Teamsters Local 805 Welfare Fund

SUMMARY PLAN DESCRIPTION - TABLE OF CONTENTS

BENEFITS AT A GLANCE

GLOSSARY

ELIGIBILITY AND EFFECTIVE DATES OF COVERAGE

Who Is Eligible For Coverage
Who Are Your eligible Dependents
When Do Benefits Begin
When do Benefits End

 

CONTINUED COVERAGE DURING CERTAIN ABSENCES

Temporary Leave Of Employment
Family And Medical Leave Act
Disability Leave
Military Duty In The United States Armed Forces

COBRA - Continuation of Health Coverage (For Medical, Dental, Vision and Prescription Drug Benefits Only)

Health Insurance Portability And Accountability Act

PLAN BENEFITS

Reasonable and Customary And Other Recognized Charges
Medically Necessary Care
Lifetime maximum Benefit Limitation

HOW TO CLAIM BENEFITS UNDER THIS PLAN

How To Claim hospital And Major Medical Benefits

DENIAL OF CLAIMS AND PROCEDURES FOR APPEAL

General Information
Timing Of Initial Claim Determinations. Pre-Service Claims
Post-Service Claims
Urgent Care Claims
Concurrent Care Claims (Ongoing Course of Treatment)
Notice of Initial Claim Determinations
Requests for Review of Claim Denials and Other Adverse Benefit Determinations

INSTITUTING LEGAL ACTION

HOSPITALIZATION AND MAJOR MEDICAL BENEFITS

Network And non-Network Coverage
Hospitalization Benefits
Hospital Exclusions
Major Medical Benefits
Surgical Ana Anesthesia Benefits
The Women’s Health And Cancer Rights Act
Major Medical Exclusions

GENERAL LIMITATIONS AND EXCLUSIONS

DENTAL BENEFITS

General Benefits Provided And Commencement
Alternative Benefit Provision
Prior Approval
Managed Care Option
Standard Reimbursement Option
Special Limitations Applicable to Specific Dental Services
Schedule Of Covered Dental Expenses
Dental Expenses not Covered

OPTICAL BENEFITS

PRESCRIPTION DRUG BENEFITS

Amount of Coverage
Covered Drugs
General Exclusions
Dispensing Limits
Generic And Brand name Drugs
New Drugs
Mail Service Prescription Drug Plan: Aetna RX Home Delivery
Specialty And Injectible Medications: Aetna Specialty Pharmacy (ASRX)
How To Claim Prescription Drug Benefits

DEATH BENEFITS

COVERAGE UNDER MORE THAN ONE GROUP HEALTH PLAN: COORDINATION OF BENEFITS (COB)

MEDICARE AND OTHER GOVERNMENT PLANS

REPAYMENT OF MEDICAL BENEFITS (SUBROGATION)

OVERPAYMENTS

YOUR RIGHTS UNDER THE EMPLOYEE RETIREMNT INCOME SECURITY ACT OF 1974 (ERISA)

HIPAA PRIVACY OF PROTECTED HEALTH INFORMATION

OTHER INFORMATION YOU SHOULD KNOW

Notices Sent to Participants Or Dependents
Misrepresentation And Fraud
Assignment And Alienation
No Interest Due On Payments
Plan Amendment, Modification And Termination
Plan Interpretation

ASSISTANCE WITH YOUR QUESTIONS

GENERAL INFORMATION