Tri-State Generic Plan/Tri-State RX Plan SPD >> Table of Contents

• ALERT: 12/16/09 NEW Please click here for important benefit changes>>

  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
  • FMLA
  • Military Leave
• Dependent Eligibility
• When Your Dependents Are No Longer Eligible
• How to Enroll
• Your Notification Responsibility
• What Benefits Are Provided
• Prescription Drug Benefits
  • At the Pharmacy
  • Through Mail Order
  • Eligible Drugs
  • Excluded Drugs
• Claims and Appeals Procedures
• Claims Reviewers
• Appeals Reviewers
• Glossary
• Footnotes
• Translation Notice
• Contact Information

Tri-State Generic/Tri-State RX: Section II >> Table of Contents

• Your Rights And Other Important Plan Information
• Plan Facts   ALERT: 12/16/09 NEW Click here for important benefit changes>>
  • Funding of Benefits and Type of Administration
  • Agent for Service of Legal Process
  • Plan Sponsor and Administrator.
  • Participating Employers
• Your Disclosures To The Fund
• Fraud
• Overpayments
• Claims and Appeals Procedures
• Claims for Benefits
  • Filing Hospital and Medical Claims
  • Filing Dental Claims
  • Filing Pharmacy Claims
  • Filing Employee Assistance Program (EAP) Claims
  • Filing Vision Claims
  • Filing Pensioner’s Death Benefit Claim
  • Filing Life Insurance and AD&D Claims
• Where to Send Claim Forms
• Approval and Denial of Claims
  • Health Service Claims (hospital/medical, EAP, pharmacy, 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, EAP or Dental Claim Appeal
  • Post-Service Medical, Hospital, Pharmacy, EAP, Dental, or Life and AD&D Claim Appeal
  • Voluntary Second Level Appeal of a Medical, Hospital, Pharmacy, EAP, Dental, or Life and AD&D Claim
  • Vision, or Pensioner’s Death Benefit Claim Appeal
  • Appeal Decision Notice
• Further Action
• Coordination Of Benefits   ALERT: 12/16/09 NEW Click here for important benefit changes>>
  • Medicare
  • TRI-CARE
  • No-fault Benefits
  • Other Coverage Provided By State or Federal Law
  • Workers’ Compensation
• Subrogation And Reimbursement
• Continued Group Health Coverage   ALERT: 12/16/09 NEW Click here for important benefit changes>>
  • 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
  • How Benefits May Be Reduced, Delayed or Lost
  • Compliance with Federal Law
  • Plan Amendment or Termination
  • Statement of Rights under the Employee Retirement Income
    Security Act of 1974 as Amended