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Northern Illinois Benefit Fund

Contact the Benefits Office

The Northern Illinois Benefit Fund administers the Health & Welfare benefits for the Plumbers and Pipefitters Local 501. A Joint Board of Employer and Union Trustees design the plan with the help of their consultants and attorneys. Federal law insures complete privacy to the member regarding health related issues with the Northern Illinois Benefit Fund as a separate entity from the Plumbers and Pipefitters Local 501.

Health & Welfare is one of the collectively bargained benefits that members of the Plumbers and Pipefitters Local 501 are entitled to as a union member. The Employer makes monthly contributions based on the number of hours worked at a rate agreed upon in the Collective Bargaining Agreement. The member receives the Health & Welfare Benefits in addition to his wages. There is no deduction from the paycheck for these benefits. The member’s spouse and dependent children are covered under the plan at no cost to the member. Dependent children are covered through their 25th birthday as long as they are full-time students.  The benefits provided by the Northern Illinois Benefit Fund include Medical, Dental, Vision, Prescription, Life, Disability and Retiree coverage. Click here for a quick view of these benefits.

On November 18, 2009, we received notification from Rutherford Publishing that they are closing their doors and will no longer publish the Total Wellness newsletter.
As always, the Plan Documents and Amendments supercede any other documents or any of the information listed above and can be changed by the Board of Trustees at any time without any prior notice.

MEET OUR STAFF

Robert E. Niksa Administrative Manager
Gaile Hogue Claims Supervisor
Penny Bennish Claims Adjustor
Cindy Ellsworth Administrative Assistant
Patty Gruber General Office Clerk
Tracey Glassford Accounts Receivable Specialist
Teresa DeJong Fund Accountant



Announcements
Sep 13, 2013

Please be aware of the following important announcements:

*      Delta Dental has released their new quarterly magazine...grin!.  Click here to view this publication.

*      In light of the recent tornados in the Oklahoma area, ERS wants to encourgage you and your family to access their website or call them at 1-800-292-2780 for support.  Please read this flyer for more information.

*      Information has been posted on the Employee Resource Systems's website regarding the recent events (Texas plant explosion, Boston Marathon bombings, etc...).  ERS wants to encourage you and your family to access the website or call us at 1-800-292-2780 for additional support.  Remember our Employee/Member Assistance Program (EAP/MAP) gives you access to many resources such as elder care, child care, etc...  Check us out at www.ers-eap.com.

*     The Midwest Employee Benefit Funds Coalition, Interactive Health Solutions and the Board of Trustees is again offering the 2013 Building Bridges to Health fair.  Please click on this link to view the information about this comprehensive medical program.

*     Rockford Memorial Hospital is considered a non-PPO provider.  Out-of- network higher deductibles and higher out-of-pocket apply.

*     The Plan of Benefits states that any x-ray; CT scan; MRI done or ordered by a chiropractor (D.C.) is limited to the $100 @ 100% paid annually. If an MRI or CT is ordered by a member’s chiropractor, we MUST limit our payment to $100.  

*     Annual claim forms will be needed at the first of the year– we suggest that members complete a form for each of their family members to avoid holding up 2013 claims. The forms must be filled out COMPLETELY, signed and dated.

*     Please be advised that you should use your unique ID number for all vendors.  Your unique ID number is found on your medical and Caremark ID cards.  It may be used for BlueCross BlueShield, Delta Dental, Caremark and Vision Service Plan (VSP).  

*     The Board of Trustees is pleased to announce a new Member Assistance Program to all Active & Retired Participants in the Northern Illinois Benefit Fund.  The Program provides access to free counseling services designed to help you and your family deal with a variety of situations.  Also, the Basic Work-Life Services program offers 24 hour access to web-based informational tools.  Please click on this link to view this information.

*     Effective January 1, 2010, you now have the option to purchase long-term medication, up to a 90-day supply, directly from a CVS Pharmacy near you.  Please click on this link to see the details of the "Maintenance Choice Program".

*     The Board of Trustees is pleased to announce a new Disease Management Program, at no cost to you, to help those with diabetes, cardiovascular disease or obesity to improve their qualify of life.  Please click on this link to see more on our Living Well Health Management Program.

*     Medicaid and the Children's Health Insurance Program (CHIP) Offer Free or Low-Cost Healh Coverage to Children and Familes.  Please click on this link to read this notification.


Eligibility
Jun 08, 2010

Contact the Benefits Office

Starting with credited hours earned on and after January 1, 2004, an employee can become eligible on the first day of the second calendar month after he has 300 credited hours. This new rule will accelerate the initial eligibility process for many employees. Once a person earns initial eligibility, he will remain eligible through the end of the benefit quarter in which his initial eligibility date falls. The 300 hours needed for initial eligibility must be worked within 3 consecutive months.  

Once initial eligibility has been established, 250 hours must be worked and contributions paid to the Northern Illinois Benefit Fund per eligibility quarter to maintain eligibility in following benefit quarters.                                                                                      
The following chart indicates the months that comprise each eligibility quarter and the benefit quarter that the eligibility quarter corresponds to:                       
ELIGIBILITY QUARTERS
BENEFIT QUARTERS
MAR-APR-MAY for coverage in JUL-AUG-SEP
JUN-JUL-AUG for coverage in OCT-NOV-DEC
SEP-OCT-NOV for coverage in JAN-FEB-MAR
DEC-JAN-FEB for coverage in APR-MAY-JUN

FAQ's
Oct 09, 2012

 

Contact the Benefits Office

  1. I am an apprentice and will be a new participant in the Northern Illinois Benefit Fund.  When will I be eligible?
  2. What is my Deductible?
  3. Does my medical treatment require Pre-Certification?
  4. What is Pre-Certification and who is Med-Care Management?
  5. Do I need a second opinion before I have any procedure performed?
  6. What is the Chiropractic Care Benefit?
  7. What do I do when I get married, get divorced, have a baby or adopt a child?
  8. When I visit a Blue Cross Blue Shield of Illinois PPO provider, do I pay my co-pay to the provider at the time of my visit?
  9. Do I pay a Blue Cross Blue Shield of Illinois PPO provider for the service when I receive them?
  10. Do I send my co-pay and yearly deductible to the Fund office? 
  11. Can I make my COBRA payments late and can I make up a payment that I have missed?
  12. How do I know when I have to make a self-payment due to lack of credited hours?
  13. When are self-payments due in the Fund Office?  What happens if my self-payment for coverage is late?
  14. I am a retiree making self-payments. When are my payments due in the Fund Office?  Can my payments be late?
  15. My child is over 19 and is attending college. What do I need to provide the Fund Office to continue his/her coverage? When do I submit this information to the Fund Office?
  16. How do I get routine vision care benefits?
  17. How do I get Dental and Orthodontia Benefits?
  18. How do I get Prescription Benefits?
  19. When I am out of work, am I entitled to any Loss of Time Benefits?
  20. If I get sick or get hurt, not related to work, can I go to any doctor or hospital?
  21. Can I add my spouse to my Health Plan at a later date?
  22. Since the State of Illinois requires my children to have routine school physicals and immunizations, why doesn't my Health & Welfare coverage pay all of the charges?
  23. Are immunizations administered by the County Health Department covered for benefits under the Routine Physical Examination Benefit?
  24. Should I keep a photocopy of information that I submit to the Fund Office?
  25. What should I do if I am required to have an MRI, CT Scan or Mammogram?
  26. Where can I get copies of my marriage license or birth certificates?
1.)    I am an apprentice and will be a new participant in the Northern Illinois Benefit Fund.  When will I be eligible?
If you are a first-year apprentice, or a 501 member reinstating lost eligibility for benefits, you will be eligible the first day of the second calendar month after you have 300 credited hours.  Beginning with credited hours earned on or after January 1, 2004, the new rule will accelerate the initial eligibility process for many employees.  For example, if Fred has 150 hours in March and 150 hours in April, he will become eligible June 1.  Coverage would have started July 1 under the old rule.
Once a person earns initial eligibility, he will remain eligible through the end of the benefit quarter in which his initial eligibility date falls.  (Benefit quarters end on March 31, June 30, September 30, and December 31.)  In the above example, since Fred became eligible on June 1, he will remain eligible through June 30, the end of that benefit quarter.  If Fred had become initially eligible on May 1 instead, he would still have remained eligible through June 30.  In either case, he will continue to be eligible in July-August-September if he has 500 credited hours in March-April-May.
The 300 hours needed for initial eligibility must be worked within 3 consecutive months. 
2.)    What is my Deductible?
        Calendar Year Deductibles:
a.)     PPO deductibles ( amounts of covered medical expenses applied to PPO deductibles also apply to  the non-PPO deductibles and vice versa):
               Individual Deductible........................ $200.00
               Family Deductible ............................ $600.00
                (satisfied by 3 or more family members)
       b.)    Non PPO deductibles
                Individual Deductible  .................... $300.00
              Family Deductible ..........................  $900.00
              (satisfied by 3 or more family members)
      c.)     Chemical Dependency deductible per person per Calendar year or covered expenses incurred for Chemical dependency treatment...$200.00 (in addition to the deductibles noted above).
3.)    Does my medical treatment require Pre-Certification?
Yes, the Plan does require pre-certification.
Pre-certification means that any hospital confinement, surgical procedure, mental/nervous or chemical dependency treatment must be reviewed, so that both you and the Fund can be sure that you are receiving the most appropriate treatment for your condition.  Med-Care Management is the provider that the Fund uses for pre-certification.  They can also assist you if you need special services such as nursing care, or rental or purchase of durable medical equipment.  Their number is 1-800-367-1934.  If you are on Medicare, you do not need pre-authorization through Med-Care Management.
The Plan does not require a second opinion, however, you must call Med-Care Management for pre-certification on all in-patient and out-patient hospitalizations, all surgical procedures, mental/nervous services or chemical dependency services.
The Plan pays 100% (no deductible applies) of covered expenses you or an eligible dependent incur for chiropractic treatment up to a maximum benefit of $35.00 per visit, subject to a calendar year maximum  benefit of $750.00. The Plan also pays 100% of the covered expenses incurred for diagnostic x-rays up to a maximum benefit of $100.00 per calendar year, which applies to the $750.00 overall maximum benefit for chiropractic  treatment.  (Benefits paid for chiropractic care during a year will also apply to a person's Comprehensive Benefit lifetime maximum benefit.) 
Please contact the Fund office as soon as possible if any of the above events take place. Your membership file needs to be updated to add or remove your dependent.  If you are adding a dependent, you will be supplied with a new Participant Data Form that needs to be fully completed and returned to the Fund office along with a copy of the marriage certificate, the divorce decree or adoption papers (whichever one applies to your situation).  If you are newly married, have a baby or adopt a child, we also require a certified state copy of their birth certificate and a copy of their social security cards. 
8.)   When I visit a Blue Cross Blue Shield of Illinois PPO provider,  doI pay my co-insurance to the provider at the time of my visit?
No, do not pay your co-pay to the provider's office at the time of your visit.  You are entitled to Blue Cross Blue Shield of Illinois discounts on the services provided.  The provider is unable to determine the discounted amount until the claim has been processed for payment; therefore, your provider is unable to determine the actual co-insurance that is owed.  Your 20% co-insurance is based on  the discounted amount not on the actual charge.  If you pay 20% co-insurance on the fees charged at the time services are provided, once Blue Cross Blue Shield of Illinois has discounted the charge, your co-insurance would be less than the amount you paid at the time of treatment and your account with the physician's office will be overpaid.
9.)    Do I pay a Blue Cross Blue Shield of Illinois PPO provider for the service when I receive them?
No, please do not pay the provider of service if he/she is a participating  member in the Blue Cross Blue Shield of Illinois Preferred Provider Organization.  These providers have a contract with Blue Cross Blue Shield of Illinois which states that they will accept the "discounted" fee as established by the contract for the services rendered.  NORTHERN ILLINOIS BENEFIT FUND has a contract with Blue Cross  Blue Shield of Illinois that states that the payments issued for services provided by a PPO provider will be paid directly to the provider of the service.  If you pay the provider at the time services are received,  you will be  paying the actual fee for the services and not the "discounted" amount.  In addition, once your provider submits the claim for consideration, the Fund office will issue any benefits that are payable for the services provided directly to the provider of service, which could also result in a overpayment to the provider. Again, please do not payyour provider for treatment rendered until you have received the explanation of benefits (EOB) from NORTHERN ILLINOIS BENEFIT FUND.   The EOB will indicate the charges for the services rendered, the discounted amount, the amount paid by NORTHERN ILLINOIS BENEFIT FUND and the amount that is the responsibility of the member.
No, please do not send your checks for the co-insurance or your yearly cash deductible to NORTHERN ILLINOIS BENEFIT FUND.  The co-insurance and deductible amounts should be paid directly to the provider of service. This amount is indicated on the explanation of benefits (EOB) that you receive from the Fund office.  The EOB also includes the name of the provider and the date of service so that it will be easier for you to identify the individual  to whom you should send your deductible amount and the co-insurance. 
11.)   Can I make my COBRA payments late and can I make up a payment that I have missed?
As of October 1, 2000, the Fund Office will no longer be able to accept late COBRA continuation coverage Payments.
Your Summary Plan Description states:
  • A person electing COBRA continuation coverage has 45 days after the signed 
    election form is returned to the Fund Office to make the initial payment.
    However, if a person waits 45 days to make the initial payment, one or more monthly payments may also fall due within that period and must be paid at that time for continuation of coverage.
  • All subsequent monthly COBRA self-payments are due on the first day of the month for which payment is being made.  A payment will be considered on time if it is received within 30 days of the date due.
  • If a COBRA self-payment is not made within the time allowed, COBRA coverage for all affected family members will terminate.  You may not make up the payment or reinstate coverage by making future payments.
The Fund Office recommends in order to continuously keep your COBRA Coverage in effect without a lapse in benefits that you mail your COBRA self-payments along with the coupon that has been provided by the Fund Office, to the Fund Office no later than the 15th of the month prior to the month for which payment is being made.  For example: mail your August 2004 COBRA self-payment and coupon to the Fund Office on July 15, 2004.  This will ensure that the payment is received and credited prior to the first of the month, therefore, eliminating a lapse in coverage.
12.)   How do I know when I have to make a self-payment due to lack of credited hours?
If you lack credited hours during the eligibility quarter, the Fund Office will send a self-payment notice to you at your last known address, telling you how much your regular self-payment will be and when it is due.
While the Fund Office will attempt to notify you when a regular self-payment is due, it is your responsibility to keep track of the credited hours and make any required Regular Self-payments on time whether or not you receive a notice from the Fund Office.
13.)   When are self-payments due in the Fund Office?  What happens if my self-payment for coverage is late?
The properly completed self-payment form, whether due to total disability or due to lack of hours, along with your Regular self-payment must be received by the Fund Office on or before the first day of the month of the first month of the benefit quarter for which you are paying.  Effective July 1, 2001 you can take the form and the Regular Self-payment to the Fund Office or you can mail them to the Lock Box.  However, failure of the U. S. Postal Service to deliver your payment to the Fund Office on time will not extend the due date; so if you mail your payment, be sure to give it sufficient time in which to be delivered. As of October 1, 2000, the Fund Office will no longer be able to accept late self-payments. If payments are not received by the Fund Office as indicated above, your coverage and your family's coverage will terminate.
14.)   I am a retiree making self-payments. When are my payments due in the Fund Office?  Can my payments be late?
You must make your first self-payment on or before the due date on which a self-payment to maintain continuous coverage is due.  There must be no lapse in coverage between active employee coverage and the Retiree Benefits coverage.
Effective July 1, 2001, we will be using a lock box for Retiree Self-Payments.  You can make your self-payments in person at the Fund Office or you can mail your self-payments to the Lock Box.  Each payment must be personally delivered or post-marked no later than the first of the month for which you are paying in order to be accepted by the Fund Office.  For example, to be covered for benefits during October, your self- payment must be delivered or post- marked no later than October 1.
If you fail to make a self-payment on or before the date it is due, your eligibility for Retiree Benefits will terminate at the end of the last month for which you have already paid.  You will not be allowed to make any future self-payments.
As of October 1, 2000, the Fund Office will no longer be able to accept late payments for your retiree coverage.
*Please note:  If the Fund Office received a check that is returned from the bank for "non-sufficient funds", it will be the same as if the payment had not been received by the Fund Office by the due date and the corresponding coverage will be terminated.
15.)  My child is over 19 and is attending college. What do I need to provide the Fund Office to continue his/her coverage? When do I submit this information to the Fund Office?
Your Plan through Northern Illinois Benefit Fund provides coverage for a dependent who is age 19 or less than age 24, provided he/she is a registered student in an accredited secondary school, college or university or vocational, technical or trade school, enrolled for a minimum of the credit hours required to meet the school's criteria for "full-time" status, and  is dependent on you for more than 50% of his/her support and maintenance (proof of dependency and/or full -time student status for each school term may be required before such child will be considered a covered dependent.)
Change in Definition of Dependent-Effective for coverage on and after September 1, 2007 the Plan will cover unmarried children who are full-time students age 19 or older ONLY when the child:
1.      Is age 19 but less than age 24 at the end of the current calendar year; and
2.       Is a registered, full-time student in an accredited secondary school, college or university, or at a vocational, technical, vocational/technical, or trade school or institute; and
3.      Is dependent upon you (the participant) for the major portion of his support and maintenance; and
4.      otherwise meets the Plan’s definition of dependent.
A child who meets all the requirements above except that he will be age 24 or age 25 at the end of the current calendar year can make self-payments for continued coverage under the new Self-Pay Program for Older Students (described below), OR the child can elect and make self-payments for COBRA coverage.
If the child elects COBRA coverage, he is waiving his right to make student self-pays.  Likewise, a child who makes student self-pays is waiving his right to COBRA coverage.
Self-Pay Program for Older Students - An unmarried child who loses eligible dependent status because of exceeding the age limit (24 at the end of the calendar year) may continue his coverage under the Self-Pay Program for Older Students provided he meets the applicable requirements specified below:
1.   He must satisfy all of the requirements for being an eligible dependent other than the maximum age requirement; and
2.   At the beginning of any month for which coverage is provided, he must not be older than age 25.
The amount of the monthly self-payment is currently $50.  This amount is determined by the Trustees and may be changed at any time.
The benefits provided under this program are the same benefits provided to eligible dependents under age 24 at the end of the calendar year. 
Coverage will terminate: 1) at the end of the month during which the child reaches age 25 or otherwise fails to satisfy the requirements for continued eligibility, or 2) at the end of the month for which the last correct and timely self-payment was made. 
The Fund does require proof that the dependent child is enrolled in and attending classes.  The best way to provide this proof to the Fund Office is to submit a copy of your child's class schedule at the beginning of each semester.  Once this is received, your child's file will be updated to reflect that he/she is attending school as a full-time student. At the end of the semester, please forward a copy of your child's grades to the Fund Office.  This is verification that your child maintained his/her status as a full-time student.  If your child is a continuing student, submit a copy of the pre-registration for the next semester at the same time as the current grade report and all files will be updated accordingly.
Please remember that if your child  "drops" classes in the middle of the semester and the remaining total of classes do not meet the "full-time" student criteria, coverage will terminate on the date that the classes are dropped.  If this happens, please notify the Fund Office immediately in order that a COBRA election notice may be sent to you.
16.)  How do I get routine vision care benefits?
Please refer to page 75 of your Benefit Fund Summary Plan Description for an overview of the Vision Service Plan. Consult the VSP pamphlet that is contained in the inside cover of your Summary Plan Description for a listing of VSP providers in your area.
When you use one of the participating VSP optometrists, you must tell them you have benefits with the Vision Service Plan. They will obtain all authorization for you without any forms to complete.
If you see a non-VSP provider such as Lenscrafters or Sears, then you will need to pay the provider of service in full and obtain a paid receipt and an itemized bill.  Please send the receipt and the itemized bill along with the member's social security number to:Vision Service Plan, P. O. Box 997100, Sacramento, CA 95899-0001.
If you need any additional information, please phone 1-800-877-7195 or you can also check www.vsp.com on the Web.  VSP will reimburse you for applicable out-of-network benefits. You must file these claims with VSP within 6 months of the service date or VSP will not consider the claim.  Refer to Page 8 of your Summary Plan Description.  The Fund Office cannot process any routine vision claims.
17.)  How do I get Dental and Orthodontia Benefits?
Please refer to Pages 59-64 of your Benefit Fund Summary Plan Description for an explanation of your Dental and Orthodontia Expense Benefit.  An organization called Delta USA administers your Dental and Orthodontia Expense Benefit and pays all dental and orthodontia benefits on behalf of the Fund.  Delta administers three types of dental programs.  The benefits and your out-of- pocket costs will vary depending on whether your dentist is a member of one or two dental provider networks or if he is not a member of either network.
You do not have to sign up with any of the three dental programs; simply make an appointment with whatever dentist you choose. You can use one program for some of your dental care and a different program for the rest of your dental care.  You may switch from one program to another at any time.  Some family members can use one program and others use a different program. The three programs are:
1.    Delta Preferred Dentist--If you use a Delta Preferred dentist, benefits will be payable according to the Delta Preferred Network Schedule on the schedule of Dental Benefits. Please refer to Page 17 of your Summary Plan Description for an outline of these Benefits.  Delta Preferred dentists' fees are discounted so the amount you pay as your co-pay percentage share of the covered dental expenses will be lower.
2.    Delta Premier Dentist:  If you use a Delta Premier dentist, benefits will be payable according to the Delta Premier Network Schedule as outlined on the Schedule of Dental Benefits on Page 17 of your Summary Plan Description.  Delta Premier dentists have agreed to base their fees on Delta Dental's usual and customary fees.  You are not responsible for charges exceeding Delta's usual and customary fee schedule.
3.  Out-of-Network Dentist:  If you use an out-of-network dentist (a dentist who is neither a Delta Preferred or Delta Premier dentist), benefits will be payable according to the Out-of Network Schedule on the Schedule of Dental Benefits as outlined on Page 17 of your Summary Plan Description.  Because Delta Dental has no fee arrangement with out-of-network dentists, you are responsible for the difference between the dentist's fee and Delta's payment to the dentist in addition to your co-pay percentage of the covered dental expense.
To find out if a dentist is in the Delta Preferred or Delta Premier network:
  • Call Delta's customer service department (1-800-452-1987)
  • Visit Delta's web site at  www.deltadentalil.com
  • Simply ask the dentist if he/she is a member of the Delta Preferred or Delta Premier Networks.
To alert your dentist to send his bill to Delta, and to identify yourself as a participant in this program, be sure to present your Delta I. D. cards when you receive dental services.
As a reminder, it is no longer necessary for your Dental claims to be submitted to the Fund Office. Please have all dental claims submitted to: Delta Dental Plan of Illinois P. O. Box  5402 Lisle, IL  60532.
18.)  How do I get Prescription Benefits?
Your prescription drug plan is offered through the Prescription Service Division of CVS/Caremark, Inc.
There are three components to your prescription drug program:
  • Retail Pharmacy Prescription Drug Card for short-term medications;
  • Mail Service Pharmacy for long-term medications; or,
  • CVS Pharmacy for long-term medications
For short-term medications, such as antibiotics, it is important that you use your Caremark Prescription Drug Card at a Caremark Participating Pharmacy in order to get the best price and the greatest savings.  The Caremark Retail Program includes over 50,000 participating pharmacies nationwide, including more than 20,000 independent community pharmacies.  To locate a Caremark Participating Pharmacy in your area, simply access the Caremark Pharmacy Locator on the Caremark website (www.caremark.com ) or call Caremark's Customer Service toll-free at (800) 841-5550.
Your co-payment at the Caremark Participating Pharmacy for up to a 30-day supply will be:
  • 10% for a generic drug
  • 10% for a brand name drug
Effective January 1, 2020, you can purchase long-term medications, up to a 90-day supply, at a CVS Pharmacy near you.  You can also use the Caremark Mail Service Program to obtain your long-term medications which is a cost-effective choice for your long-term needs.  Simply mail your original prescriptions, along with the Patient Profile/Order Form and your medication will be sent directly to your home.  If you are currently receiving any long-term medications, contact your doctor for a new prescription and send it to Caremark.  Ask your doctor to write your prescription for up to a 90-day supply, plus refills, when appropriate.
Your co-payment to Caremark under the Mail Service Pharmacy Program or direct purchase at a CVS Pharmacy near you for up to a 90-day supply will be:
  • $15.00 for a generic drug
  • $30.00 for a brand name drug
The following services are available at  www.caremark.com for your convenience:
  • Prescription Refills
  • Forms
  • Order Status
  • Frequently Asked Questions
  • Pharmacy Locations
  • Other Helpful Information
You may contact Caremark at (800) 841-5550 if you have any questions.
19.)  When I am out of work, am I entitled to any Loss of Time Benefits?
Loss of Time Benefits are provided for active eligible bargaining unit employees and active eligible Class A non-bargaining unit employees. (Loss of Time Benefits are not provided for Class B non-bargaining unit employees or for ANY employee whose Plan coverage is being continued under COBRA Coverage.)
To be eligible to receive weekly benefits, you must be eligible for Loss of Time benefits on the date your disability begins and you must be totally disabled and be completely prevented from engaging in any occupation or employment for compensation, wages or profit as a result of a non-occupational accidental bodily injury or sickness.
The amount of your weekly benefit is currently $350.00 per week.  The weekly benefit will be paid on the basis of a 7-day week.  If benefits are due you for a partial week, you will receive one-seventh of the weekly benefit for each day of the partial week, payable at the end of the disability.
In accordance with Federal Law, the Plan will withhold your share of FICA (Social Security) tax from each weekly payment and will send it to the government.  Also, you must include the weekly benefits you received in your gross income and pay Federal Income Tax on them.
Period of Payment/When Benefits Start--Weekly benefits are payable for up to 26 weeks while you are totally disabled, but not for more than 26 weeks for any one continuous period of disability.
Weekly benefits will begin:
  • On the first day of disability due to a non-occupational accidental injury
For disabilities due to sickness:
  • On the first day of disability due to patient surgery, or
  • On the first day of a hospital stay if hospitalized before the eighth day of sickness; or
  • On the eighth day of a disability if not hospitalized.
If a female employee is disabled due to maternity or pregnancy-related condition, the disability will be treated as a disability due to sickness.
For a full explanation of the Loss of Time Benefit, please refer to page 49 of the Benefit Fund Summary Plan Description.
20.)  If I get sick or get hurt, not related to work, can I go to any doctor or hospital?
Yes, you may seek medical treatment from any physician or medical facility that you wish; however, you and your family should use the Blue Cross/Blue Shield of Illinois PPO providers whenever you need medical or hospital care.  If you do, you will save on your out-of-pocket share of your family's non-emergency doctor and hospital expenses because the calendar year deductibles and out-of-pocket limits are lower when you use the Blue Cross/Blue Shield or Illinois providers.
Remember to show your Northern Illinois Benefit Fund medical card to the provider of service.  If an admission into the hospital is necessary, the card is intended to alert you or your physician to contact Med-Care Management to obtain pre-admission authorization.
If you are married when you become eligible for benefits, your spouse and family are eligible for benefits on the same day that you become eligible for benefits.  When completing your Participant Data Form, please include all information that pertains to you and your family. In addition to the Participant Data Form, the Fund office requires a copy of your marriage license,  a copy of your spouse's and children's birth certificates and social security cards.  You must also select beneficiaries for the Life Insurance, Pension Fund and Retirement Fund.
If you marry after your coverage becomes effective, your spouse is eligible for benefits as of the date of marriage.  Please advise the Fund Office as soon as possible after the marriage.  You will be required to complete a new Participant Data Form that includes your spouse's name and return it to the Fund Office with a copy of your marriage certificate and a copy of your wife's birth certificate and social security card.
22.)   Since the State of Illinois requires my children to have routine school physicals and immunizations, why doesn't my Health & Welfare coverage pay all of the charges?
Prior to July 1, 1999 the Health & Welfare Plan for Northern Illinois Benefit Fund paid 100% of covered services for a routine physical examination up to a maximum of $300.00 per person per calendar year. Routine physical examination benefits were payable for employees, retirees, spouses and dependent children under age 5.
Effective January 1, 2006 the Board of Trustees increased benefits for routine physical examinations to help with the cost of the school physicals and immunizations that are mandated by the State of Illinois.   
For Employees, Retirees and Spouses--the covered expenses incurred inexcess of $300.00  during a calendar year will be covered under the regular provisions of the Comprehensive Benefit.  The Comprehensive Benefit deductibles, co-pay percentages, maximum benefit limitations and exclusions will apply.
Well-Child Care for Dependent Children--Effective January 1, 2008, the Plan will pay 100% (no deductible) up to the following maximums:
  • $1,000 first year of life - child's birth through day before child's 1st birthday.
  • $300 second year of life - child's 1st birthday through day before child's 2nd birthday.
  • $300 third year of life - child's 2nd birthday through day before child's 3rd birthday.
  • $300 fourth year of life - child's 3rd birthday through day before child's 4th birthday.
  • $300 fifth year of life - child's 4th birthday through day before child's 5th birthday.
  • $600 for the period from the child's fifth birthday through day before child's 13th birthday.
  • $600 for the period from the child's 13th birthday through day before child's 19th birthday.
These maximum benefits will apply to all covered well-child care expenses - exams, immunizations and inoculations. 
EXCESS CHARGES WILL CARRY-OVER TO MAJOR MEDICAL - Covered expenses incurred on and after January 1, 2008 that are in excess of the maximums listed above WILL carry over to the major medical benefit (the “Comprehensive Benefit”) and be paid subject to the deductible and co-payment provisions.  As with other covered expenses, the Plan pays higher benefits when you use physicians in the BlueCross PPO network.
 Only charges incurred on and after January 1, 2008 are eligible for the increased benefits.  No additional benefits are payable for claims incurred prior to that date.
There is not a Routine Physical Examinations Benefit for Dependent Children over the age of 19.
23.)    Are immunizations administered by the County Health Department covered for benefits under the Routine Physical Examination Benefit?
Yes, immunizations administered by the County Health Department are reimbursable under the Routine Physical Examination Benefit.  Since the County Health Department usually administers routine immunizations at a lower fee than your physician, obtaining your immunizations from the Health Department will help to stretch the $1,000.00 or $300.00/$600.00  benefit.
If you obtain your immunizations from the Health Department, please obtain a receipt that indicates the date of the immunization, the type of immunization received and the cost of the immunization.  Please forward this receipt with the member's name, social security number and name of the individual who received the immunization to the Fund Office for consideration of benefits.
24.)    Should I keep a photocopy of information that I submit to the Fund Office?
Yes, it is advisable to keep a personal record of all claims and correspondence that is sent to the Health & Welfare Office.  Therefore, if we show no record of receiving the material submitted for consideration you will have a copy that can be resubmitted to our office.
25.)    What should I do if I am required to have an MRI, CT Scan or Mammogram? 

Effective October 1, 2012, the Northern Illinois Benefit Fund will no longer use the DBM (DiaTri) network for diagnostic imaging services, such as MRIs, and CT, CRA and PET scans.  The Plan’s new preferred imaging network is American Imaging Management (AIM), an organization affiliated with the Blue Cross and Blue Shield of Illinois program.  AIM is an imaging management organization that will provide you with safe, appropriate and quality diagnostic imaging services, while ensuring you receive the maximum benefits afforded by the Plan. 

In the event you need non-acute (non-emergency) diagnostic imaging services, your physician should call AIM at (847) 564-8500 or log onto www.americanimaging.net.  AIM will review your medical condition with your physician and recommend several nearby in-network facilities which are equipped to provide the services you need. 

We have asked BlueCross BlueShield of Illinois to re-issue I.D. cards to Fund participants.  The new cards will replace the contact information for the old network with information about the new imaging network.  Your new I.D. cards will be mailed to you within the next few weeks. 

When your diagnostic imaging is arranged through AIM, the Plan will pay 100% of your covered charges (no deductible).

Certified copies of marriage records or birth records are available from the county clerk in the county where the marriage or birth occurred.  Visit Illinois's website at http://www.idph.state.il.us/ .  If you were born, married, divorced, etc. outside the state of Illinois you can also visit www.vitalcheck.com for links to other states.


Forms
Aug 02, 2012

 Contact the Benefits Office

Health and Welfare Forms
 

 


Provider List
Jun 13, 2013

Delta Dental Plan of Illinois
P.O. Box 5402
Lisle, IL 60532
(800) 323-1743
BlueCross BlueShield of Illinois
P.O. Box 1364
Chicago, IL 60690
(800) 570-1043
Caremark 
P.O. Box 7624
Mt. Prospect, IL 60056-7624
(800) 803-1461
Vision Service Plan
P.O. Box 997105
Sacramento, CA  95899-7105
(800) 877-7195
Epic Hearing Healthcare 
17870 Castleton Street
Suite 320
City of Industry, CA 91748 
(877) 606-3742
Med-Care Management 
(Pre-hospitalization approval)
P.O. Box 20564
West Palm Beach, FL 33416-0564
(800) 367-1934

Delta Sleep

(At home sleep studies)

(1-888-540-2727)

 

Employee Resource Systems, Inc.
(Member Assistance Program)
(800) 292-2780

Contact the Benefits Office


Quick View of your Benefits
Oct 09, 2012

 Contact the Benefits Office

  • The Northern Illinois Benefit Fund uses Blue Cross Blue Shield of Illinois to provide the members with their hospital and doctor PPO Network. 
  • As of January 1, 2003, the network expanded to include Blue Cross Blue Shield PPO providers across the entire United States. 
  • Effective October 1, 2012, the Northern Illinois Benefit Fund will NO LONGER use DBM (DiaTri) network for diagnostic imaging services.  The Plan's new preferred imaging network is American Imaging Management (AIM).  In the event you need non-acute (non-emergency) diagnostic imaging services, your physician should call AIM at (847) 564-8500 or log onto www.americanimaging.net. AIM will review your medical condition with your physician and recommend several nearby in-network facilities which are equipped to provide the services you need.
  • Referrals to a specialist are not required.  
  • Use of a Blue Cross Blue Shield PPO physician or hospital is not required; a member can see any physician or use any hospital facility that he chooses. 
  • The plan has a $200 individual/$600 family calendar year deductible for PPO providers and a $300 individual/$900 family calendar year deductible for non-PPO providers. 
  • Once the deductible has been met for PPO providers, bills are paid at 80%.  Bills are paid at 60% for non-PPO providers.
  • The out-of-pocket amount for PPO providers is $1,500 individual/$3,000 family and $3,000 individual/$4,000 family for non-PPO providers. 
  • When the out-of-pocket limits have been met for the calendar year, bills are paid at 100% for the remainder of that calendar year to a lifetime maximum benefit of $2,000,000. 
  • Blue Cross Blue Shield of Illinois providers can be viewed on the Blue Cross Blue Shield of Illinois website at www.bcbsil.com
  • Delta Dental of Illinois administers the dental benefits for the Northern Illinois Benefit Fund.  
  • Delta Dental has two provider networks. 
  •  If a dentist is a member of the DeltaPreferred network, the calendar year maximum benefit per family member is $1500.  
  • If a dentist is a member of the DeltaPremier network, the calendar year maximum benefit per family member is $1250. If a dentist does not participate in the Delta networks, the calendar year benefit per family member is $1000.
  • Routine care is paid at 100% and restorative services are paid at 80% under all three benefit plans. Orthodontic coverage is available to dependent children through the 19th birthday. 
  •  Providers in both the DeltaPreferred and DeltaPremier networks can be viewed at www.deltadentalil.com.
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Vision Service Plan administers vision benefits. The Plan provides for a free vision exam, lenses and frames every 12 months for the member and his dependents if visiting a Vision Service Plan eye doctor. Providers in the Vision Service Plan network can be viewed at www.vsp.com.

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Prescription drugs are purchased through the CVS/Caremark Prescription Drug program. Short-term prescriptions are purchased at retail pharmacies with a drug card. The member pays $5.00 min./10% for generic drugs or $10 min./10% for brand name drugs. Maintenance medications are purchased through the mail for a $15 co-payment for a 90-day supply of generic drugs and a $30 co-payment for a 90-day supply of brand name drugs. Effective January 1, 2010, you can purchase long-term medication, up to a 90-day supply, at a CVS Pharmacy near you.  The Caremark website can be viewed at www.caremark.com.

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Once the member has gained initial eligibility for benefits, he is entitled to a $20,000 life insurance benefit payable to the beneficiary of his choosing. There is an additional $20,000 payable if the death was accidental.  The Retiree life insurance benefit is $5,000.

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If a member is totally disabled due to a non-occupational illness or injury, he is entitled to a $350 per week disability benefit for up to 26 weeks. Benefits begin on the first day of disability for injury or hospital confinement and the eighth day for an illness. Disability hours are credited so that Health & Welfare eligibility is not lost due to disability.   If a member is totally disabled due to an occupational illness or injury, he is credited with disability hours for up to 26 weeks so that he does not lose Health & Welfare eligibility.

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EARLY/DISABLED RETIREES (Under Age 62) - If you were covered under the Plan as an active bargaining unit or Class A non-bargaining unit employee, you must meet all of the following eligibility requirements in order to be eligible for Retiree Benefits for yourself and any dependents:

  1. You must be retired from work with all contributing employers.
  2. You must be receiving early retirement or disability pension benefits from the Pension Fund.
  3. You must have been covered under the Northern Illinois Benefit Fund as an active eligible employee during the 5 years (60 consecutive months) immediately prior to retirement.
  4. You must have a minimum of 10 years of service in the industry during you lifetime.  (The 10 years of service in the industry can include the 5 years of immediate past coverage.)
  5. You must make correct and on-time self-payments to the Fund.
When you become age 62, and if you meet the 10-year immediate past coverage requirement, you will no longer be required to make self-payments for Retiree Benefits for yourself and your spouse.  If you want to cover your dependent children, you must continue to make self-payments for their coverage.
NORMAL RETIREES (Age 62 and Over) - If you are a normal bargaining unit retiree, you must meet all of the following eligibility requirements in order to be eligible for Retiree Benefits for yourself and your dependent spouse:
  1. You must be retired from work with all contributing employers.
  2. You must be at least 62 years old.
  3. You must have been covered under the Northern Illinois Benefit Fund as an active eligible employee during the 5 years (60 consecutive months) immediately prior to retirement.
  4. You must have a minimum of 10 years of service in the industry during your lifetime.  (The 10 years of industry service can include the 5 years of immediate past coverage.)
  5. You must be receiving normal retirement pension benefits from the Pension Fund.
No Self-Payments if you meet 10-Year Immediate Past Coverage Requirement - If you meet the normal retirement eligibility requirements above, you do not have to make self-payments for Retiree Benefits after age 62 if you were continuously eligible under the active employee benefits of the Plan for the full 10-year period immediately preceding your retirement.
If you are an early retiree, you must make self-payments for Retiree Benefit coverage until you become age 62.  At that time, you will no longer have to make self-payments for you and your spouse if you meet the 10-year immediate past coverage requirement.  Otherwise, you must continue to make self-payments after you reach age 62.
If a member will not have 10 years of continuous eligibility at age 62, he may self-pay for the same benefits provided to active members for the remainder of his (and his spouse’s) life with a rate reduction once he reaches the age of 65 and is on Medicare, if he has five (5) consecutive years of eligibility immediately prior to retirement and ten (10) years of service in covered employment during his lifetime.    
       
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Schedule of Benefits
May 07, 2013

 Contact the Benefits Office

As always, the Plan Documents and Amendments supercede any other documents or any of the information listed above and can be changed by the Board of Trustees at any time without any prior notice.

Benefits for Employees Only Benefits For Retirees Only

Life Insurance 

Benefits For Employees, Retirees, and Their Dependents
Schedule of Dental Benefits
Vision Care Expense Benefit
Benefits for Employees Only
Life Insurance
 
$20,000
Accidental Death And Dismemberment (AD&D) Insurance
 

$20,000

Maximum period that benefits are payable per sickness/injury
26 weeks
Day of disability that benefits start:
Disabilities due to Accidental injury 1st day
Disabilities due to sickness:
Outpatient surgery 1st day
Not hospital confined 8th day
Hospital Confined 1st day of confinement before 8th day
Benefits For Retirees Only
Retiree Life Insurance
$5,000
Benefits For Employees, Retirees, and Their Dependents
Maximum benefit payable per person per accident for covered expenses incurred within 90 days of the accident
$250
Plan co-pay percentage (no deductible applies)
100%
(Excess covered expenses are considered for payment under the Comprehensive Benefit, subject to the deductibles, co-pay percentage, out-of--pocket limits, etc.)
Maximum benefit payable per person per employee, retiree or dependent spouse for covered expenses incurred for routine examinations and preventative services $300
Plan co-pay percentage (no deductible applies)
100%
Well-Child Care for Dependent Children--the Plan will pay 100% (no deductible) up to the following maximums:
  • $1,000 first year of life - child's birth through day before child's 1st birthday.
  • $300 second year of life - child's 1st birthday through day before child's 2nd birthday.
  • $300 third year of life - child's 2nd birthday through day before child's 3rd birthday.
  • $300 fourth year of life - child's 3rd birthday through day before child's 4th birthday.
  • $300 fifth year of life - child's 4th birthday through day before child's 5th birthday.
  • $600 for the period from the child's fifth birthday through day before child's 13th birthday.
  • $600 for the period from the child's 13th birthday through day before child's 19th birthday.
  • $600 for the period from the child's 19th birthday through day before child's 26th birthday.
These maximum benefits will apply to all covered well-child care expenses - exams, immunizations and inoculations.  Amounts paid under the prior well-child care benefits will apply to the new maximums shown above.
Excess charges will carry over to major medical - Covered expenses incurred on and after January 1, 2008 that are in excess of the maximums listed above WILL carry over to the major medical benefit (the "Comprehensive Benefit") and be paid subject to the deductible and co-payment provisions.  As with other covered expenses, the Plan pays higher benefits when you use physicians in the Blue Cross PPO Network.
Only charges incurred on and after January 1, 2008 are eligible for the increased benefits.  No additional benefits are payable for claims incurred prior to that date.
Maximum benefit payable per person for covered expenses incurred for hearing care  $1,500 each ear
every 5 years
Plan co-pay percentage (no deductible applies)
80%
(Excess charges do not carry over to the Comprehensive Benefit)
Calendar year maximum benefit payable per person for diagnostic x-rays $100
Calendar year maximum benefit payable per person for all chiropractic treatment, including up to $100 for  x-rays $750
Maximum benefit payable per visit $35
Plan co-pay percentage (no deductible applies)
100%
(Excess charges do not carry over to the Comprehensive Benefit)
  • Only the  "covered medical expenses" listed on pages 63-66 will be considered for payment under the Comprehensive Benefit. Only covered medical expenses can be used to satisfy deductibles. Only a person's out-of-pocket payments for his co-pay percentage share of  covered medical expenses count toward out-of-pocket limits. You are responsible for paying all amounts of charges incurred by you and your dependents that are not considered medical expenses.
  • If non-emergency care is received from a non-PPO provider (hospital or doctor) and there is no equivalent (same medical specialty) PPO provider within 10 miles of the non-PPO provider, benefits will be paid for the non-PPO covered medical expenses as though a PPO provider had been used.
  • Only excess covered expenses incurred under the Supplemental Accident Expense Benefit and the Routine Physical Examination Expense Benefit (except well child care) carry over for consideration for payment under the Comprehensive Benefit. Excess charges incurred under any of the other health care benefits do not carry over for payment under the Comprehensive Benefit.
  • Payments under this benefit are based only on the amounts of charges that are considered to be reasonable and customary (R&C) charges (see page 23).
Calendar Year  Maximum Benefit Payable per Person $2,000,000
Deductibles
Calendar year deductibles (amounts of covered medical expenses applied to PPO deductibles also apply to non-PPO deductibles and vice versa)
PPO deductibles (applied  to covered medical expenses incurred from PPO providers):
Individual deductible $200
Family deductible (satisfied by 2 or more family members) $600
(These deductibles apply to covered medical expenses incurred for prescription drugs, whether or not prescribed by a PPO doctor)
Non- PPO deductibles (applied to covered medical expenses incurred from non-PPO providers and other non-doctor and non-hospital providers):
Individual deductible $300
Family deductible (satisfied by 2 or more family members) $900
Plan Co-Pay/Payment Percentages subject to all maximum benefits and other stated limitations (see "Special Limitations" starting on page 15 for exceptions and additional limitations).
  • The 80% co-payment shown below does not apply to chemical dependency or mental/nervous disorders expenses ("Special Limitations"), and the Plan will not at any time pay 100% for those types of expenses.
  • Amounts of out-of-pocket payments applied toward meeting PPO out-of-pocket limits will also apply toward meeting the non-PPO out-of-pocket limits and vice versa.
Payments for PPO covered medical expenses during a calendar year:
Plan co-pay percentage per person per family for covered medical expenses incurred during a year from PPO providers and for prescription drugs after satisfaction of the PPO individual/family incentive deductible UNTIL the person/family has met the PPO individual/family out-of-pocket limit. 80%
Plan payment percentage per person per family for covered medical expenses incurred during a year from PPO providers and for prescription drugs after satisfaction of the PPO individual/family incentive deductible AFTER  the person/family has met the PPO individual/family out-of-pocket limit. 100%
Payments for non-PPO covered medical expenses during a calendar year:
Plan co-pay percentage per person per family for covered medical expenses incurred during a year from non-PPO providers and other non-doctor/non-hospital service providers after satisfaction of the non-PPO individual/family incentive deductible UNTIL the person/family has met the non-PPO individual/family out-of-pocket limit. 60%
Plan payment  percentage per person per family for covered medical expenses incurred during a year from non-PPO providers and other non-doctor/non-hospital service providers after satisfaction of the non-PPO individual/family incentive deductible AFTER  the person/family has met the non-PPO individual/family out-of-pocket limit. 100%
Out-Of Pocket Limits per Calendar Year after satisfaction of applicable deductibles.
  • Out-of-pocket limits do not include out-of-pocket payments made to satisfy deductibles or made as a person's co-pay share of covered medical expenses incurred for chemical dependency or mental/nervous disorders. (See pages 59-61 for more details).
  • Amounts of out-of-pocket payments applied toward meeting PPO out-of-pocket limits will also apply to the non-PPO out-of-pocket limits and vice versa.
PPO out-of-pocket limits:
Individual out-of-pocket limit $1,500
Family out-of-pocket limit (met by 3 or more family members) $3,000
Non-PPO out-of-pocket limits:
Individual out-of-pocket limit $3,000
Family out-of-pocket limit (met by 3 or more family members) $4,000
Special Limitations
Hospital Room and Board allowable covered medical expenses:
Semi-private or private room
Semi-private room rate
Intensive Care Units, Cardiac Care Units, etc. Hospital's R&C charge
Treatment of Mental or Nervous Disorders:
Lifetime maximum allowable number of days pf inpatient hospital treatment per person, including days of partial hospitalization and day care (intensive outpatient treatment)

Effective January 1, 2010

No limit

Calendar year maximum allowable number of regular outpatient visits per person No limit
(Benefits which apply to these maximums also apply to the person's $2,000,000 Comprehensive Benefit lifetime maximum benefit.)
Plan co-payment percentages:
Inpatient treatment 80% PPO, 60% Non-PPO
Regular Outpatient visits 80% PPO, 60% Non-PPO
Treatment for Chemical Dependency*

Lifetime maximum benefit per person

 No limit   
                                           
Calendar year maximum allowable days of inpatient and outpatient treatment combined per person No limit
Plan co-pay percentage for all inpatient and outpatient treatment 80% PPO, 60% Non-PPO
Treatment of Learning or Behavior Disorders
Plan co-pay percentage 80% PPO, 60% Non-PPO
Orthotics -Lifetime maximum benefit payable per person for covered medical expenses incurred for foot orthotics Paid at 80%, 20%, deductible applied if not met up to maximum of $1,000
Transplant Maximums Removed:  Effective July 1, 2011, the specific dollar maximums for transplants will no longer apply.
Infertility
CHANGES TO INFERTILITY BENEFITS
$40,000 Lifetime Maximum -The scheduled limits on the numbers of infertility treatments of infertility treatments covered  by the Plan have been replaced by a $40,000 maximum. This is the most the Plan will pay for  all covered treatment  received by an eligible employee and his spouse combined during the employee's lifetime. It applies to all diagnostic procedures and all treatments, including prescription drugs and surgery. It will not be reinstated if you divorce and remarry.
How Benefits Will be Paid -Covered infertility expenses in excess of your calendar year deductible will be paid at 80% up to the $40,000 maximum. Your 20% co-payments will not apply to the out-of-pocket limit, and the Plan will not pay 100% for infertility expenses if your out-of-pocket limit has been met by other claims.
Covered Expenses -The types of covered infertility expenses are not changing. As before, the Plan covers reasonable and customary charges for:
  • Office visits and consultations
  • Hormone Treatments (prescription)
  • Surgery
  • Gamete intrafallopian transfer (GIFT)
  • Intracytoplasmic sperm injection (ICSI)
  • Diagnostic tests
  • Intrauterine insemination (IUI)
  • In Vitro fertilization (IVF)
  • Zygote intrafallopian transfer (ZIFT)
Exclusions -Except for the removal of the frequency limits and the $40,000 maximum, the same limitations, provisions and exclusions will continue to apply. As before, infertility benefits will be provided for active employees and their spouses ONLY. No benefits are payable for children, or retirees and their spouses.
Effective date of change – This change was made effective November 1, 2003, but it applies to charges incurred prior to November 1, 2003.
Plan payment percentage for up to a 90-day supply of a covered prescription drug:
Generic equivalent drugs per prescription or refill
100% after your
 $15 co-payment
Brand Name drugs per prescription or refill
100% after your
 $30 co-payment
How to use the Caremark Prescription Drug Program (Retail)
  • You will be required to pay $5 minimum / 10% of the contracted price to the participating pharmacy. Contracted prices are usually lower than the pharmacy's regular retail prices. The Plan will pay the rest.
  • For each purchase you make, you will be able to get up to a 30-day quantity, or the quantity prescribed by the doctor, whichever is less.
  • There are no claims to file
  • You can use your I.D. card to get the amount of medication prescribed by your doctor plus 2 refills. After you purchase the initial supply plus 2 refills if a maintenance drug, you must use the Mail Order Program or CVS Retail for all additional refills. If a doctor prescribes a drug that must be taken on a long-term basis, ask the doctor for two prescriptions- one for 30 day supply that you can have filled immediately at a local participating pharmacy under the Drug Card Program, and one for up to a 90-day supply (with refills) that you can obtain through the Mail Order Program.
  • Your $5 minimum / 10% co-pay amounts do not apply any Plan deductibles or out-of-pocket limits.
If you use a non-participating pharmacy- If you purchase a covered prescription drug at a pharmacy that is NOT in the Caremark network, you will need to file a claim with the Fund Office for partial reimbursement under the Comprehensive Benefit.
  • The amount you paid the non-participating pharmacy will be reduced by 50% and the remaining balance will be paid at 80% (provided your $200 calendar year deductible has been satisfied).
  • Neither the 50% reduction nor your 20% co-pay will apply to any Plan deductibles or out-of-pocket limits.
  • The 50% reduction will not apply if live more than 15 miles from a participating pharmacy- be sure to note this information on your claim.
Exclusions and Limitations - You cannot use the Prescription Drug Card Program for:
  1. any products, drugs or medications which can be obtained without a doctor's written prescription
  2. experimental or investigative drugs or medications
  3. drugs or medications which are used for or in connection with any type of treatment or condition for which benefits are excluded under the Plan, even though such drugs or medications are obtained with a doctor's prescription
  4. drugs or medications that are excluded from coverage under any other provision or rule of this Plan, including but not limited to the provisions of "What the Plan Does Not Cover" starting on page 78 of your SPD.
Schedule of Dental Benefits
Delta Preferred Network
Schedule
Delta Premier Network
Schedule
Out of Network Schedule
Calendar Year Maximum Benefit
$1,500
$1,250
$1,000
(The $1,500 maximum includes all payments made under the DeltaPreferred Network, DeltaPremier Network or Out-of-Network Schedules. The $1,250 maximum includes all payments made under the DeltaPremier Network or Out-of-Network Schedules.)
Deductible
None
None
None
Delta Co-Payment Percentage:
Diagnostics and Preventive
100%
100%
100%
Routine and Major Restorative and Prosthodontics
80%
80%
80%
Orthodontics
(Dependent Children to age 19)
Lifetime Maximum Benefit
$1,5000
$1,250
$1,000
(The $1,500 maximum includes all payments made under the DeltaPreferred Network, DeltaPremier Network or Out-of-Network Schedules. The $1,250 maximum includes all payments made under the DeltaPremier Network or Out-of-Network Schedules.)
IMPORTANT NOTES
You are not responsible for the difference between the billed charges and negotiated charges
You are not responsible for the difference between the billed charges and Delta's usual & customary fees
The dentist may bill you for charges exceeding Delta's usual and customary fees.
See No. 15 on page 72 for information about benefits for tooth implantation for the sole purpose of anchoring a denture
Please contact Delta Dental at 1-800-452-1987 to verify the Schedule of Benefits
VSP DOCTOR
SCHEDULE
NON-VSP DOCTOR
REIMBURSEMENT
SCHEDULE
Vision Examination
COVERED IN FULL
Up to $30.00
Frame
$120 allowance, 20% discount off the amount over the allowance.
Up to $45.00
Lenses
Single Vision
COVERED IN FULL
Up to $30.00
Lined Bifocal Lenses COVERED IN FULL
Up to $35.00
Lined Trifocal Lenses COVERED IN FULL
Up to $45.00
Lined Lenticular Lenses COVERED IN FULL
Up to $60.00
Polycarbonate Lenses (dependent children) COVERED IN FULL N/A
Tints / Photochromics COVERED IN FULL
Up to $ 5.00
Contacts (in lieu of frame and eyeglass lenses), per pair:
Visually Necessary* COVERED IN FULL
Up to $210.00
Elective $120.00
$120

-Services and allowances are available every 12 months.

-When the schedule shows a dollar allowance, VSP will pay the lesser of the reasonable and customary charge, or the allowance for that service or supply.

* Contacts are visually necessary when a patient's vision cannot be corrected with glasses, as determined by VSP.

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Summary Annual Report
Feb 10, 2012

Contact the Benefits Office

Summary Annual Report


Summary Plan Description
Oct 08, 2010

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Summary Plan Description


Tips for Filing a Medicare Claim
Jun 08, 2010

Contact the Benefits Office

Tips for Filing a Medicare Claim 

In order to expedite the processing of your medical claims, please advise your providers of service not to submit claims to Blue Cross Blue Shield of Illinois.  Once you have incurred medical expenses, have your claims submitted to Medicare for consideration.  After Medicare has considered the claims eligible for benefits, have the provider submit a copy of the original claim and a copy of the Medicare Explanation of Benefits directly to the Fund Office.  When the Fund Office receives this information, the claims will be considered for payment.
 
Please do not submit claims to our office prior to receiving notification of Medicare payment.  If the claims are received without the explanation of benefits, we will hold the claim and request the explanation of benefits.   Please do not submit the Medicare explanation of benefits without submitting a copy of the actual claim to the Fund Office.  The claim from the provider contains information that is required to consider the charges eligible for benefits. 
 


Trustees
Jul 22, 2013

Employer Trustees

Labor Trustees

Michael Bestler - Chairman
Bestler Corporation
Thomas E. Andrews - Secretary
Pipefitters Local 597
Lori Abbott
Abbott Industries
Jim Mansfield
Plumbers Local 130
Tom Bargiel Charles Seibert
Plumbers Local 130
Brian Burns
C.W. Burns, Inc.
Randy Sosolik
Pipefitters Local 597
Dieter Holz
Apex Plumbing

Kevin Morrissey
Pipefitters Local 597

S.J. Peters
PAMCANI
Kenneth Turnquist
Plumbers Local 130

 Contact the Benefits Office              


Updates
Sep 13, 2013

Contact the Benefits Office

  • August 2000 (Behavioral, Infertitility, Chiropractic Max, Enternal & Parenteral Nutrition, Retiree Coverage, Continued Coverage for Widows)                                      

  • October 2000 (Caremark, Surviving Spouse Self-Payments, Mental/Nervous Disorders, Retiree Eligibility)

  • December 2000 (Retiree Eligibility & Self-Payment Rules)

  • December 2000 (Breast Reconstruction Coverage)

  • February 2001 (Transplant Benefits)

  • April 2001 (Self-Pay Rates, Well Child Care Benefits)

  • November 2001 (Increased Hearing, Increased Frame, Ambulance Payments, Survivor Self-Pay, Continued Coverage for Widows, Mental Health Therapists, Suicide & Self-Inflicted Injuries, Chemical Dependency, QMSCO, Loss of Time Claims)

  • March 2002  (Caremark Drug Card Program)

  • June 2002  (Roles of Association, Rights to Receive Information) 

  • October 2002  (Life Insurance / ADD Appeals)

  • November 2002  (Transplant Max, Claims & Appeals Time Limit, Surviving Spouse Self-Payments)

  • December 2002  (MRI, CT Scan & X-Ray Benefit)

  • January 2003  (Blue Card Network)

  • September 2003  (Initial Eligibility Period, Reciprocity, Widows of Retirees, COBRA)

  • December 2003  (Medical Review Program, Nurse Anesthetists, Surgical Assistants)

  • January 2004  (Infertility Benefits)

  • July 2004 (Out-of-Network Surgical Centers)

  • January 2005  (Self-Pay Rate Increase)

  • January 2005  (Chemical Dependency & Look-Back Rule)

  • July 2005 (Deductible Changes, Disabled Self-Pay Rate)

  • March 2006 (COBRA / Self-Pay Increase)

  • July 2006 (Well-Child Care, Predetermination of Dental Benefits)

  • September 2006 (Military Dependents, Retiree Life Insurance, Subrogation)

  • December 2006 (DME Benefit, Surrogacy Exclusion)

  • April 2007 - (Regular Self-Payments)

  • June 2007 - (Revised COBRA Rates)

  • June 2007 - (Lifetime Max, Surrogacy, Military Dependents, Learning/Behavior Disorders)

  • September 2007 (Changes in the Definition of Dependent)

  • December 2007 (Well-Child Care Benefits Increased)

  • April 2008 - (Temp Reduction in Self-Pay, New COBRA rates)

  • August 2008 - (Professional Neurological Services)

  • April 2009 - (Reduced Self-Pays, COBRA, Breast Reconstruction)

  • December 2009 (Mental/Chemical Benefits, Obesity Coverage, Breast Reconstruction)

  • April 2010 - (Self-Payments, Composite Fillings, Student Medical Leave)

  • January 2011 (Self-Payments, Breast Reconstruction, Life Insurance)

  • June 2011 - (Age Limit for Children Increased, Certain Dollar Limits Increased or Removed, New COBRA Self-Pay Rates, Rescission of Coverage, Grandfathered Status, Removal of Lifetime Limit, Early Retiree Reinsurance Program (ERRP)

  • June 2012 - (Dental Bite Guards)

  • September 2013 - (Health Care Exchanges)

 As always, the Plan Documents and Amendments supercede any other documents or any of the information listed above and can be changed by the Board of Trustees at any time without any prior notice.


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Page Last Updated: Sep 13, 2013 (08:53:00)
October 22, 2018
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