Medical Program

Preferred Provider Organization (PPO) Network

The Trustees of the Fund have engaged Anthem Blue Cross Blue Shield (Anthem) as the Claims Administrator and as the Preferred Provider Organization (PPO) for the Fund. Accordingly, Participants of the ITPEU Health and Welfare Fund have access to a vast Network of Physicians and Hospitals affiliated with the Anthem Network of Healthcare Providers. There are decided advantages for Plan Participants who use the services of doctors or hospitals associated with the Blue Cross Blue Shield Network. The advantages to Plan Participants who utilize the Anthem Network include the following:

• When you use Anthem Network hospitals and physicians your ITPEU Health and Welfare Plan benefits last longer, as the charges you incur are discounted. This means you have more benefits when you need them, as the benefits limits that apply to your contribution rate and hours will stretch further,
• Network physicians and hospitals may not bill you beyond the discounted fees which are billed for the services provided. However, non-Network Health Care Providers who charge more than reasonable and customary amounts as determined by Anthem, may bill you for charges above the amounts which are paid by the Fund.

Medical Benefits

All eligible Participants of the ITPEU Health and Welfare Plan are entitled to the Medical coverage provided by the Plan. Medical coverage covers only Reasonable and Necessary medical expenses, and does not apply to dental, vision or welfare benefits. Nor does it apply to any medical expenses specifically excluded from coverage in other portions of this Summary Plan Description.

The rules governing deductibles and the Out of Pocket Maximums you will be required to pay each year are determined by the contribution rate your Employer remits to the Fund on your behalf, and whether your medical care is provided by a hospital or health care provider that is part of the Anthem “Network”.  Expenses incurred from services provided by Anthem Network hospitals or health care providers are referred to as “In-Network” expenses. Expenses incurred from services provided by non-Network hospitals or health care providers are referred to as “Out-of-Network” expenses.
Subject to the family maximum described later in this paragraph, each Participant shall be responsible to pay a "Deductible" each calendar year before the balance of his or her medical expenses (both In-Network and Out-of-Network) become covered medical expenses. The amount of a Participant's Deductible is specified in the Schedule of Benefits contained in this Summary Plan Description. The amount of the Deductible shall also be specified at the Fund's website (www.itpebenefits.org). Remember, this Deductible applies to each Participant during a calendar year, regardless of the number of injuries or illnesses they may have.  There will be a maximum of 3 Deductibles per family per calendar year.  Any combination of Deductible payments for families of 2 or more Participants shall be no more than the combined Deductibles of 2 family Participants.

For In-Network Expenses the Fund shall pay 70% of all covered medical expenses per eligible Participant per calendar year in excess of the combined In and Out of Network Deductible. This 70% payment by the Fund shall be paid until the Participant's Out Of Pocket Maximum has been met or the Participant's calendar year Maximum Medical Benefit has been paid, whichever comes first. In the event the Participant's Out Of Pocket Maximum has been met and the annual Maximum Medical Benefit has not been fully paid, the balance of all covered medical expenses for the year will be paid at 100% up to the annual Maximum Medical Benefit as specified in the pertinent Schedule of Benefits.

For Out-of-Network Expenses, the Fund shall pay 60% of all covered medical expenses per eligible Participant per calendar year in excess of the Deductible. This 650 payment by the Fund shall be paid until the Participant's combined In and Out of Network Out-of-Pocket Maximum has been met or the Participant's maximum calendar year benefit has been paid, whichever comes first. In the event the Participant's Out-of-Pocket Maximum has been met and the Maximum Medical Benefit has not been fully paid, the balance of all covered medical expenses for the year will be paid at 100% up to the Maximum Medical Benefit as specified in the pertinent Schedule of Benefits.

The Out-of-Pocket Maximum Medical Benefit is combined for In and Out of Network expenses each calendar year. The calendar year Maximum Medical Benefit shall include all benefits paid at 60% and 70%, plus all benefits paid at 100%.

In addition to the Deductible, each Participant is responsible for the 30% of In-Network covered medical expenses and the 40% of Out-of-Network covered medical expenses up to his or her out-of-Pocket Maximum and all medical expenses in excess of the Participant's annual Maximum Medical Benefit as specified in the pertinent Schedule of Benefits for the calendar year in question.


Special Rule for Class III and IV Participants with Contribution Rates of $4.15/Hour or Higher, and Class I and II Participants with Contribution Rates of $4.40/Hour or Higher
For Eligible Class III and IV Participants whose contribution rates are $4.15/hour or higher, and for eligible Class I and II Participants whose contribution rates are $4.40/hour or higher, a system of co-pays shall be in effect for In-Network physician visits and In-Office testing.

For all In-Network office visits with Primary Care Physicians and all tests/diagnostic procedures performed in such physicians’ offices, the Plan shall pay 100%. The term Primary Care Physician means a general practitioner, internist, family practice physician or pediatrician. For all In-Network physician visits to specialists and all tests/diagnostic procedures performed in such specialists’ offices, the Plan shall pay 100%. No Deductible shall be applicable to such physician visits or in-office testing.

With the exception of the Hearing Aid Benefit medical benefits provided by the Fund shall renew each calendar year.

Covered Medical Expenses
The term “Covered Medical Expenses” means the expenses incurred by or on behalf of a Participant for the charges listed below if they are incurred after he or she becomes eligible for these benefits. Expenses incurred for such charges are considered Covered Medical Expenses to the extent that the services or supplies provided are prescribed and/or recommended by a Physician, are Medically Necessary for the care and treatment of an injury or illness and the charges are reasonable in light of charges for similar services in your community. Please refer to your Schedule of Benefits for information regarding co-payments, deductibles or maximum coverage.

• Hospital In-Patient Service for Treatment for Conditions Other than Mental Health Disorders-Charges made by a Hospital, on its own behalf, for room and board at semi-private room rate, for ICU/CCU charges, general nursing care and other necessary services and supplies, provided, that if the Hospital only has private rooms, the covered charges shall be based on the Hospital's prevailing room rate;

• Ambulance Services-Charges for licensed ambulance service to or from the nearest Hospital where the needed medical treatment can be provided. Air ambulance is covered subject to Medical Necessity;

• Hospital Out-Patient Services-Charges made by a Hospital, on its own behalf, for medical care and treatment received as an outpatient;

• Free-Standing Surgical Facility Services-Charges made by a free-standing surgical facility, on its own behalf, for medical care and treatment;

• Rehabilitation hospital and Subacute Facility Services-Charges made by a Rehabilitation Hospital or a subacute facility, on its own behalf, for medical care and treatment, provided that such medical care and treatment is associated with a prior hospitalization and, provided further, that the Fund shall pay for no more than ten (10) days of such medical care and treatment at a Rehabilitation Hospital or subacute facility;

• Physician Services-Charges made by a Physician for professional services;

• Anesthetics Chemo Therapy Services, Etc.-Charges made for anesthetics and their administration; chemotherapy; blood transfusions and blood not donated or replaced; oxygen and other gasses and their administration; prosthetic appliances; and dressings;

• TMJ-Charges made for surgical and non-surgical care of Temporomandibular Joint Dysfunction (TMJ), up to a lifetime maximum of $15,000.00;

• Laboratory Radiation Services, Etc.-Charges made for laboratory services, radiation therapy and other diagnostic and therapeutic and radiological procedures;

• External Prosthetic Appliances-Charges made for the purchase and fitting of external prosthetic devices ordered or prescribed by a Physician which are to be used as replacements or substitutes for missing body parts and are necessary for the alleviation or correction of sickness, injury or congenital defect. The following items shall not be considered Prosthetic Appliances:
Corrective shoes, dentures, replacing teeth or structures directly supporting teeth (except to correct traumatic injuries), electric or magnetic continence aids (either anal or urethral), hearing aids or hearing devices, implants for cosmetic purposes (except for reconstruction following a mastectomy).

• Short Term Rehabilitative Therapy and Chiropractic Care Services- Charges made for Short-Term Rehabilitative Therapy that is part of a rehabilitation program, including physical, speech, occupational, cognitive, cardiac rehabilitation and pulmonary rehabilitation therapy, when provided in the most medically appropriate setting. Also included are services that are provided by a Participating Chiropractic Physician when provided in an outpatient setting pursuant to a written treatment plan which is in accordance with the generally accepted chiropractic standard of care. Services of a Chiropractic Physician include the management of neuromusculoskeletal conditions through manipulation and ancillary physiological treatment that is rendered to restore motion, reduce pain and improve function.

Limitations on Short-Term Rehabilitative Therapy and Chiropractic Care Services
The following limitations apply to Short-Term Rehabilitative Therapy and Chiropractic Care services:

• Services which are considered custodial or educational in nature are not covered;
• Occupational therapy is provided only for purposes of enabling you to perform the activities of daily living;
• Speech therapy is not covered when (a) used to improve speech skills that have not fully developed except when speech is not fully developed in children due to underlying disease or malformation that prevented speech development; (b) intended to maintain speech communication; or (c) not restorative in nature.
• If multiple out-patient services are provided on the same day they constitute one visit, but a separate payment will apply to the services provided by each provider.

Limitations on Number of Visits per Calendar Year for Therapy Services
The Fund shall not pay for speech therapy, physical or occupational therapy, or respiratory therapy visits in excess of the following number per calendar year:

• Speech Therapy-20 visit calendar year maximum;
• Physical or Occupational Therapy-30 visit calendar year maximum;
• Respiratory Therapy-30 visit calendar year maximum

Organ Transplant Services:
The detailed rules governing the circumstances under which the Plan will pay for organ transplant services are set forth at Section 9.03(b)(15) of the Plan Document contained at page 85 of this booklet.

• Breast Reconstruction and Breast Prostheses-Charges made for reconstructive surgery following a mastectomy; benefits include: (a) surgical services for reconstruction of the breast on which surgery was performed; (b) surgical services for reconstruction of the nondiseased breast to produce symmetrical appearance; (c) postoperative breast prostheses; and (d) mastectomy bras and external prosthetics, limited to the lowest cost alternative available that meets external prosthetic placement needs. During all stages of mastectomy, treatment of physical complication, including lymphedema therapy, are covered.

• Durable Medical Equipment- Except for the exclusions set forth below, charges for the rental of Durable Medical Equipment (up to the purchase price of the equipment) that is ordered or prescribed by a physician and is appropriate for in home use, provided that such equipment is used to improve the functions of a malformed part of the body or to prevent or slow further decline of the patient's medical condition. Charges for repair, replacement or duplicative equipment shall be paid only when required due to anatomical change and/or reasonable wear and tear. All maintenance and repairs that result from a Participant's misuse shall be the responsibility of the Participant.

Definition of "Durable Medical Equipment":
The term "Durable Medical Equipment" is defined as equipment which meets the following criteria:
• It can stand repeated use;
• It is manufactured solely to serve a medical purpose;
• It is not merely for comfort or convenience;
• It is normally not useful to a person not ill or injured;
• It is ordered by a physician;
• The physician certifies in writing the medical necessity for the equipment;
• The physician also states the length of time the equipment will be required;
• It is related to the patient's physical disorder.

Durable Medical Equipment Items Excluded from Coverage:
Expenses for the following Durable Medical Equipment items shall not be considered "covered medical expenses":
• Bed related items: bed trays, over the bed tables, bed wedges, custom bedroom equipment, non-power mattresses, pillows, posturepedic mattresses, low air mattresses (powered), alternating pressure mattresses;

• Bath related items: bath lifts, non-portable whirlpool, bathtub rails, toilet rails, raised toilet seats, bath benches, bath stools, hand held showers, paraffin baths, bath mats, spas;

• Chairs, Lifts and Standing Devices: computerized or gyroscopic mobility systems, roll about chairs, geri chairs, hip chairs, seat lifts (mechanical or motorized), patient lifts (mechanical or motorized – manual hydraulic lifts are covered if the patient is two-person transfer), vitrectomy chairs, auto tilt chairs and fixtures to real property (ceiling lifts, wheelchair ramps, automobile lift customizations);

• Air quality items: room humidifiers, vaporizers, air purifiers, electrostatic machines;

• Blood/injection related items: blood pressure cuffs, centrifuges, nova pens, needle-less injectors;

• Pumps: back packs for portable pumps;

• Dialysis Machines;

• Other equipment: heat lamps, heating pads, cryounits, ultraviolet cabinets, sheepskin pads and boots, postural drainage board, AC/DC adapters, Enuresis alarms, magnetic equipment, scales (baby and adult), stair gliders, elevators, saunas, exercise equipment, diathermy machines.

• Hospital Emergency Room Services: Charges for hospital emergency room care in connection with a "Medical Emergency". For purposes of this Section 9.03(b)(18) the term "Medical Emergency" shall mean "a condition of recent onset and sufficient severity including, but not limited to severe pain, that would lead a prudent lay person, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness or injury is of such a nature that failure to obtain immediate medical care could place his or her life in danger or cause serious harm".

• Hearing Aids
A Hearing Aid Benefit shall be provided for Employees and their Covered Family Members, provided the Employees' contribution rates are $3.24 per hour and above. Your schedule of benefits specifies the maximum dollar amount for each Hearing Aid Benefit that will be paid by the Fund under this Section.  In no event shall the Fund pay more than such maximum amount for any Employee or Covered Family Member in any 24 month period."

Preventive Care Guidelines Health Services

Effective July 1, 2012, the Plan will pay 100% of the cost of all "Preventive Health Services" required by the Affordable Care Act when such services are provided by Network Healthcare Providers.  Such services include well-care baby visits, preventive care physical examinations for adults, screening testsfor children and adults, and immunizations for children and adults.  Set forth below is an overview of the types of preventive services which are covered.  If you have questions as to whether a particular service is a "Preventive Health Service" required to be provided by the Plan without cost to you under the Affordable Care Act, please call the Claims Administrator at 1-877-331-4329.

Medical Expenses Not Covered
No payment will be made for medical expenses incurred for which benefits are not payable under the General Exclusions and Limitations section of this Site, or for private Hospital rooms unless such rooms are determined to be Medically Necessary or the Hospital only offers private rooms.