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SHEET METAL WORKERS LOCAL 98 WELFARE FUND

BENEFITS AT A GLANCE

CLASS I

COMPREHENSIVE MAJOR MEDICAL BENEFITS

All benefits will be based upon Reasonable & Customary allowances.

Network (PPO Providers)

Calendar Year Deductible

Per Individual Per Family
$ 750 $1,500

Most eligible charges will generally be paid at 80% until the maximum out-of-pocket amount has been satisfied. After the maximum out-of-pocket amount has been satisfied, 100% payment on eligible charges thereafter for that individual for the remainder of that Calendar Year.

Maximum Out-of-Pocket Expense per Calendar Year (including the deductible)

Per Individual Per Family
$3,000 $6,000

Prescription Maximum Out-of-Pocket Expense per Calendar Year (including the deductible)

Per Individual Per Family
$3,850 $7,700
Non-Network (Non-PPO Providers)

Calendar Year Deductible

Per Individual Per Family
$1,500.00 $3,000.00

Most eligible charges will generally be paid at 60% of the Reasonable and Customary until the maximum out-of-pocket amount has been satisfied. After the maximum out-of-pocket amount has been satisfied, 100% payment on eligible charges thereafter for that individual for the remainder of that Calendar Year.

Maximum Out-of-Pocket Expense per Calendar Year (including the deductible)

Per Individual Per Family
$ 6,000.00 $12,000.00

NOTE: Once a person or family reaches the Out-of-Pocket maximum for Non-Network benefits, all future Out-of-Network benefits will be paid at 80% of the Reasonable and Customary charges for the remainder of the Calendar Year. In Network and Non-Network Deductibles and Out-of-Pocket amounts will cross-apply. This means that Non-Network expenses apply toward your Network deductible and Network Out-of-Pocket maximum.

PRESCRIPTION DRUG BENEFITS

Prescription Drug Benefits What You Pay
Out-of-Pocket Maximum¹ (In-Network only) $3,850 per person; $7,700 per family
Retail Pharmacy Program For up to a 30-day supply:
Generic $10 copayment
Preferred Brand $50 copayment
Non-Preferred Brand $70 copayment
Immunosuppressive and HIV-related Medications 20%
Mail Order Program² For up to a 90-day supply:
Generic $20 copayment
Preferred Brand $50 copayment
Non-Preferred Brand $70 copayment
Immunosuppressive and HIV-related Medications 20%
¹Premiums, medical claims, balance-billed charges, and health care that the Plan does not cover are not included in the out-of-pocket maximum.
²Maintenance medication prescriptions must be filled in 90-day supplies through CVS Pharmacy or CVS Caremark Mail Service Pharmacy

DENTAL BENEFITS

Dental Benefits What the Plan Pays
Annual Maximum (Adult) $1,500 per person
Annual Maximum (Dependents to age 19) Unlimited
Predetermination Recommendation $500
Dental Benefits In-Network What You Pay Out-of-Network What You Pay
Preventive Services
  • Oral Exams - one per 6 month period
  • Bite Wing X-Rays - one per 6 month period
  • Full Mouth/Panorex X-rays - one every 36 months
  • Diagnostic X-rays
  • Prophylaxis (cleaning) - one per 6 month period
  • Fluoride Treatment - one treatment per calendar year, limited to dependents up to age 19
  • Sealants - one every rolling 36 months per tooth
  • Space Maintainers - limited to eligible dependents up to age 19
  • Sealants - one every rolling 36 months per tooth
  • Emergency Palliative Treatment - includes emergency oral exam
 $0 $0
Basic Restorative Services
  • Consultations and Other Exams by Specialist
  • Amalgam Fillings
  • Endodontics / Pulp Services
  • Periodontal Services
  • Repairs, Relines & Adjustments of Prosthetics
  • Simple Extraction
  • Impacted Extractions 1 (bony impactions not subject to annual maximum)
  • General Anesthesia
  • Drug Injection / Antibiotic Med
  • Gold Foil Restoration
  • Inlays, Onlays - Per tooth, one every five years
  • Crowns - Per tooth, one every five years
 10% 20%
Complex Restorative Services
  • Partial and Complete Dentures - one every five years
  • Bridgework (Pontics & Abutments) - one every five years
 40% 50%
Orthodontics - dependents under age 19 only ($1,000 per person)
  • Orthodontic Diagnostic Services
  • Minor Treatment for Tooth Guidance
  • Minor Treatment for Harmful Habits
  • Interceptive Orthodontic Treatment
  • Comprehensive Orthodontic Treatment
 50% 50%

CLASS II

COMPREHENSIVE MAJOR MEDICAL BENEFITS

All benefits will be based upon Reasonable & Customary allowances.

Network (PPO Providers)

Calendar Year Deductible

Per Individual Per Family
$4,000 $8,000

Most eligible charges will generally be paid at 70% until the maximum out-of-pocket amount has been satisfied. After the maximum out-of-pocket amount has been satisfied, 100% payment on eligible charges thereafter for that individual for the remainder of that Calendar Year.

Medical Maximum Out-of-Pocket Expense per Calendar Year (including the deductible)

Per Individual Per Family
$6,000 $12,000

Prescription Maximum Out-of-Pocket Expense per Calendar Year (including the deductible)

Per Individual Per Family
$ 850 $1,700
Non-Network (Non-PPO Providers)

Calendar Year Deductible

Per Individual Per Family
$ 8,000 $16,000

Most eligible charges will generally be paid at 50% of the Reasonable and Customary until the maximum out-of-pocket amount has been satisfied. After the maximum out-of-pocket amount has been satisfied, 100% payment on eligible charges thereafter for that individual for the remainder of that Calendar Year.

Maximum Out-of-Pocket Expense per Calendar Year (including the deductible)

Per Individual Per Family
unlimited unlimited

NOTE: Once a person or family reaches the Out-of-Pocket maximum for Non-Network benefits, all future Out-of-Network benefits will be paid at 80% of the Reasonable and Customary charges for the remainder of the Calendar Year. In Network and Non-Network Deductibles and Out-of-Pocket amounts will cross-apply. This means that Non-Network expenses apply toward your Network deductible and Network Out-of-Pocket maximum.

PRESCRIPTION DRUG BENEFITS

¹1Premiums, medical claims, balance-billed charges, and health care that the Plan does not cover are not included in the out-of-pocket maximum.
²2Maintenance medication prescriptions must be filled in 90-day supplies through CVS Pharmacy or CVS Caremark Mail Service Pharmacy

DENTAL BENEFITS - NONE