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Tri-State Preferred Plan SPD
>> Table of Contents
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Important Notice
- Eligibility and Participation
- When You Are Eligible
- When You Are No Longer Eligible
- If You Come Back to Work
- Extension of Health Benefits
- COBRA
- 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
- About the Empire Networks
- 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
- 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 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)
- 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, Pensioner’s Death Benefit, Life and AD&D 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
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