Metropolitan and Suburban Plan SPD >> Table of Contents

• Important Notice


• Eligibility and Participation
  • When You Are When You Are Eligible  
  • When You Are No Longer Eligible
  • If You Come Back to Work Health Benefits
    • Extension of Health Benefits
    • COBRA
    • Retirement between Ages 62 and 65
    • Disability
    • Arbitration
    • FMLA
    • Military Leave
  • Dependent Eligibility
  • When Your Dependents Are No Longer Eligible
  • How to Enroll
  • Your Notification Responsibility
  • What Benefits Are Provided
  • Hospital and Medical Benefits
  • Overview of Eligible Expenses> When You Go In-Network
  • When You Go Out-of-Network
  • Coverage When You Are Away from Home
  • Benefit Maximums
  • Conditions for Hospital and Medical Expense Reimbursement
  • Pre-Certification
  • Covered Services
    • In the Hospital and Outpatient Treatment Centers
    • Skilled Nursing Facility
    • Hospice Care Facility
    • Home Health Care
    • Emergency Care
    • Care in the Doctor’s Office
    • Preventive Medical Care
    • Pregnancy and Maternity Care
    • Physical, Occupational, Speech or Vision Therapy (including rehabilitation)
    • Durable Medical Equipment and Supplies
  • Excluded Hospital And Medical Expenses
  • Prescription Drug Benefits
    • At the Pharmacy
    • Through Mail Order
    • Eligible Drugs
    • Excluded Drugs
  • Employee Assistance Program (EAP)
    • Behavioral and Substance Abuse Treatment
    • Confidentiality
    • Pre-Certifying Behavioral or Substance Abuse Treatment
    • Eligible Providers
    • Conditions for Coverage
    • What Is Not Covered
  • Dental Benefits
    • How the Plan Works
    • The 32BJ Dental Center
    • Participating Dental Providers
    • Non-Participating Dentists
    • Prior Approval
    • What Dental Services Are Covered
    • Frequency Limitations
    • Schedule of Covered Dental Services
    • Alternate Benefit
    • What Is Not Covered
    • Coordination of Dental Benefits
  • Vision Care Benefits
    • Eligible Expenses
    • Excluded Expenses
  • Long Term Disability (LTD) Benefits
    • Eligibility
    • LTD Benefit Amount
    • When Benefits Begin
    • Receiving LTD Benefits
    • When Benefits End
    • What Is Not Covered
  • Life Insurance Benefits
    • Benefit Amount
    • Naming a Beneficiary
    • Life Insurance Disability Extension
    • When Coverage Ends
  • Accidental Death & Dismemberment (AD&D) Benefits
  • How AD&D Benefits Work
  • What Is Not Covered
  • When Coverage Ends
  • Death Benefit For Pensioners
  • Claims and Appeals Procedures
  • Claims for Benefits
    • Filing Hospital and Medical Claims
    • Filing Dental Claims
    • Filing Pharmacy Claims
    • Filing EAP Claims
    • Filing Vision Claims
    • Filing Long Term Disability (LTD) Claims
    • Filing for a Pensioner’s Death Benefit
    • Filing Life Insurance and AD&D Claims
  • Where to Send Claim Forms
  • Approval and Denial of Claims
    • Health Service Claims (hospital/medical, pharmacy, EAP, dental and vision)
    • Long-Term Disability (LTD) Claims
    • Life and AD&D Claims
    • Pensioner’s Death Benefit Claims
    • Notice of Decision
  • Appealing Denied Claims
    • Filing an Appeal
    • Where to File an Appeal
    • Time Frames for Decisions on Appeals
    • Expedited Appeals for Urgent Care Claims
    • Pre-Service or Concurrent Medical, Hospital, Pharmacy or EAP Claim Appeal
    • Post-Service Medical, Hospital, Pharmacy or EAP Claim Appeal
    • Voluntary Second Level Appeal of a Medical, Hospital, Pharmacy or EAP Claim
    • Vision, LTD, Pensioner Death Benefits, Life, AD&D and Dental Claim Appeal
    • Appeal Decision Notice
  • Further Action
  • Incompetence
  • Mailing Address
  • Coordination Of Benefits
  • Your Disclosures To The Fund
  • Subrogation and Reimbursement
  • Fraud
  • Overpayments
  • Continued Group Health Coverage
    • During a Family and Medical Leave
    • During Military Leave
    • Under COBRA
    • COBRA Continuation of Coverage
  • Other Health Plan Information You Should Know
    • Assignment of Plan Benefits
    • No Liability for Practice of Medicine
    • Privacy of Protected Health Information
    • Certificate of Creditable Coverage
    • Converting to Individual Coverage
  • General Information
    • Employer Contributions
    • How Benefits May Be Reduced, Delayed or Lost
    • Compliance with Federal Law
    • Plan Amendment or Termination
    • Plan Administration
    • Statement of Rights under the Employee Retirement Income Security Act of 1974 as Amended
  • Plan Facts
  • Glossary
  • Footnotes
  • Translation Notice
  • Contact Information