan Benefit Description and Associated Riders
Physician Office Visit Benefit

In General, The Fund shall pay Allowable Physician Office Visit Charges incurred by a Participant and or Dependent if such benefits are provided under the Participant’s Schedule of Benefits, such benefits after application of appropriate discounts, co-payments, fee allowances, out-of-pocket maximums and other applicable provisions.

  • Allowable Physician Office Visit Charges As used in this section, “Allowable Physician Office Visit Charges” shall include the office visit charge, second and third opinions, as well as all lab, x-ray, drugs (i.e. chemotherapy, allergy), administration charges (i.e. vaccines) and all other products or services provided within the confines of and charged by a Physician’s office. In addition to charges from a Physician, benefits will be provided for charges submitted by a licensed psychologist, licensed optometrist or ophthalmologist, licensed counselor or social worker, and Registered or Licensed Practical Nurse (other than a member of the Participant or Dependent’s family).

Limitations
No payment will be made for expenses which are not payable under the limitations set forth in the “General Limitations” section of this SPD.

Covered Prescription Drugs

In General, after application of the appropriate deductibles, discounts, fee allowances, out-of-pocket maximums, Coinsurance or Co-payment and other applicable provisions and in fill limits established in the Participant’s Schedule of Benefits, the Plan shall provide Prescription Drug Expense Benefits to Participants and Dependents for Allowable Drugs if such benefits are provided under the Participant’s Schedule of Benefits.

Allowable Drugs
As used in this section, “Allowable Drugs” shall include the following non-Hospital items:

  • Drugs and medicines lawfully obtainable upon the written prescription of a licensed Physician;
  • Insulin and supplies, including syringes, needles and test materials considered necessary items in cases of a diabetic individual;
  • Birth control drugs, hormone replacement therapy drugs (under certain conditions); drugs to treat cancer and drugs to treat HIV/AIDS.
  • Drugs that do not require a prescription by law (“over the counter” drugs), if any, that are listed on the Fallon Health Plan formulary or Blue Cross Blue Shield plan formulary as a covered drug. The Plan will also cover over the counter preventative medications as required by the PPACA.
  • The Fund uses the Blue Cross Blue Shield standard three (3) Tier open formulary. For participants and their dependents enrolled in a Blue Cross Blue Shield Plan, drugs listed by Blue Cross Blue Shield as “non-covered” will be placed in Tier 3 cost sharing arrangement, unless otherwise excluded under the plan benefits.

For a more detailed description of allowable drugs you should review your Schedule of Benefits.

All Allowable Drugs must be purchased at either a participating retail pharmacy or the Fund’s appointed mail order prescription drug companies or specialty drug companies.

Controlled Substances
No “controlled substance” as defined in the Controlled Substances Act (21 U.S.C.§812) may be purchased from the mail order pharmacy.

Limitations
No payment shall be made for:

  • Drugs or medicines dispensed only for the purpose of cosmetic purposes;
  • Drugs or medicines as set forth as exclusions established by Fallon Health for participants and dependents enrolled in a Fallon Plan;
  • Drugs dispensed without first receiving prior authorization, when required, by the Fund’s Prescription Benefit Manager, Blue Cross Blue Shield/Express Scripts for Participants and their dependents enrolled in a Blue Cross Blue Shield Plan;
  • Drugs dispensed without first receiving prior authorization, when required, by the Fallon Health Plan Pharmacy Manager, for Participants and their dependents enrolled in a Fallon Plan;
  • Drugs or medicines in excess of fill limitations established by Blue Cross Blue Shield/ Express Scripts for Participants and their dependents enrolled in a Blue Cross Blue Shield Plan;
  • Drugs or medicines in excess of fill limitations established by Fallon Health Plan for Participants and their dependents enrolled in a Fallon Health Plan;
  • Drugs dispensed without following the step therapy requirements established by Blue Cross Blue Shield/Express Scripts for Participants and their dependents enrolled in the Blue Cross Blue Shield plan;
  • Drugs dispensed without following the step therapy requirements established by Fallon Health Plan for Participants and their dependents enrolled in a Fallon Health Plan;
  • Services, supplies, care or treatment that are experimental or investigational as determined by the plan;
  • >No payment will be made for expenses which are not payable under the limitations set forth in the “General Limitations” section of this Summary Plan Description;
  • Drugs which are excluded in any formulary established by Fallon Health for participants and dependents enrolled in a Fallon plan;
  • Drugs which are excluded in any formulary established on behalf of the Fund.

For a more detailed description of limitations you should review your Schedule of Benefits.

In addition, for both Fallon and Blue Cross Plans, if a participant or dependent purchases a brand name drug when a generic equivalent is available, the participant or dependent is normally required to pay the difference between the cost of the brand name drug and the cost of the generic equivalent drug.   See your Schedule of Benefits for a more detailed explanation of this requirement.

Diagnostic X-ray, Imaging and Laboratory Expense Benefit

In General, The Fund shall pay Allowable X-ray/Lab Expenses incurred by a Participant and or Dependent if such benefits are provided under the Participant’s Schedule of Benefits and after application of appropriate deductibles, discounts, coinsurance, co-payments, fee allowances, out-of-pocket maximums and other applicable provisions. As used in the preceding sentence, the term “Allowable X-ray/Lab Expenses” is defined as expenses for a diagnostic X-ray or laboratory examination as the result of a non-occupational injury or illness.  The expenses may include CT scans, MRIs, PET scans and nuclear cardiac imaging tests and other out-patient tests and pre-operative tests.

Limitations No payment will be made for expenses which are not payable under the limitations set forth in the “General Limitations” section of this Summary Plan Description.

Surgical Expense Benefit

In General, The Fund shall pay all expenses associated with and the Physician’s fee incurred by a Participant and or Dependent for an Allowable Surgical Procedure if such benefits are provided under the Participant’s Schedule of Benefits and after application of appropriate deductibles, discounts, fee allowances, coinsurance, co-payments, out-of-pocket maximums and other applicable provisions as used in the preceding sentence, “Allowable Surgical Procedure” is defined as a surgical procedure that is performed as a result of a non-occupational Injury or Illness.

Limitations No payment will be made for expenses which are not payable under the limitations set forth in the “General Limitations” section of this Summary Plan Description.

Inpatient Hospital Expense Benefit

In General, The Fund shall pay the expenses incurred by a Participant and or Dependent for charges by a Hospital if such benefits are provided under the Participant’s Schedule of Benefits and after application of appropriate deductibles, discounts, fee allowances, co-insurances, co-payments, out-of-pocket maximums and other applicable provisions for the following:

  • Room and board for each day of hospital confinement;
  • Necessary services and supplies for each day of hospital confinement.

Limitations No payment will be made for:

  • Personal comfort items;
  • Expenses which exceed any benefit limits as forth in the Participant’s Schedule of Benefits. For example, a rehabilitation hospital will often limit admissions to a 60day benefit time period, per member, per year; or

No payment will be made for expenses which are not payable under the limitations set forth in the “General Limitations” section of this Summary Plan Description.

Emergency Room Benefit

In General, The Fund shall pay the emergency room charge and any related charges incurred as a result of an emergency room visit incurred by a Participant and/or Dependent, if such benefits are provided under the Participant’s Schedule of Benefits and after application of the appropriate deductibles, discounts, fee allowances, co-payments, out-of-pocket maximums and other applicable provisions for the following.

Limitations No payment will be made for expenses which are not payable under the limitations set forth in the “General Limitations” section of this Summary Plan Description.

Rehabilitation Expense Benefit

In General, The Fund will pay Allowable Rehabilitative Expenses incurred by a Participant and or Dependent, if such benefits are provided under the Participant’s Schedule of Benefits, after application of appropriate deductibles, discounts, coinsurance, co-payments, fee allowances, out-of-pocket, out-of-pocket and maximums and other applicable provisions for the Rehabilitation Program connected to the recovery from a non-occupational injury or illness which are medically necessary.

Limitations Allowable Rehabilitative Expenses will not include, and no payment will be made for expenses incurred for:

  • Expenses which exceed any benefit limit under the Participant’s Schedule of Benefits;
  • No payment will be made for expenses which are not payable under the limitations set forth in the “General Limitations” section of this Summary Plan Description.
Organ Transplant Expense Benefit

In General, The Fund will pay Allowable Organ Transplant Expenses incurred by a Participant and or Dependent if such benefits are provided under the Participant’s Schedule of Benefits after deductibles, discounts, coinsurance, co-payments, fee allowances, out-of-pocket maximums and other applicable provisions. As used in the preceding sentence, the term “Allowable Organ Transplant Expenses” is defined as expenses for the transplantation of an organ, patient and donor screening, organ procurement, and transportation of the organ.

Follow Up Care The Fund will pay Follow Up Care Expenses incurred by a Participant and or Dependent if such benefits are provided under the Participant’s Schedule of Benefits after application of appropriate deductibles, discounts, coinsurance, co-payments, fee allowances, out-of-pocket maximums, and other applicable provisions.

No payment will be made for expenses which are not payable under the limitations set forth in the  “General Limitations” section of this Summary Plan Description.

Live Donor Charges

The Fund will pay live donor charges incurred by a Participant and or Dependent, if such benefits are provided under the Participant’s Schedule of Benefits; after application of appropriate deductibles, discounts, co-insurance, co-payments, fee allowances, out-of-pocket and other applicable provisions.

Limitations
No payment shall be made for:

  • Any transplant considered experimental or investigational;
  • Expenses for transportation for surgeons or family members;
  • Expenses which exceed any benefit limitation as set forth in a Participant’s Schedule of Benefits; or
  • No payment will be made for expenses which are not payable under the limitations set forth in the “General Limitations” section of this Summary Plan Description.
Musculoskeletal (Chiropractic) Expense Benefit

In General The Fund shall pay Allowable Musculoskeletal Expenses incurred by a Participant and or Dependent if such benefits are provided under the Participant’s Schedule of Benefits after application of appropriate deductibles, discounts, coinsurance, co-payments, fee allowances, out-of-pocket maximums visit maximums, and other applicable provisions. As used in the preceding sentence, the term “Allowable Musculoskeletal Expenses” is defined as expenses for treatment of conditions relating to musculoskeletal problems of the spine, provided that the service or procedure is:

  • Medically necessary to treat the musculoskeletal problems

Allowable Musculoskeletal Expenses include, but are not limited to diagnostic lab tests such as blood tests, diagnostic x-ray and other imagine tests, and include manipulation and physical therapy.

Limitations
No payment will be made for expenses which are not payable under the limitations set forth in the “General Limitations” section of this Summary Plan Description.

Temporomandibular Joint Disorders

The Fund shall pay expenses incurred by a Participant and or Dependent regarding the diagnosis and/or treatment of Temporomandibular Joint (TMJ) disorders if such benefits are provided under the Participant’s Schedule of Benefits and after application of appropriate deductibles, discounts, coinsurance, co-payments, fee allowances, out-of-pocket maximums, and other applicable provisions.

Limitations
No payments shall be made for:

  • Expenses which exceed any benefit limitation as set forth in a Participant’s Schedule of Benefits; or
  • Expenses which are excluded as set forth in a Participant’s Schedule of Benefits; or
  • Treatment expenses will not include and no payment will be made for expenses incurred for: expenses limited in a Participant’s Schedule of Benefits. For example TMJ disorders are generally only covered that are caused by or specific medical condition (such as degenerative arthritis and jaw fractures or dislocations); or
  • No payment will be made for expenses which are not payable under the limitations set forth in the “General Limitations” section of this Summary Plan Description.
Preventive Health Services

The Fund shall pay expenses incurred by a Participant and or Dependent regarding preventative health services, if such benefits are provided under the Participant’s Schedule of Benefits, after application of appropriate deductibles, discounts, coinsurance, co-payments, fee allowances, out-of-pocket maximums, and other applicable provisions.  These benefits may include but are not limited to: routine pediatric care, routine adult exams and tests, routine gyn exams, family planning, routine hearing exams and tests, (including new born hearing screening).  There are limitations imposed upon fitness and weight loss benefits as set forth in the Participant’s Schedule of Benefits.

Limitations No payment will be made for expenses which are not payable under the limitations set forth in the “General Limitations” section of this Summary Plan Description.

Maternity Health Services

The Fund shall pay expenses incurred by a Participant and or Dependent regarding Maternity Health Services, if such benefits are provided under the Participant’s Schedule of Benefits, after application of appropriate Deductibles, discounts, Coinsurance, Co-payments, Fee Allowances, out-of-pocket maximums, and other applicable provisions. These maternity services shall include well newborn inpatient care, delivery, pre-natal and post-natal care.

Limitations
No payment shall be made for:

  • Expenses which exceed any benefit limitation as set forth in a Participant’s Schedule of Benefits; and
  • No payment will be made for expenses which are not payable under the limitations set forth in the “General Limitations” section of this Summary Plan Description.
Infertility Services

The Fund shall pay expenses incurred by a Participant and or Dependent regarding infertility services, if such benefits are provided under the Participant’s Schedule of Benefits, after application of appropriate deductibles, discounts, coinsurance, co-payments, fee allowances, out-of-pocket maximums, and other applicable provisions.

Limitations
No payment shall be made for:

  • Expenses which exceed any benefit limitation as set forth in a Participant’s Schedule of Benefits; and
  • No payment will be made for expenses which are not payable under the limitations set forth in the “General Limitations” section of this Summary Plan Description.
Medical Formulas

The Fund shall pay expenses incurred by a Participant or Dependent regarding medical formulas, if such benefits are provided under the Participant’s Schedule of Benefits.

Limitations
No payment shall be made for:

  • Expenses which exceed any benefit limitation as set forth in a Participant’s Schedule of Benefits; and
  • No payment will be made for expenses which are not payable under the limitations set forth in the “General Limitations” section of this Summary Plan Description.
Dental Benefits

The Fund provides and pays for dental benefits to all of its participants and their dependents (including participants and dependents enrolled in a Fallon Plan) through the Blue Cross Blue Shield plans known as Dental Blue Freedom with benefit maximums for retired employees and each of their dependents and benefit maximums for active employees and each of their dependents.  Incorporated by reference are the Schedule of Benefits, Benefit Descriptions and Riders of these dental plans.

In General
The Fund shall pay expenses incurred by a Participant and or Dependent for eligible dental services if such benefits are provided under the Participant’s Schedule of Benefits, Benefit Description/Riders, after the application of deductibles, discounts, co-insurance, fee allowance, and/or out-of-pocket maximums and the applicable provisions and not to exceed the maximum provided in the Participant’s Schedule of Benefits, Benefit Description and Riders.  Benefits may be categorized summarily as preventive, basic, major or orthodontic.  The preventive group would include services such as oral exams, x-rays or routine cleaning.  Basic services would include services such as restorative services, periodontics, or other services.   Major services include crowns and dentures. These expenses are subject to maximums and exclusions as set forth under the Participant’s Schedule of Benefits, Benefit Description and Riders.  The Dental Plan for Retired employees and their dependents provides coverage for diagnostic and preventative services (i.e. cleanings and x-rays).  The Retiree plan does not provide coverage for basic or major services. There are no annual benefit maximums, under either the active or retiree plan for enrolled dependents under the age of 19.

Limitations
No payment shall be made for:

  • Expenses incurred for dental services rendered solely for cosmetic purposes;
  • Charges for appointments that are not kept;
  • Orthodontic services unless such benefits are provided under the Participant’s Schedule of Benefits, Benefit Description and Riders, and if so, subject to any benefit maximums as set forth in the Schedule of Benefits, Benefit Descriptions and Riders;
  • Services deemed to be unnecessary or inappropriate;
  • Services or products which exceed any benefit maximums or are otherwise excluded pursuant to the Participants Schedule of Benefits, Benefit Description and Riders.
  • No payment will be made for expenses which are not payable under the limitations set forth in the “General Limitations” section of this Summary Plan Description.
Orthodontic Care Expense Benefit

In General, The Fund shall pay allowable Orthodontic care incurred by a Participant under the age of nineteen (19) or a dependent under the age nineteen (19), if such benefits are provided under the Participant’s Schedule of Benefits.

Limitations
No payments shall be made for:

  • Orthodontic services which are excluded and/or which exceed maximums as set forth in the Participant’s Schedule of Benefits;
  • Surgical service for the correction of congenital anomalies
  • Replacement of orthodontic appliances for reasons such as theft, abuse, misuse, misplacement, loss, improper fit, allergies, breakage or ingestion.
  • Speech therapy
  • Instructions for muscle exercises to prevent or correct misalignments of the teeth (myofunctional therapy).
Vision Benefits

Davis Vision, Inc. is a national provider of vision care programs that provides eyeglass services and other vision service (eye exams, etc.) to the Fund.  The cost sharing arrangements at Davis Vision are the same for all participants, irrespective as to whether the member is enrolled in Tier 1 or Tier 2 and irrespective as to whether the member is enrolled at Blue Cross Blue Shield or Fallon Health Plan. The “Vision Care Plan Benefit Description” provides additional detail on the vision benefit and can be found in Attachment #9 of this document.

Vision Care Plan Benefit Description

In General The Fund shall pay Allowable Vision Care Expenses incurred by a Participant or Dependent, subject to the benefit limitations set forth in the Davis Vision Plan.  This benefit is more fully described in a separate Plan Document entitled “Vision Care Plan Benefit Description”.  These benefits include, for eye exams, frames and eye glasses, lenses or contact lenses.

Limitations
No payment shall be made for expenses incurred:

  • For more than one (1) complete eye examination during any calendar year;
  • For more than two (2) sets of eye glasses (frames and lenses) or contact lenses during any one (1) year cycle, and subject to exclusions for special lens designs or coatings as described in the Davis Vision plan benefit description. Coverage does include digital progressive lenses with no co-pay; coverage includes standard, premium and ultra anti reflective coating for lenses and coverage does include transition lenses;
  • For medical treatment for eye disease or Injury;
  • For vision therapy;
  • Non-prescription (PLANO) lenses;
  • Services not performed by licensed personnel;
  • No payment will be made for expenses which are not payable under the limitations set forth in the “General Limitations” section of this SPD.
General Limitations

Limitations

  • Employment Related Injury or Illness No payment will be made for expenses for or in connection with an injury or illness for which a Participant or Dependent is entitled to benefits under any Workers’ Compensation or similar law.
  • Payment of Benefits Pending Appeal If a Participant or Dependent is denied Worker’s Compensation benefits after providing his Employer’s Worker’s Compensation carrier a timely and valid application for benefits, the Fund may pay benefits after receipt of a denial. Payments will be made for benefits provided in the Participant’s Schedule of Benefits which are not provided or paid for under the applicable Worker’s Compensation award or benefits.
  • Prohibited Payments No payment will be made for expenses to the extent that payment under the Plan is prohibited by law of the jurisdiction in which the Participant or his Dependent resides at the time the expenses are incurred.
  • Non-legally Required Payments No payment will be made for expenses for charges which the Participant or his Dependent are not legally required to pay except to the extent as required by the Federal Government for services furnished by a department or agency of the United States.
  • Claim Form Charges No payment will be made for expenses for completion of any claim forms, administrative services or service charges.
  • Cosmetic No payment will be made for expenses for or in connection with any procedures, products or services that affect appearance only, or which are performed for a purely aesthetic superficial benefit, except as required to repair damage received in an Injury incurred while eligible for benefits, or as provided for by Federal law including but not limited to the provisions of the Women’s Health Act of 1998.
  • Work-Related Examination No payment will be made for expenses for or in connection with any work-related examination such as a Department of Transportation physical.
  • Experimental Procedures/Drugs No payment will be made for expenses for or in connection with any experimental or investigational procedures or drugs unless deemed medically necessary. The Plan has the authority to make the final determination as to whether the procedure or drug is experimental or investigational.
  • Medically Unnecessary No payment will be made for expenses for services and supplies provided by a Hospital, Physician, Chiropractor or other provider of health care services not consistent with the patient’s condition, diagnosis, Illness or Injury or for services not consistent with standards of good medical practice. The Plan has the authority to make the final determination as to whether the service or supplies are medically necessary.
  • Custodial Care No payment will be made for expenses for charges for Custodial Care.
  • Employer Ceasing to be a Participating Employer If a Participating Employer ceases to make Contributions on behalf of its Employees in Active Service, the Fund will cease providing benefits to every active Employee employed by that Employer and to his Dependents on the date the eligibility of those Active Service Employees ceases, except as prohibited by federal laws and regulations (including COBRA) and notwithstanding any other provisions of this Plan Document.
  • Unnecessary Care or Treatment No payment will be made for any unnecessary care, treatment or supplies.
  • Failure to Keep Visit No payment will be made for expenses for failure to keep a scheduled visit.
  • Benefit Limitations Notwithstanding anything contained in this plan, no payment will be made for expenses in excess of a benefit limitation as set forth in the Participant’s Schedule of Benefits.
  • Failure to Provided Advance Notice Payment, in the discretion of the Trustees may or may not be made for expenses where a Participant or his Dependent fails to provide advance notice or fails to obtain prior authorization as required by Blue Cross Blue Shield or Fallon Health.  Generally, in the absence of an emergency, a Participant is required to provide advance notification to obtain a covered service.  The Trustees reserve the right, in their discretion, to determine whether any expenses should be paid if a Participant or his Dependent fails to provide advance notice or to obtain the required authorization as required by this Plan.
  • Admission Notification No payment will be made for expenses of any charges that are a result of reduction in benefit payment due to non-compliance of admission notification requirements, if any.
  • Failure to Obtain Prior Approval or Proper Referral Payment, in the discretion of the Trustees may or may not be made for expenses if a Participant or his Dependent is required to obtain prior approval or a proper referral and fails to do so. For HMO plans, in the absence of an emergency, or in the absence of pre-approval, generally, there will be no coverage or reduced coverage provided for out-of-network
  • Excess Charges No part of an expense for care and treatment of an illness or injury that is in excess of the allowable charge.