Medical Summary Plan Description

Please note there have been several changes to the Summary Plan Description(SPD) from when it was initially printed. Below is information and links to amendments to the Medical Plan. Please call the Fund Office for any questions.

Highmark Preventive Schedule - 2012

This schedule, based on recommendations from the Centers for Disease Control and Prevention, the American College of Obstetricians and Gynecologists, the American Cancer Society January 2008 Colorectal Cancer Screening guidelines and items/services required under the Patient Protection and Affordable Care Act of 2010 (PPACA), is a reference tool for planning your family's preventive care. Your specific needs may vary according to your personal risk factors. Your doctor is always your best resource for determining if you're at an increased risk for a condition. If you have questions about your coverage, please call the toll-free Member Service number on your identification card.  2012 Highmark Preventive Schedule

Highmark Preventive Schedule - 2011

This schedule, based on recommendations from the Centers for Disease Control and Prevention, the American College of Obstetricians and Gynecologists, the American Cancer Society January 2008 Colorectal Cancer Screening guidelines and items/services required under the Patient Protection and Affordable Care Act of 2010 (PPACA), is a reference tool for planning your family's preventive care. Your specific needs may vary according to your personal risk factors. Your doctor is always your best resource for determining if you're at an increased risk for a condition. If you have questions about your coverage, please call the toll-free Member Service number on your identification card.  2011 Highmark Preventive Schedule

Changes effective January 1, 2011

  • Inpatient deductible will be $600 per family per year.
  • Office visit deductible will be $200 per individual per year.
  • Emergency room copay of $200 which will be waived if the patient is admitted to the hospital
  • Therapy services copay of $15 for various therapy services such as chiropractic, speech, occupational and rehabilitation therapy and radiation therapy.
  • Established a member copay equal to 10% of the inpatient benefit and 20% of the outpatient benefit.  The annual out of pocket maximum will be $1000 per individual / $2000 maximum per family.  The inpatient and office visit deductibles and any copays for emergency room or therapy services will not count towards the $1000 / $2000 maximums.
  • Complete list of plan provisions:  Comparison of Medical Plan Design January 2011

Effective January 1, 2011 (as required by law)

  • The Plan will cover children up to the age 26 without regard to marital status, student status, financial dependency or other special requirements.  Should you have a child under the age of 26 who has been terminated under our plan, please contact the Fund Office.
  • The Plan will cover stepchildren up to the age 26 in the same manner as biological children.  If you have a stepchild / stepchildren that you want to add to the plan, please contact the Fund Office.

Change in routine physicals

Effective April 1, 2009, active members and early retirees and their eligible dependents can get a routine physical once per year rather than every two years. This improvement will be administered through Highmark.

Smoking Cessation

Effective April 1, 2009, there will be a smoking cessation benefit administered through the Fund Office. There will be a $700 lifetime maximum. Reimbursements will be at 100%. Physician visits, medication treatments, nicotine replacement therapy and counseling will be covered. Over-the-counter medications will not be covered. This benefit would apply only to active members and early retirees and their eligible dependents.

Sick Pay provision change

Be advised that the Board has approved a change in one provision affecting our sick pay benefit. Our sick pay benefit is $200.00 per week for a maximum of fifteen weeks. In addition, disability credits are issued which assist a member in maintaining medical coverage. Before this change, successive periods of disability had to be separated by at least 200 hours of employment, unless the disability arose from different and unrelated causes.

We are retaining the 200 hour requirement between the first and second period of disability but there will now be a 1000 hour employment requirement after a second period of disability.  If you have a different and unrelated disability, and return to work for one full day, you will then be entitled to a new benefit period.

Change in annual prescription maximum for active members and early retirees and their eligible dependents

Retroactive to January 1, 2009, the annual prescription cap increased to $5,000 with the excess of eligible charges over $5,000 covered at 50%.

Active and retiree eligibility requirements

Eligibility for retirees changed on effective benefit period starting April 1, 2006. Eligibility requirements can be found in the eligibility page on this website.

Understanding Medicare Drug Coverage

read this announcement, which explains how the Medical Drug Coverage works, summarizes standard Medicare Prescription Drug Coverage and other resources for more information.

Change in orthotic benefits

Effective April 21, 2005, All members eligible for the orthotic benefit under durable medical equipment (page 42 of the medical handbook). Please be advised that, effective immediately, there will be a $400.00 cap per calendar year on the orthotic benefit provided by our Plan.

Inpatient hospital deductible

Effective April 1, 2004, The inpatient hospital deductible for active members and early retirees will be $400 once per family per year rather than $200 once per family per year.

Prescription plan changes

Effective April 1, 2004, Our prescription program will move to a three tier program with three levels of copays.  Prescription Plan information

Oral surgery benefits eliminated

Effective April 1, 2004, The plan will no longer provide the oral surgery benefit outlined on pages 40 and 41 of your benefit handbook. Voluntary dental care benefits are available.

Vision care benefits eliminated

Effective April 1, 2004, The plan will no longer provide a vision care benefit. The vision care benefit was outlined on page 44 of your handbook. Voluntary vision care benefits are available.

Flu, Meningitis and pneumonia immunizations

Effective April 16, 2003, the Medical Board voted to add coverage through Highmark Blue Cross Blue Shield for Flu, Meningitis and Pneumonia Immunizations. This benefit is now available to active members and non-Medicare retirees.

Change in filing durable medical equipment claims

Effective August 2003, As you know, individuals in groups 51242-00, 02, 04, 06, 08 and 70 have coverage for durable medical equipment. Coverage is 80% of the usual and customary fee. For many years, these claims were processed through the Fund Office. On January 1, 2002, you were advised that these claims should be submitted direct to Highmark Blue Cross Blue Shield. We were under the impression that the 80% reasonable benefits maximum amount paid by Highmark would be accepted by most providers and that they would bill you for only the additional 20% not covered by the Plan. This would have saved money for you and the Plan. However, we have found that this is not the case, and Effective immediately, all claims for durable medical equipment should again be submitted directly to the Fund Office as you did prior to January 1, 2002.

Change in filing claims

Effective January 1, 2002 payments for office visits, counseling and durable medical equipment will be be processed through Highmark BlueCross BlueShield rather than through the Fund Office. Read more...