Eligibility
Your employer pays the cost of this coverage. It is NOT a deduction from your hourly wage, but a contribution over and above your hourly wage. There are no premium payments made by you or any of your eligible dependents for this coverage while you meet the eligibility requirements. If you fail to meet these requirements, you will be allowed to pay to continue your coverage. It’s possible that you will not be eligible for benefits three months from the date that you begin working.
Availability of benefits is based on employment. You become initially eligible on the first day of the benefit month corresponding to the eligibility month in which you first accumulate at least 140 hours of worked and reported or 200 hours worked and reported in two consecutive months. If the Fund Office receives contributions for 140 hours worked during one month, you will be eligible for benefits for one month, but three months ahead. For example, if 140 hours are reported for June, you will be eligible for benefits in September.
Available Benefits
Prior to the start of your eligibility, you will be sent a notification from the Fund Office as well as more detailed information regarding the benefits summarized below. These benefits are available for you and your family when medically necessary and not the result of a work-related accident.
Medical Coverage
After you have met the yearly deductible of $350 per person or $1050 per family, the FMCP will pay 85% of the plan allowance for:
• doctor visits
• preventive services and wellness benefits for children (Prevented Services 100% See Attached for more details)
• annual pap smear
• annual mammogram for women aged 35 or over
• annual physical exam for members and their spouses
• x-rays
• diagnostic laboratory and pathology tests
• surgeons' fees in or out of the hospital
• emergency medical care expenses
• anesthesiologists' charges
• equipment such as splints, braces and crutches, chiropractic care and physical therapy
• inpatient and outpatient
• mental health benefits including alcohol/substance abuse with prior approval
Hospitalization
A $100 deductible applies to each occurrence of hospital emergency room treatment, whether the treatment is
for an accident or illness, and whether the hospital is a PPO or non-PPO hospital. This includes outpatient hospital stays as well.
Prescription Drug Program
When you use your card at a participating pharmacy, you pay 0% for generic drugs, 20% for preferred drugs and 30% ($40 minimum) for non-preferred for a 30-day supply ($80 for 90-day supply). Most grocery store pharmacies and drug store pharmacies are participating pharmacies. Wal-mart and Sam's Club are NOT in your network. The annual out-of-pocket limit is $1000/person or $2000/family.
Dental Plan
Preventive Care (80%)
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Routine oral examination and prophylaxis (scaling and cleaning of teeth, including periodontal maintenance
prophylaxis), up to two per calendar year.
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Emergency palliative treatment.
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Dental x-rays, including full mouth x-rays (once in a period of 60 consecutive months), supplementary
Bite-wing x-rays (one per calendar year), and such other dental x-rays as are required in connection with the
Diagnosis of a specific condition requires treatment.
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For dependent children under age 19 (only):
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Topical application of fluoride once per calendar year.
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Space maintainers that replace prematurely lost teeth.
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Sealants on permanent molars and bicuspids, no more than once every five years.
Basic Restorative Care (80%)
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Extractions.
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Oral surgery.
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Amalgam, silicate, acrylic, synthetic porcelain, and composite filling restorations to restore diseased or accidentally broken teeth.
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General anesthetics when medically necessary and administered in connection with oral surgery.
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Treatment of periodontal and other diseases of the gums and tissues of the mouth.
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Endodontic treatment, including root canal therapy.
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Injection of antibiotic drugs by the attending dentist.
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Repair or cementing of crowns, inlays, onlays, bridgework, implants or dentures, up to one repair per prosthetic every twelve months; or relining or rebasing of dentures
Vision Care
Whether you use a VSP doctor, an out-of-network provider, or a combination of both, you can receive benefits.
for:
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One vision examination per calendar year.
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Either of the following per calendar year:
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One frame with a pair of corrective lenses; or
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Contact lenses. The contact lens allowance includes the lens fitting and evaluation fee. As long as your contact lenses contain a prescription, your allowance remains the same for all types of contact lenses. ($150 for VSP providers, $120 for out-of-network providers). If the contact lenses, fitting and evaluation fees exceed the allowable amount, you are responsible for the payment of any remaining balance. VSP has guidelines and limitations regarding certain disposable contact lens materials. Please contact VSP at 1-800-877-7195 for more information.
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One pair of safety glasses per calendar year for active eligible employees. VSP doctors will use materials certified as safe for a work environment by meeting the required test standards as set forth by the American National Standards Institute (ANSI).
Visually necessary contact lenses received from a VSP doctor are provided in full, subject to prior authorization from VSP. “Visually necessary contact lenses” are prescribed for treatment following cataract surgery, to correct extreme vision problems not correctable with prescription glasses, and for certain conditions of anisometropia and/or keratoconus. An allowance of $210 is provided when visually necessary contacts are purchased from an
out-of-network provider. Coverage is subject to review and authorization from VSP’s optometric consultants, regardless of whether the lenses are obtained from a member doctor or an out-of-network provider.
Hearing Aid
The hearing aid allowance is one standard hearing aid per ear per lifetime.
Death & Dismemberment Benefits
These benefits are available only to the employee -- not to the dependents. The Plan pays:
• $10,000 death benefit for active employees
• $7,500 death benefit for retired employees
Supplemental Worker's Compensation Accident Benefits ensure that you receive the same benefits regardless of where the accident occurred.
