Recent Changes to the Health and Welfare Coverage
Optum Rx (effective 1/01/2019) download notice here
We are pleased to announce that OptumRx has been chosen to replace CVS/Caremark as your Prescription Benefit Manager (PBM) effective January 1, 2019.
In regards to this decision, your H&W Fund participates in the Internationals (IUOE) Healthcare Coalition, which represents over 440,000 lives. During their most recent negotiation for services for the 2019 – 2021 contract, OptumRx was chosen as the sole vendor by exceeding value and savings for the participants. Remember, you can continue to use your same pharmacy, you will need to present your new OptumRx ID card so they can update your PBM information, and verify they are in your network. An exciting improvement is that you can now have a 90 day supply filled at any participating pharmacy. Also, there have been no changes to your benefit co-payment amounts.
If you received a letter from OptumRx advising that you will need to change your current medication to a less expensive version, you can disregard this message as we have informed OptumRx that we do not require our participants to use a less expensive medication, it is your choice.
Should you have any questions or need to order additional ID cards, you can contact OptumRx member services by calling 1-855-295-9140. You can also print a temporary member ID card at optumrx.com. In the coming weeks, we will also be mailing you new Medical ID cards that will include your new OptumRx information, then you will have all of your information on a single card.
Residential Treatment (effective 5/01/2017) download notice here
Ineligible Medical Expenses, page 35 of the Summary Plan Description, No benefits are payable for any services provided by an out-of-network residential treatment facility for services rendered on and after May 1, 2017. Please note, this exclusion would include, but not limited to, services for inpatient or residential skilled nursing, alcohol and/or drug dependence rehabilitation. Expenses submitted by an in-network provider will continue to be covered. However, there will be no benefits payable for any charges submitted by an out-of-network provider, which are related to an in-network residential treatment.
Benefit Updates (effective 1/01/2017) download notice here
As required by federal law, effective January 1, 2017, the benefit exclusion for “any operation or treatment in connection with the sex transformation or treatment in connection with the sex transformation or treatment of sexual dysfunction that is not organic in nature” is removed in its entirety.
Effective January 1, 2017, any references to “woman”, “women”, “female”, “females”, “men”, “man”, “male”, or “males” shall be replace with either “individual” or “individuals” throughout the document.
The IUOE Local 132 H&W Fund complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. The IUOE Local 132 H&W Fund does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.
- Provides free aides and services to people with disabilities to communicate effectively with us, such as:
- Qualified sign language interpreters
- Written information in other formats (large print, audio, accessible electronic formats, other formats)
- Provides free language services to people whose primary language is not English, such as:
- Qualified interpreters
- Information written in other languages
If you need these services, contact:
IUOE Local 132 H&W Fund
PO Box 2626
Huntington, WV 25726-2626
Phone: 304-525-0482 or 1-800-642-3525
If you believe that the IUOE Local 132 H&W Fund has failed to provide these services or discriminated in any other way on the basis of race, color, national origin, disability or sex, you can file a grievance with:
IUOE Local 132 H&W Fund
PO Box 2626
Huntington, WV 25726-2626
Phone: 304-525-0482 or 1-800-642-3525
You can file a grievance in person or by mail, fax or e-mail. If you need help filing a grievance, the Plan Administrator is available to help you.
You can also file a civil rights complaint with the US Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail at: US Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-868-1019, 800-537-7697 (TDD).
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Prescription Contraceptives (effective 2/01/2015)
Prescription Contraceptives are now an eligible expense with the Prescription Drug benefits. These prescriptions will be subject to the same annual deductible and co-payment factors currently used by your Plan.
Shingles Vaccinations (effective 2/01/2015)
Coverage for Shingles Vaccinations has been added for the Medicare Supplemental eligible participants at a maximum of $300 paid at 80%, which is the same percentage used by the Fund in the processing of Medicare deductibles and co-payments.
Elimination of Pre-Existing Conditions Limitations (effective 7/01/2014)
The Plan will no longer exclude benefit coverage (for up to twelve months) for charges incurred for the treatment and services related to a medical condition that was diagnosed within the six-month period prior to your effective date of coverage or your dependent’s effective date of coverage.
Weekly Disability Benefit (effective 4/01/2013)
The Weekly Disability benefit has been increased from $200 to $350 per week.
Oral/Vision Care Benefit (effective 4/01/2013)
The Oral/Vision Care benefit maximum benefit which will be paid on behalf of a covered individual for expenses incurred in a calendar year has been increased from $500 to $750, reimbursed at 100%.
In regards to the pediatric oral/vision care benefit, if an eligible minor child(ren), age 19 or less, incurs expenses for oral or vision care services which are not covered under the Major Medical benefit, such expenses will be reimbursed at 100% of the first $750, then 50% thereafter.
Any portion of the $500 Oral/Vision Care benefit which was met during January 1, 2013 through March 31, 2013, is also included in the 2013 calendar year maximum reimbursed at 100%.
Prescription Benefits 90-day Supply (effective 4/01/2013)
In regards to your prescription benefits, you can now choose to fill your 90-day supply prescriptions at any local CVS/pharmacy location or with the CVS Caremark Mail Service Pharmacy for the same low price. To find the right 90-day option for you, speak to a pharmacist at your local CVS/pharmacy, visit www.caremark.com or call Customer Care toll-free at 1-888-739-7991.
Patient Protection and Affordable Care Act of 2010 (effective 7/01/2011)
For services on and after July 1, 2011, the following improvements have been made to your medical coverage through the Fund:
- Extend coverage for adult children to age 26;
- Eliminate pre-existing conditions limitations for dependents less than age 19;
- Eliminate lifetime Limits for “essential health benefits”;
- The Annual limit for 2011 is increased to $750,000, 2012 is increased to $1,250,000, 2013 is increased to $2,000,000, and in 2014 there will be no annual limit;
- The Pediatric Oral/Vision Care benefit will provide coverage for eligible children age 19 or less, with expenses paid at 100% of the first $500, then 50% thereafter;
- The Preventive Care benefit will provide coverage for eligible expenses to be paid at 100% of the first $1,000, then 50% thereafter.
Please note, there has been no change to the adult Oral/Vision Care benefit. Also note that Orthodontics are not considered an Oral Care Benefit, for both adults and children.
The Preventive Care Benefit will provide coverage for eligible expenses to be paid at 100% of the first $1,000, then 50% thereafter.
Reduction in Required Hours from 350 to 325 (effective 8/01/2010)
Effective with the April, May and June 2010 Work Quarter, which determines eligibility for the August, September and October 2010 Benefit Quarter, eligibility for Fund benefits will require a minimum of 325 hours worked in a Work Quarter. If you are unable to earn enough hours in a Work Quarter to qualify, and you are currently eligible for coverage, the rate to maintain coverage will remain at $5.25 per hour for each deficit hour, based on 325 hours required during the Work Quarter.
Dependent Coverage (effective 7/01/2010)
Michelle’s Law” was signed into law on October 9, 2008, therefore effective July 1, 2010 the dependent definition is amended by adding the following language:
- The dependent is a student at a post-secondary institution immediately prior to the onset of the medical leave of absence;
- The medical leave of absence commences while the student is suffering from a serious illness or injury, the medical leave of absence is medically necessary and the medical leave of absence causes the student to lose full-time student status; and
- The Plan receives written certification from a treating physician attesting to the serious medical illness or injury and that the leave of absence is medically necessary.
The continuation of the student dependent status applies until the earlier of:
- One year from the onset of the medical leave of absence; or
- The date that coverage would otherwise terminate under the Plan (based on the attained age).
Oral/Vision Care Benefit (effective 6/01/2010)
Effective June 1, 2010 the current $300 Dental Benefit has been increased and expanded to a $500 Dental/Vision benefit.
Reduction in Required Hours from 375 to 350 (effective 5/01/2010)
Effective with the January, February and March 2010 Work Quarter, which determines eligibility for the May, June and July 2010 Benefit Quarter, eligibility for Fund benefits will require a minimum of 350 hours worked in a Work Quarter. If you are unable to earn enough hours in a Work Quarter to qualify, and you are currently eligible for coverage, the rate to maintain coverage will remain at $5.15 per hour for each deficit hour, based on 350 hours required during the Work Quarter.
Free-Standing Laboratory Facility Coverage (effective 4/01/2010)
For service on and after April 1, 2010, the Trustees have voted to expand the benefit coverage for the charges of a free-standing (non-hospital) laboratory facility. The Plan will pay 100% of covered charges submitted by a free-standing Blue Cross Blue Shield network laboratory facility, without application of the calendar year deductible.
The 100% benefit will apply to free-standing (non-hospital) laboratory facilities for outpatient laboratory testing.
The 100% benefit will not apply to laboratory charges submitted by a hospital, whether the patient is confined or not confined.
There is no change in the benefit allowance for non-network laboratory charges.
This change does not apply to the Medicare Supplemental participants as Medicare is your primary insurance carrier.
Preferred Provider Organization (PPO) (effective 4/01/2009)
For service on and after April 1, 2009, Anthem Blue Cross Blue Shield has replaced 4MOST as the Plan’s in-network provider. By associating with Anthem Blue Cross Blue Shield the plan and it’s participants will have access to the BlueCard program. This program electronically links all Blue Cross Blue Shield Plans and their providers, creating one large, national network. The network includes more than 80 percent of the hospitals and 90 percent of the physicians in the United States. And, the plan and its members will have access to them all. This broader network provides better healthcare discounts that help keep your expenses down, lowers the amount you are responsible for related to coinsurance, and it helps the plan control its overall claims costs.
Hospital In-Network Benefits (effective 4/01/2008)
For service on or after April 1, 2008, the Board has increased the payment percentage from 80% to 85%.
Diabetic Education Benefit (effective 4/01/2008)
Effective April 1, 2008, the Board has added a benefit for Diabetic Educational services limited to a maximum payable of $500 per calendar year.
Chiropractic Benefits (effective 4/01/2008)
The calendar year maximum benefits payable has been increased from $800 to $1,000.
Expenses Not Covered (effective 12/01/2007)
The INELIGIBLE MEDICAL EXPENSES section has been amended as follows:
No benefits are payable for intentionally self-inflicted injury, whether sane or insane, or injury resulting from the participation in the commission of a felony.
No benefits are payable for intentionally self-inflicted injury or injury sustained in the commission of a felony, unless the injury is the direct result of a medical condition (such as mental illness or depression).
Weekly Disability Benefit (effective 6/01/2007)
The Weekly Disability Benefit has been increased from $100 to $200 per week, for periods of disability commencing on or after June 1, 2007.
Life Insurance Benefit (effective 6/01/2007)
The benefits underwritten by Boston Mutual Life Insurance Company have been increased to the following:
|Employee Life Insurance
Employee AD&D Benefit
|Dependent Life Insurance
Dental Benefit (effective 4/01/2007)
This limited benefit will provide a maximum reimbursement of $300 per calendar year per eligible family member for services provided in a dentist’s office. There will be no schedule of allowances or different percentages for reimbursements based on the type of treatment. All dental expenses will be covered at 100% up to $300 in a calendar year for each eligible family member.
This program is intended to be a reimbursement arrangement where you pay the dentist’s bill and submit a receipt to the Fund Office for reimbursement. However, if you and the dentist can reach an agreement where the dentist will accept payment from the Fund, with you responsible for any difference, you can instruct the dentist to submit his bill directly to the Fund Office and the Fund’s check will be made payable to the dentist.
Preventive Benefit (effective 4/01/2007)
Benefits for preventive care, as detailed below, will be paid at 100%, up to the reasonable and customary amount for the covered service, without application of the calendar year deductible, subject to a calendar year maximum benefit of $1,000 per covered individual. Covered services include:
- Mammogram, limited to one exam per calendar year;
- Pap smear and related office visit, limited to one exam per calendar year;
- HPV testing and vaccination, limited to one exam per three (3) calendar years;
- Immunizations, including flu shots and vaccines;
- Routine physical exam, limited to one exam per calendar year;
- Prostate exam, limited to one exam per calendar year;
- Colonoscopy exam for screening purposes, limited to one exam per ten calendar years for individuals less than age fifty (50) and limited to one exam per five calendar years for individuals age fifty (50) and over.
Benefits will not be provided under this Preventive Care Benefit for treatment, including diagnostic testing, of any illness or injury. Charges for treatment of an illness or injury will be considered under the Comprehensive Major Medical Benefit.
X-Ray, Laboratory and Exam Benefit (effective 4/01/2007)
The X-Ray, Laboratory and Exam Benefit has been eliminated from the Schedule of Benefits.
Hospital Services Payment Factor (effective 4/01/2007)
The payment factor for in-network (Preferred Provider PPO) hospital services have been increased from 75% to 80%.
Self-Contribution Provisions – Retirees (effective 4/01/2007)
The following language has been revised:
If you work in a jurisdiction outside of the Fund’s area and elect to authorize the transfer of reciprocal hours to this Fund, your hours earned will be credited based upon the Work Quarter and eligibility will be granted for the ensuing Benefit Quarter. If necessary for you to maintain coverage, you will be permitted to make a self-contribution in an amount equal to the difference between the required hours for eligibility and the number of hours credited times the prevailing building trades contribution rate applicable under the terms of the IUOE Local 132 Collective Bargaining Agreement in effect at the time.
Calendar Year Deductible (effective 1/01/2007)
The annual calendar year deductible was decreased from $500 to $250 per individual. An aggregate family calendar year deductible of $500 per family has been added to the Schedule of Benefits.
Annual Maximum (effective 1/01/2007)
The annual maximum for all covered expenses was increased from $200,000 to $300,000.
Lifetime Maximum (effective 1/01/2007)
The Lifetime maximum for all covered expenses was increased from $500,000 to $750,000.