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OPERATING ENGINEERS
TRUST FUNDS

Health and Welfare Benefit Summaries

  • Covered Features

    This is a Self Funded PPO Plan with coverage worldwide for medically necessary treatments. After you or your family meet the annual deductible, the plan will pay for services generally at 90% or 70% until you reach the annual Out-of-Pocket Maximum. After that, the Plan will pay 100% for the rest of the year.
  • General Program Information

    The Plan contracts with the Anthem BlueCross for its Preferred Provider Organization (PPO) and medical case management services. Using a provider from the PPO network saves both you and the Plan money. To find a PPO provider, access the Anthem BlueCross Website.

  • Calendar Year Deductibles

    PPO Non-PPO
    $250 per person $500 per person
    $750 per family $1,500 per family
  • Annual Out-of-Pocket Maximum

    PPO Non-PPO
    $3,000 per person $6,000 per person
    $6,000 per family $12,000 per family
  • Benefits

    The benefits apply to the following Covered Services for reasonable and customary charges for services, treatment, and supplies for the care and treatment of an illness or injury except as noted.

    PPO Non-PPO
    Hospital Visits Plan pays 90% of the contract rate Plan pays 70% of reasonable and customary charges
    Lab and X-Ray Plan pays 90% of the contract rate Plan pays 70% of reasonable and customary charges
    Surgeon Plan pays 90% of the contract rate Plan pays 70% of reasonable and customary charges
    Anesthetist Plan pays 90% of the contract rate Plan pays 70% of reasonable and customary charges
    Urgent Care Services Plan pays 90% of the contract rate Plan pays 70% of reasonable and customary charges
    Inpatient Care
    Semi-Private Room and Misc Charges
    Plan pays 90% of the contract rate Plan pays 70% of reasonable and customary charges
    Ambulatory Surgical Facility Plan pays 90% of the contract rate Plan pays 70% of reasonable and customary charges
    Inpatient Psychiatric Care Plan pays 90% of the contract rate
    Benefits provided through MHN
    Plan pays 70% of reasonable and customary charges
    Benefits provided through MHN
    Inpatient Alcohol and Substance Abuse Care Plan pays 90% of the contract rate
    Benefits provided through MHN
    Plan pays 70% of reasonable and customary charges
    Benefits provided through MHN
    Durable Medical Equipment Plan pays 90% of the contract rate, not to exceed purchase price Plan pays 70% of reasonable and customary charges, not to exceed purchase price
    Prosthetic Appliances Plan pays 90% of the contract rate Plan pays 70% of reasonable and customary charges
  • Mental Health and Substance Abuse Treatment Benefits

    PPO Non-PPO
    Inpatient Psychiatric Care 90% of the contract rate
    (Benefits provided through MHN)
    70% of reasonable and customary charges
    (Benefits provided through MHN)
    Inpatient Alcohol and Substance Abuse Care 90% of the contract rate
    (Benefits provided through MHN)
    70% of reasonable and customary charges
    (Benefits provided through MHN)
  • Certain Tests Covered at 100%

    100% of lesser of Contracted Rate, or Usual Reasonable & Customary Charges for:

    All preventative services mandated under the Patient Protection and Affordable Care Act when services are rendered by an in-network (contracting) provider or an in-network (contracting) facility.

  • Acupuncture, Chiropractic, and Physical Therapy

    PPO Non-PPO
    Chiropractic – Plan pays 50% of the contract rate

    Acupuncture and Physical Therapy – Plan pays 90% of the contract rate after a $20 co-pay per visit

    Acupuncture and Chiropractic care have a combined limit of 26 visits per calendar year

    Plan pays a maximum of $15 per visit with a combined limit of 26 viists per calendar year for Acupuncture and Chiropractic
  • Prescription Drugs

  • Charges incurred as a result of a work related injury or illness or for which a third party is responsible are not covered under the Plan.

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