Tri-State 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
    • Fund-paid 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
  • Pre-Certification for Medical/Hospital
  • Covered Services
    • In the Hospital and Outpatient Treatment Centers
    • Skilled Nursing Care 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
  • Annual Maximum
  • 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
  • Annual Maximum
  • Participating Dental Providers
  • Non-Participating Dentists
  • Predeterminations/Pre-treatment Estimates
  • What Dental Services Are Covered
  • Frequency Limitations
  • Schedule of Covered Dental Services
  • Alternate Benefit
  • What Is Not Covered
• 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
• Short Term Disability Benefits (STD)
  • Eligibility
  • STD Benefit Amount
  • When Benefits Begin
• 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
    • Filing Short Term Disability Benefit
  • 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 and Short Term Disability Benefits
    • 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, Dental or EAP Claim Appeal
    • Voluntary Second Level Appeal of a Medical, Hospital, Pharmacy, Dental, Life Insurance, AD&D or EAP Claim
    • Vision, Short Term disability and Pensioner’s Death Benefit Claim Appeal
    • Appeal Decision Noticee
  • 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