Section 22: Questions and Answers

QUESTIONS AND ANSWERS

The following question and answer section is included in this booklet to provide you with answers to commonly asked questions about how some of your benefits are paid. Please read over the next few pages. If you have any questions that are not answered here, or if you want more information regarding your benefits, you should call the Fund Office at (312) 372-3653.

22.1 Eligibility of Dependents

Q. My son is a college student. Does he still qualify as my dependent for medical coverage?

A. Yes, if he maintains “full-time status” (12 credit hours) each semester. Benefits normally terminate when a dependent reaches age 19, but coverage will continue each year until the earlier of graduation or age 23 if the Fund Office receives proof of your dependent’s full-time student status from an accredited school in September and February of each school year. (See Section 1.2).

22.2 Comprehensive Major Medical Benefit

Q. My doctor suggests that I be hospitalized for back surgery. What should I do?

A. Any time your doctor suggests elective, non-emergency surgery, you or your doctor should call the Blue Cross Blue Shield MSA for precertification at least one business day before you go into the hospital. If you fail to call the Blue Cross Blue Shield MSA, you will have to pay an additional $250 co-payment before the Fund begins to pay any of your covered costs. The phone number for the Blue Cross Blue Shield MSA is 1-800-255-5192.

Q. I had a wisdom tooth pulled at my dentist’s office. Since the anesthesia was not covered under the dental benefit, can I claim it under the comprehensive major medical?

A. No. Comprehensive major medical only covers anesthesia for the extraction of a wisdom tooth when performed in a hospital. (See Section 10.6).

Q. What is my coverage if I have an emergency appendectomy and I’m hospitalized at a non-PPO hospital?

A. If you are hospitalized for an emergency or maternity treatment at a non-PPO hospital and call the Blue Cross Blue Shield MSA within two business days of your admission to the hospital, you will receive the same coverage as if you were treated at a PPO hospital. If you fail to call the Blue Cross Blue Shield MSA within two business days of your admission to the hospital, you will have to pay an additional $250 co-payment before the Fund begins to pay any of your covered costs.

Q. Please explain how the comprehensive major medical deductible works. There are five people in my family.

A. Each eligible individual member of your family must incur $250.00 of covered expenses before comprehensive major medical benefits are payable for that family member. There is a family limit of 3 individual deductibles per calendar year. This means that when 3 of your family members satisfy the individual deductible, the remaining family members do not need to satisfy a deductible before their expenses are covered.

Q. My doctor wants me to lose weight and suggested that I go to the Optifast Program at the hospital he is affiliated with. Will it be covered since my doctor recommended it?

A. Diet programs such as Optifast, Medfast, Jenny Craig and Nutrisystem are not covered by the Plan. With proper diagnosis, the Physician and lab charges will be covered. However, the nutrients supplied with the diet programs and the pre-paid maintenance charges will not be covered. (See Section 15).

Q. What does the Plan pay for covered expenses after the deductible is met?

A. The Plan pays the percentage of covered expenses that is listed in your Schedule of Benefits. The Plan pays a higher percentage when you use providers and facilities in the PPO network than when you use out-of-network providers and facilities.

Q. What is the lifetime maximum benefit?

A. In general, lifetime benefits are unlimited. However, in many instances, the Plan limits the maximum amount that will be paid for specific services such as treatment of alcohol and drug abuse, infertility or hospice care, to name a few. In some cases, the Plan also limits the number of treatments or appliances that are covered or the amount that is paid for a particular item or service.

Q. What coverage do I have for non-emergeny treatment of an illness at a Non-PPO Hospital?

A. If you receive treatment for a non-emergency illness at a Non-PPO Hospital, the Plan will pay 70% of covered expenses.

22.3. Prescription Drug Benefit

Q. My doctor gave me a prescription for birth control pills. Why was my claim denied?

A. Expenses related to prevention of pregnancy are not covered. (See page ___).

Q. Are cold pills covered?

A. Cold pills available “over-the-counter” are not covered. Cold medication requiring a written prescription from a physician and dispensed only by a licensed pharmacist are covered. (See Section 14.3).

Q. What if I need to start taking a maintenance medication right away?

A. Ask your doctor for two prescriptions – one for a 34-day supply to be filled immediately at a local pharmacy and a second to be submitted to Caremark for up to a 90-day supply with appropriate refill instructions. (See Section 14.2).

22.4. Dental Benefit

Q. My dentist wants to put in a crown. Why do I need to submit a form to predetermine my benefits?

A. The Fund Office wants you to be aware of what benefits will be payable before you have costly dental work done. This way you won’t be surprised by the portion of the bill that is your responsibility. (See Section 11.1).

22.5. Mental and Nervous Disorders and/or Substance Abuse

Q. Our doctor recommended a drug addiction treatment program for my son. Will my medical plan cover it?

A. Contact the Fund Office to see if the recommended facility is approved by Blue Cross Blue Shield of Illinois. Benefits will only be paid for treatment received in Blue Cross Blue Shield of Illinois approved facilities. Blue Cross Blue Shield of Illinois approved facilities include both PPO and Non-PPO facilities and will be paid at the appropriate rate for that facility. Since benefits will not be paid for treatment received in facilities not approved by Blue Cross Blue Shield MSA, you may want to ask your doctor to recommend a different facility if the original
recommended facility is not Blue Cross Blue Shield approved. (See Section 10).

Q. My doctor said I should see a therapist for my depression. Will it be covered?

A. Coverage will be provided if you see a psychiatrist, psychologist, mental health counselor, substance abuse counselor or social worker with a masters degree or
higher. The provider must be legally licensed or authorized to practice or provide service, care or treatment for such conditions under state law, and act within the scope of that license. The Plan will pay 50% for outpatient treatment up to the maximums in the Schedule of Benefits.

Q. My wife wants to see a marriage counselor. Is that considered outpatient treatment for a mental or nervous disorder?

A. No, the Plan only covers medically necessary treatment. Marriage counseling is not considered Medically Necessary by the Plan. (See Section 10.6).

22.6. Skilled Nursing Facility Care

Q. My wife had a stroke. Now that the crisis stage is over the doctor wants to move her to a skilled nursing home. Are skilled nursing homes covered?

A. Contact the Fund Office to see if the facility is approved by Blue Cross Blue Shield of Illinois. Many skilled nursing homes are not Blue Cross Blue Shield approved and benefits will not be paid. Proper diagnosis is also necessary for determination of benefits. (See Section 10.6).

22.7. Administrative Information

Q. I would like to have a copy of all the claims I’ve submitted during the past year. How can I get copies?

A. The Fund Office does not provide services of this type. Please make copies of your claims before submitting them. You are responsible for maintaining your own records.

Q. I will be downtown next week and would like to stop by the Fund Office to check on my medical claims. Is that o.k?

A. Please call for an appointment if you feel a visit to the Fund Office is necessary. This will benefit both you and the Fund Office, since the Fund Office personnel will be able to have your records available at the time of your appointment. They will be able to give your problems or concerns prompt attention.

Q. Are annual physical check-ups covered under the program?

A. Yes – within limits for you and your spouse. Wellness benefits (annual checkups and covered related expenses) are covered for you – the employee – and your spouse as described in Section 9, Wellness Expense Benefits. Routine child and adolescent immunizations and physician’s examinations or check-ups until age 16, as well as some of the expenses you incur for your dependent child’s physical check-up such as laboratory work, blood work, and the like will be covered under the major medical portion of your coverage.

22.8. General Exclusions and Limitations

Q. I have multiple sclerosis and my doctor indicated that I might need a wheelchair some time in the future. Would this expense be covered?

A. If you need durable medical equipment, you should call the Fund Office to determine if the expense is covered and if so, if the equipment should be rented or purchased. A physician’s prescription of necessity and the length of time you are expected to need the equipment plus the rental and purchase prices are necessary to determine coverage.

If the purchase of the equipment is less expensive than the rental, you will be required to purchase the equipment. This Plan will purchase such durable medical equipment in accordance with the Plan’s major medical coverage only
once in an individual’s lifetime. Please note that repairs of the equipment are not covered by the Plan. (See Section 10.6 and Appendix A.)