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Benefits at a Glance


Medical Benefits


In-Network


Out-of-Network

Annual Deductible

Individual

$500

$500

Family

$1500

$1500

Annual Out-of-Pocket Maximum

Individual

$4500

Unlimited

Family

$4500

Unlimited

Annual Maximum

Unlimited

Unlimited

Doctor’s Office Visits

$20 co-pay then 85% after Deductible

$20 co-pay then 70% after deductible

Outpatient Lab & Radiology

85% after deductible

70% after deductible

Inpatient Hospital Services

Benefits will be reduced by $150 if you fail to pre-authorize non-emergency hospitalizations

85% after deductible

70% after deductible

Emergency Room

Co-pay waived if visit is within 24 hours of an accidental injury or for a life threatening illness

$150 co-pay then 85% after deductible

$150 co-pay then 70% after deductible

Outpatient Surgery

85% after deductible

70% after deductible

Ambulance To Nearest Hospital

85% after deductible

85% after deductible

Routine and Preventative Care

One routine physical exam per calendar year; annual cancer screenings, well baby care, immunizations and vaccinations.

100% no deductible

70% after deductible


Pregnancy

Prenatal Care

For all covered employees & dependents

85% after deductible

70% after deductible

Delivery, Impatient Services, and Postnatal Care

Limited to employees or spouse only

85% after deductible

70% after deductible

Babytime – Healthy Pregnancy Program

Limited to employee or spouse only. Enroll within the first 16 weeks of pregnancy and the newborn’s annual deductible will be waived for the year of birth.


Therapy Services

Physical & Occupational Therapy

Up to 100 days following accident, stroke or surgery. All other conditions or following the first 100 days, visits are limited to 30 visits per calendar year.

85% after deductible

70% after deductible

Cardio & Pulmonary Rehabilitation

85% after deductible

70% after deductible

Speech Therapy

Only to restore lost speech following injury or illness.

85% after deductible

70% after deductible

Spinal Manipulations

24 visits per calendar year – participants
12 visits per calendar year – dependents

85% after deductible, $25 max benefit per visit

70% after deductible, $25 max benefit per visit

Mental Health Care

Office Visits

$20 co-pay then 85% after deductible

$20 co-pay then 70% after deductible

Inpatient

85% after deductible

70% after deductible

Substance Use Treatment

Office Visits

$20 co-pay then 85% after deductible

$20 co-pay then 70% after deductible

Inpatient

85% after deductible

70% after deductible

What is Not Covered

This is an abbreviated list of exclusions. A complete listing of benefits, eligibility rules, limitations and exclusions is in the booklet.

  • Services not medically necessary

  •  Expenses related to organ donation for non-member recipients

  • Services or supplies that are experimental or investigative, except as provided for under the Affordable Care Act

  •  Travel and accommodation expenses

  • Abortion (elective)

  •  Expenses related to injury or sickness resulting from voluntary taking of or being under the influence of any controlled substance, drug, hallucinogen, or narcotic not administered on the advice of a physician

  • Infertility, including assisted fertilization techniques

  •  Occupational injury or sickness

  • Reversal of voluntary sterilization

  •  Expenses related to injury or sickness caused by a third party where an opportunity for recovery exists

  • Sexual dysfunction

  •  Government coverage. Care and services furnished by a program or agency funded by any government

  • Custodial care

  •  Expenses related to injury or sickness sustained while engaging in illegal acts including DUI

  • Educational or vocational testing

  • Exercise programs

  • Hair loss, except for up to one wig following the loss of hair due to chemo-therapy

  • Cosmetic services and supplies

  • Complications of non-covered treatments

Summary of Active Hour Bank Eligibility Rules

  • Eligibility is determined on the basis of an hour bank system.

  • For initial eligibility for medical and prescription drug coverage, a minimum of 350 hours must be accumulated in a six month period. If 350 hours are not accumulated in the first six months of Covered Employment, the Trust will look to subsequent six month periods until the 350 hour requirement is met.

  • Initial eligibility will be effective the first day of the second month following the accrual of 350 hours.

  • Once the minimum eligibility requirement has been established, 300 hours will be deducted for the first month of eligibility and 130 hours will be deducted from the employee’s hour bank for each subsequent month of coverage.

  • For Initial eligibility for dental, vision, time loss and life and AD & D coverage, a minimum of 1,000 hours is required in the hour bank (prior to deduction of hours for medical and prescription drug coverage). Coverage for dental, vision, time loss, life and AD & D will become effective on the first day of the second month following accumulation of the 1,000 hours.

  • An employee will continue to be covered as long as there are 130 hours or more in the hour bank.

  • A maximum hour bank of six consecutive months of prepaid continuous coverage (780 hours) can be accumulated.

  • If the hours in the hour bank drop below 130, they remain in the hour bank for 10 months from the last date of eligibility, after which the hour bank will be forfeited. In the event the hour bank is forfeited, an employee will again become eligible upon completion of the initial eligibility requirement for new employees as noted above.


Disclaimer

This page provides general information about the Northwest Laborers-Employers Health & Security Trust. For more information please refer to the Plan Booklet and benefits updates that are available at www.zenith-american.com  or by calling Zenith American Solutions. In the event of conflicting information, the Plan Document and the Plan Booklet will govern. Trust Office – 206-282-3600 or toll free 800-826-2101.

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