Mo-Kan Sheet Metal Workers Welfare Fund Benefits
Benefit Summary
2008 Life Plan - Download the 2008 Group Life Insurance Benefits Plan.
2008 Benefits Summary - Download the benefits summary.
To access a list of providers available in the Kansas City area, please visit the Preferred Health Professionals’ website at www.phpkc.com or call Preferred Health Professionals’ Customer Service Department at (913) 685-6300 or toll-free at (800) 544-3014; and in the Omaha, Nebraska area, please visit the Beechstreet website at www.beechstreet.com or call Beechstreet’s Customer Service Department at (800) 432-1776.
The following notice is required each year under the Women’s Health and Cancer Rights Act (WHCRA).
Under the Women’s Health and Cancer Rights Act, group health plans that provide medical and surgical benefits in connection with mastectomy, like this Plan, must provide benefits for certain reconstructive surgery. This benefit covers reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction on the other breast to produce a symmetrical appearance, and prostheses and treatment of physical complications of all states of mastectomy, including lymphedemas. This coverage is subject to the plan’s deductible and coinsurance provisions which are described in Your Summary Plan Description (SPD).
Mo-Kan Sheet Metal Workers Welfare Fund
January 2008 Benefit Summary
Plan A
Benefit |
In-Network |
Out-of Network |
Deductible |
$500/$1000 |
$500/$1000 |
Calendar Year Out-of-Pocket maximum (includes deductible) |
$1300/$2600 |
$2100/$4200 |
Co-insurance |
20% |
40% |
Individual Lifetime Max |
$1,500,000 |
$1,500,000 |
Office Visits |
20% after deductible |
40% after deductible |
Co-Payments |
|
|
Inpatient (waived if admitted twice in six months) |
$300 co-pay and 20% after deductible |
$600 co-pay and 40% after deductible |
Emergency Room |
$100 co-pay and 20% after deductible |
$100 co-pay and 40% after deductible |
Routine Physical Exam
(newborn to adult) |
100% up to $500 then 20% after deductible |
100% up to $500 then 40% after deductible |
Routine Immunizations |
Covered for children to age 25 at 100% |
40% after deductible |
Mammogram |
One annual routine exam after age 35 covered at 100% |
40% after deductible |
Cervical Cancer Screening |
One test per year, covered at 100% |
40% after deductible |
Prostate Exam &PSA Test |
One test per year covered at 100% |
40% after deductible |
Prescription Drugs |
Generic co-pay applies to OTC smoking cessation, Allergy, Ant-acids, Anti-fungal, Asthma, and Decongestants. Retail co-pay applies to smoking cessation prescription medications. |
Member pays out of pocket and then sends receipts to WellDyne/Rx West for reimbursement. Only reimbursed contracted amount. |
Retail Generic (30 days) |
$10 co-pay |
Member pays out of pocket and then sends receipts to WellDyne/Rx West for reimbursement. Only reimbursed contracted amount. |
Retail Brand (30 days) |
50% up to $50 |
Mail Order Generic(90 days) |
$20 co-pay |
Mail Order Brand (90 days) |
50% up to $100 |
Smoking Cessation Program
$500 annual max $2000 lifetime. Does not apply to RX out of pocket maximum. |
$10.00 OTC
50% up to $50.00 for RX
Both require a prescription |
OTC program
Examples: Prilosec, Claritin |
$10.00 generic
$20.00 mail order |
Out of Pocket Max for RX |
$1,000 Ind. $2000 family |
Laboratory and X-Ray |
First $150 of Lab and X-Ray covered at 100% then 20% after deductible |
First $150 of Lab and X-Ray covered at 100% then 40% after deductible |
Lab |
100% benefit if collected and tested at a Lab One collection facility. |
40% after deductible |
Supplemental Accident
This benefit pays the first $300 of an accident claim. |
$300 per calendar year |
$300 per calendar year |
Mental Illness |
|
|
Inpatient |
20% after deductible |
40% after Deductible |
Outpatient |
20% after deductible |
40% after deductible |
Chemical Dependency
($30,000 maximum inpatient per lifetime)
($50 maximum per visit) |
50% after deductible |
60% after deductible |
Valley Hope Association |
10% after deductible |
|
Chiropractic Treatment
$1000 maximum per calendar year (includes x-rays) |
20% after deductible |
40% after deductible |
Physical Therapy $5,000 limit |
20% after deductible |
40% after deductible |
Hospice |
20% after deductible |
40% after deductible |
Home Health Care
(100 visit limit) |
20% after deductible |
40% after deductible |
Bereavement Counseling
(maximum 6 visits in 12 months) |
$50 co-pay per visit |
Not covered |
All other covered services |
20% after deductible |
40% after deductible |
Dental (maximum for Preventive, Basic and Restorative is $1550) |
Freedom Network Dental available for Kansas City area. |
|
Deductible |
$25 |
|
Coinsurance |
20% |
|
Preventative
2 cleanings per calendar (Class I) |
100% |
100% |
Basic (Class II) |
20% after deductible |
20% after deductible |
Major (Class III) |
20% after deductible |
20% after deductible |
Orthodontia (Class IV)
($1,800 lifetime maximum) |
50% after deductible |
|
Vision |
|
|
Maximum Calendar year
(can be used for Lasik) |
$300 per person |
|
Frames and lenses for safety glasses with permanent side shields only once per calendar year. |
50% up to $70 |
This benefit payable only to actively working Participants upon presentation of a signed authorization form available from the Fund Office. |
Hearing Aide Benefit |
$1550 Maximum per person per 3 consecutive year period. |
|
Life Insurance Benefit |
Active: $10,000
Basic Retiree: $2,000
Long-term Retiree: $3,000 |
|
Loss of Time
Member must be totally disabled and unable to perform any amount of work |
Weekly Benefit……$250.00
Waiting Period:
Injury……………….….None
Illness or Pregnancy ....7 Days
Maximum Period of Benefits
Per Any Continuous Twelve Month Period is 26 weeks |
|
Wellness Program
Opportunity to earn up to $200 in HRA credit |
|
|
**When obtaining services from a provider not contracted with Mo-Kan Sheet Metal Workers Welfare Fund, you may be responsible for charges in excess of Allowable Charges, as determined by Mo-Kan Sheet Metal Workers Welfare Fund. Additional service area restrictions may apply.
Preferred Health Professionals provide a wide range of doctors and hospitals. You can find these physicians at www.phpkc.com or you can call 1-800-544-3014. The Beech Street network can be accessed at www.beechstreet.com or by calling 1-800-432-1776.
Prescription Drug Plan
Effective January 1, 2007,
Mo-Kan Sheet Metal Workers Welfare Fund has added a new benefit for
over-the-counter medications under the prescription drug
program. Members are
now able to purchase certain over-the-counter medications at $10.00
retail co-pay and $20.00 mail order copay. In order to receive the
appropriate generic co-pay, you must present a
prescription from your physician, for the over-the-counter
product, to your pharmacist to process the claim.
You
may have heard in the news, many prescription brand medications now
have an over-the-counter alternative that have the same, or similar,
active ingredients. Just a few examples are listed below. OTC options can offer you,
the member, significant savings.
| If you are
currently taking one of the following prescription
drugs..... |
the following
are potential over-the-counter (OTC)
alternatives: |
| Nexium, Aciphex,
Prevacid, Protonix |
Prilosec OTC,
Pepcid AC, Tagamet |
| Zyrtec,
Allegra |
Alavert,
Claritin |
| Lipitor,
Zocor |
Corowise
(avail. ONLY thru WellDyne/RXWest
mail order) |
| Celebrex,
Naprosyn |
Aleve |
We certainly hope you take advantage of this new, cost
savings benefit. If you
have any further questions, please contact us at 816-531-0334 or
1-866-531-5488.
Please note our
mailing address:
P.O.
Box
300019
Kansas
City
,
MO
64130-0019
Effective April 1,
2005 your prescription drug plan changed.
Your new drug plan is as
follows:
Retail Pharmacy (30 day
supply):
Generic- $10 copayment
Brand
Name- You pay 50% of the cost of the prescription drug up to a
maximum of $50. This means the maximum amount you’ll pay out of your
pocket per prescription for Brand name drugs is $50.
Mail Order (90 day
supply):
Generic- $20 copayment
Brand
Name- You pay 50% of the cost of the prescription drug up to a
maximum of $100. This means the maximum amount you’ll pay out of
your pocket per prescription for Brand name drugs is
$100.
Out-of-Pocket
Maximum:
The maximum amount you’ll pay
out-of-pocket for prescription drugs in a calendar year is $1,000
per member or $2,000 per member for family coverage.
ID Cards and Locating
Providers:
Please present your new Rx
West I.D. Card to the pharmacy. To locate a participating pharmacy
provider in your area, please access the Rx West website at http://www.rxwest.com/ or contact Rx West
Member Services at (888) 479-2000.
Questions?
Contact the Funds Office at (816) 531-0334 or toll free
outside of the Kansas City area at (866) 531-5488. For Rx West
customer service, access their website at http://www.rxwest.com/ or contact (888) 479-2000.
When filling your next prescription,
please remember that you might have a choice…pay extra for a brand
name drug or save money by substituting a generic equivalent. Please
ask your doctor or pharmacist if a lower cost alternative drug is
available.
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Summary Plan
2008 Summary Plan Description - Download the the complete Summary Plan Description.
For more information about MO-KAN Sheet Metal Workers Welfare Fund, please contact the Fund Office at (816) 531-0334 or toll free outside the Kansas City Metropolitan area at (866) 531-5488.
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