Welcome to your Medical Benefits. Click on any of the boxes below to read about what is covered under your plan and find any documents related to it.
The Plan covers Bariatric Surgery only when the required criteria are met. All covered expenses must be incurred at an in-network Center of Excellence. THERE IS NO COVERAGE FOR BARIATRIC SURGERY PERFORMED OUT-OF-THE PPO NETWORK. Prior authorization is required for all bariatric surgery services.
Please click here for a more detailed explanation of the benefit.
The Plan covers chiropractic care and acupuncture only when all of the following criteria is met:
- Only when rendered by a physician; and,
- only for eligible participants, spouses, and dependents over the age of 5; and,
- only for the treatment of the back, neck, spine, and vertebra; and,
- only for conditions due to subluxation, strains, sprains, and nerve root problems.
The Plan does not cover physical therapy services provided by a Chiropractor. (See Physical Therapy benefits.) The Plan does not cover chiropractic care received at the same time as physical therapy.
The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), allows you to extend certain coverage for yourself and your eligible dependents when certain circumstances, or qualifying events, would normally cause coverage to end. Please click on the link(s) for more information.
The Plan provides benefits for charges for immunizations for you, your spouse, and your Dependent children in accordance with medically acceptable guidelines such as the U.S. Preventive Services Task Force, CDC Advisory Committee on Immunization Practices, and the Health Resources and Services Administration. These eligible expenses are covered immediately at 100% of the allowable charges through the medical portion of the Plan. You may now receive your seasonal immunizations (various types of influenza and commercially available COVID-19) at any participating pharmacy when you show your CVS Caremark prescription benefit card. You do not need to satisfy the individual annual deductible before receiving benefits.
AllOne Health provides all eligible participants and their families free access to the Member Assistance Program and Online Work-Life Services for information and resources. Counselors are available 24/7/365 to provide support and referrals.
- For confidential help call any time 1-800-292-2780
- Log on to www.ers-eap.com (UN: laborers PW: foxvalley)
You deserve to benefit from the convenience of having MAP Counselors and Work-Life Consultants provide support services, research assistance, resources and referrals for matters related to these and other topics:
- Marital and family conflict
- Stress management
- Budgeting & financial issues
- Parenting challenges
- Job performance
- Childcare resources
- Eldercare resources
- Skill Builder online courses
- Pet care
- Daily living needs
- Dining and entertainment
- Prescription savings
The Plan provides benefits for mental disorder treatment. Allowable charges incurred for mental disorder treatment will be paid at 90% (80% if outside of the PPO Network) after the annual deductible for each eligible participant or eligible dependent each calendar year. Allowable mental disorder treatment charges count towards satisfaction of the Out‐of‐Pocket limit and are then paid in accordance with that provision. Charges for mental disorder treatment are covered when provided by a licensed psychiatrist or Doctor of Medicine. Treatment may be covered when provided by a clinical psychologist, licensed clinical professional counselor, or a licensed social worker if the treatment is prescribed by and under the ongoing supervision of a licensed psychiatrist or Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.).
A mental disorder treatment is any illness:
- identified in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). For the purpose of this benefit, it excludes psychological and/or physiological dependence or addiction to alcohol or psychoactive drugs or medications, regardless of any underlying physical or organic cause (treatment for these may be covered under the substance abuse benefit); and,
- where the psychotherapy or other psychotherapeutic methods are the primary sources of treatment.
All inpatient services given by a mental health facility or area of a hospital that provides mental health or substance abuse treatment for an illness identified in the DSM are covered by the Plan. Detoxification services, adjustment reactions, developmental delays, and marriage and family counseling are not considered under this Plan to be mental disorder treatment.
Benefits are payable for an annual routine physical exam performed by a Medical Doctor (M.D. or D.O.) for you, your spouse, and your Dependent children in accordance with medically acceptable guidelines such as the U.S. Preventive Services Task Force, CDC Advisory Committee on Immunization Practices, and the Health Resources and Services Administration. Benefits include expenses incurred for X-ray and laboratory tests.
Your eligible expenses for a physical exam are fully covered immediately at 100% of the Allowable Charges. You do not need to satisfy the individual annual deductible before receiving benefits.
The following expenses are not covered:
- charges for services or supplies that are covered in whole or in part under any other provisions of the Plan;
- any expense for a physical exam that is not performed by a physician;
- charges that exceed allowable charges; or
- any expense in connection with an illness or injury.
The Plan provides for treatment of a physical disability for which there is a reasonable expectation of significant improvement in the status of that disability as determined by the Plan. The Plan covers services provided by a registered physical therapist, registered speech therapist, or a registered or state licensed occupational therapist for short-term therapy.
Services must be ordered by a physician, physician assistant, or nurse practitioner under the supervision of a physician under an individual treatment plan and must be certified by the physician as necessary for the improvement of the patient’s condition through “short-term” care. The prescriber must provide a written prescription which includes frequency, duration, and prognosis.
The term “short-term” for purposes of Physical/Occupational Therapy benefits is defined as a continuous course of treatment of “up to 26 weeks” for a specific condition/diagnosis. The “up to 26 weeks” period begins on the first day of therapy. Subsequent short- term treatment for a reinjury or relapse restarts the course of treatment.
If medically necessary, a Participant may request an extension of “short-term” therapy benefits. Requests for an extension of the maximum 26-week period must be recommended by a physician, physician assistant, or nurse practitioner under the supervision of a physician and reviewed by the Fund Office and Medical Management. An extension of benefits will be considered only after a medical review to determine medical necessity, reasonable expectation of significant improvement, and non-experimental treatment status according to accepted standards of medical practices through established medical review mechanism. Extension of benefits will be approved in four week increments with an overall maximum benefit of no more than 52 weeks.
In addition, occupational and physical therapy services will be covered for treatment of a Dependent with a congenital disability without regard to the reasonable expectation of significant improvement of the disability or the “short-term” care of up to 26 weeks limitation.
The Plan covers Organ Transplants only when the required criteria is met. All covered expenses must be incurred at an in-network transplant Center of Excellence for all covered transplants except cornea and kidney incurred at a PPO hospital. THERE IS NO COVERAGE FOR TRANSPLANTS PERFORMED OUT-OF-THE PPO NETWORK. Prior authorization is required for all covered transplant services.
Please click here for more information.
The Welfare Plan can help replace part of your income if you become temporarily disabled and cannot work. To receive this benefit you must be eligible, totally disabled, unable to perform your job and under the care of a medical doctor. Refer to the attachment for a detailed explanation of the Weekly Loss of Time benefit.
Please click here for more information.