Table of Contents

ELECTRICAL WELFARE TRUST FUND (EWTF) OVERVIEW

Board of Trustees

Important Contact Information

Trustee Letter to All Participants

Grandfathered Status Under the Patient Protection and Affordable Care Act (PPACA)

SCHEDULE OF BENEFITS

Medical Deductibles Chart

Medical Benefits Chart

Mental Health Benefits Chart

Prescription Drug Benefits Chart

Dental Benefits Chart

Vision Benefits Chart

Hearing Benefits Chart

Accident Dismemberment and Loss of Sight Benefits Chart

Weekly Accident and Sickness Benefits Chart

Death Benefits Chart

Supplemental Occupational Accident Benefits Chart

UNDERSTANDING THE EWTF PLAN

Plan Basics

Payment for Coverage

The Annual Deductible

Coverage for Participants Covered Twice

Out-of-Pocket Maximum

Plan Features

Specific Plan / Benefits Exclusions

General Plan Exclusions

If You Have Questions

PLAN PARTICIPATION

Plans Available by Work Categories

Termination of Coverage for Participants in All Categories

ELIGIBILITY

Eligibility for Active Electrical Workers

Hours Bank Donation Program

Eligibility for Active Non-Bargaining Unit Employees

Eligibility for Retired Employees

Eligibility for Dependents (including Spouses)

Surviving Spouse Coverage

Annual Enrollment Verification Process

COBRA CONTINUATION COVERAGE

COBRA for Yourself

COBRA for Your Dependents

How to Elect COBRA Continuation Coverage

Cost of COBRA Coverage

Duration of COBRA Coverage

Acquiring a New Dependent(s) while Covered by COBRA

Loss of Other Group Health Plan Coverage or Other Health Insurance Coverage

When COBRA Coverage Ends

Confirmation of Coverage to Health Care Providers

Interaction of COBRA, the Affordable Care Act and Medicare – Other Options

If You Have Questions

Keep Your Plan Informed of Address Changes

LIFE EVENTS

What You Need To Do

If You Take a Leave of Absence (FMLA)

If You Enter Active Military Service

If You Want to Dis-enroll

YOUR MEDICAL BENEFITS

Understanding Your Medical Benefits

Advantages of Using the UHC Choice Plus Network

The Power to Save

Telemedicine Services

Self-Funded Plan

Provider Directories

EWTF Benefit Card

Out-of-Pocket Maximum (Catastrophic Benefit)

Hospitalization and Surgery

What You Need To Do

Hospitalization

Surgery

Second Surgical Opinion

What’s Not Covered

Organ Transplants

What’s Not Covered

Disease Management Program

Routine Physical Exam for Member and Spouse

Child Wellness Visits and Examinations

Well Woman

Bariatric Surgery

Gardasil

Outpatient Medical Expenses

What’s Not Covered

Covered Chiropractic Care

What’s Not Covered

Home Health Care, Nursing Home Care and Hospice Care Benefits

Durable Medical Equipment

Gynecological Care and Maternity

Mastectomy and Breast Reconstructive Surgery

What’s Not Covered

PRESCRIPTION DRUG BENEFITS

Medicare Part D

Mail Service Program

Using Your Prescription Card

Using a Non-Network Pharmacy

Prior Authorization

Drug Choice Management Program

Specialty Pharmacy

Opioid Utilization Management Program

CVS Health Vaccination Program

Covered Expenses

What’s Not Covered

MENTAL HEALTH/ EMPLOYEE ASSISTANCE PROGRAM (EAP)

How the Employee Assistance Program (EAP) Works

Mental Health and Substance Misuse Benefits

What You Need To Do

Outpatient Benefits

Inpatient Benefits

Psychological Testing

Filing Claim

EWTF Group Number

What’s Not Covered 

DENTAL BENEFITS

​What You Need To Do

Maximum Annual Benefit (Age 18 & Older)

Submitting your Dental Claims

EWTF Group Number

Non-PPO Dental Coverage

Covered Preventive Services

Covered Basic Dental Services

Covered Major Dental Services

Covered Orthodontia Services

When a Treatment Plan is Required

Continuing Treatment When Your Coverage Ends

What’s Not Covered

VISION BENEFITS

What You Need To Do

VSP Provider 

Non–VSP Provider

Safety Glasses

Computer Glasses

What’s Not Covered

HEARING AID BENEFITS

What You Need To Do

What’s Not Covered

SUPPLEMENTAL MEDICARE BENEFITS

Medicare Parts A & B

Medicare Part D

What’s Not Covered

WEEKLY ACCIDENT AND SICKNESS BENEFIT

Eligibility

What You Need to Do

How the Weekly Accident and Sickness Benefit Works

Maintaining Eligibility While On Disability

Multiple Periods of Disability

What’s Not Covered

ACCIDENTAL DISMEMBERMENT AND LOSS OF SIGHT BENEFITS

What You Need To Do

What’s Not Covered

SUPPLEMENTAL OCCUPATIONAL ACCIDENT BENEFITS

What You Need To Do

Supplemental Workers’ Compensation Benefits (Insured through Nationwide)

Workers’ Compensation Supplemental Income (Self-insured by EWTF)

When Your Worker’s Compensation Supplemental Income Coverage Ends

What’s Not Covered

DEATH BENEFIT

What You Need To Do

Eligible Active Electrical Worker or Active Non-Bargaining Unit Employee

Eligible Retired Employee

Designating Your Beneficiary

FILING YOUR BENEFITS CLAIMS

What You Need To Do

Filing a Claim 

Status of Claim

Contact with Your Providers

Proof of Payment

Federally Issued Identification Numbers

Payment of Claim

Overpayment of Benefits

Assignment of Benefits

Claim Denial

CLAIMS AND APPEALS PROCEDURE

Plan Provisions and Consistent Treatment Requirement

Claims for Benefits

Timing of Notification of Benefit Determination for Initial Claims

Concurrent Care Decisions

Pre-Service Claims Timing Rules

Post-Service Timing Rules

Calculating Time Periods 

Manner and Content of Notification of Benefit Determination or
Adverse Notification on Appeal

Urgent Care Claims

Appeal of Adverse Benefit Determinations

Urgent Care Appeals

Appeals of Concurrent Care Denials 

Right to Supplement Claims 

Right to Access to Documents 

Right to Consideration of All Documentation 

RECOVERY FOR THIRD PARTY LIABILITY (SUBROGATION)

Purpose of Third-Party Liability Provisions

How Third Party Liability Recovery Works 

What You Need To Do

Failure to Comply with Third Party Liability Procedures

Recovery Incentive Program

COORDINATION OF BENEFITS

What You Need to Do

Methods of Coordination

Order of Benefit Determination Rules

Steps to Follow if You or Your Family Members are Covered by More Than One Plan

Coordination Of Benefits With Medicare

TRICARE

Motor Vehicle No-Fault Coverage Required By Law

Workers’ Compensation

Medicaid

YOUR PRIVACY RIGHTS

How the Plan May Use or Disclose Your Health Information

When The Plan May Not Use or Disclose Your Health Information

When EWTF Must Provide You a Breach Notification

Disclosure of Your Health Information to Family Members

Statement of Your Health Information Rights

Changes to this Notice of Privacy Practices

Personal Representatives

Complaints

Federal Regulations

YOUR ERISA RIGHTS

Receive Information about Your Plan and Benefits

Prudent Actions by Plan Fiduciaries

Enforce Your Rights

Assistance with Your Questions

GLOSSARY

PLAN INFORMATION

Name of Plan

Type of Plan

Name of Plan Sponsor

Agent for Service of Legal Process

Type of Administration

IRS Employer Identification Number

Plan Number

Plan Year

Sources of Plan Financing

Sponsoring Organizations

Healthcare Network

Dental Benefits

Vision Benefits

Prescription Drug Benefits

Utilization Review

Employee Assistance Plan (EAP)

Supplemental Occupational Accident Benefits

Plan Administrator

Collective Bargaining Agreement

DOCUMENTS FOR EXAMINATION

Documents to Be Made Available for Examination

Summary Plan Descriptions and Summaries of Material Modification

Providing Documents at Employer Establishments or the Union Offices

DISCRETIONARY AUTHORITY OF THE BOARD OF TRUSTEES AND ITS DESIGNEES

PLAN AMENDMENT AND TERMINATION