Your Health Care Benefits

Expenses That Are Not Covered

 

Since the resources of the Plan are limited, no benefits are payable with respect to any treatment, service or supply not specifically provided for in the Plan or for any expense, charge, or fee incurred in connection with any of the following:
 

Medical Exclusions

  • any injury or illness resulting from or arising out of any employment or occupation for compensation or profit
  • any injury or illness for which benefits are payable under any workers’ compensation law, occupational disease law or similar legislation
  • any care, treatment or supplies to the extent obtained from any federal, state or local government agency or program or from a government-owned hospital or institution unless otherwise required by law
  • any injury or illness for which medical care, treatment and supplies are available without cost or are not required to be paid
  • any service, care or treatment that is experimental in nature or which is not considered a generally accepted medical practice (A determination of whether the service, care or treatment is experimental in nature or not considered a generally accepted medical practice shall be solely within the discretion of the Board of Trustees, whose determination on that issue shall be final and binding on all concerned.  In addressing whether any service, care or treatment comes within the terms of this exclusion, the Trustees will consult and consider such sources available to the Board within the medical community as the Trustees shall deem in their sole discretion to be reliable, reasonable, up to date and independent of influence by parties who may have a proprietary or economic interest in the outcome)
  • any injury or illness resulting from or occurring during an attempt to commit or the commission of a crime
  • any prosthetic device or supportive appliance or its repair unless specifically covered under this Plan
  • expenses for treatment of learning deficiencies or behavioral problems (except as specifically covered under this Plan) or for special education
  • orthopedic shoes or supportive devices for the feet, such as arch supports, heel lifts, etc., except for orthotics when medically necessary and used in lieu of surgery, following surgery, or after an accidental injury to support, align, prevent or correct deformities or to improve the function of moveable parts of the body
  • in-vitro fertilization, artificial insemination, or other treatment of male or female infertility, or services to reverse tubal ligation, vasectomy, or other voluntary, surgically-induced infertility (The Plan will cover the diagnostic procedures for determining impotence or infertility.)
  • callus or corn paring; toenail trimming or excision for toenail trimming; treatment of local chronic conditions of the foot, such as weak or fallen arches, flat or pronated foot metatarsalgia, or foot strain
  • humidifiers, air conditioners, exercise equipment or whirlpools; and other non-essential durable medical equipment such as supplies or equipment for personal hygiene, comfort or convenience such as telephone, television or similar items not required for medical care
  • benefits for claims not filed within one year of service date
  • charges incurred prior to the individual becoming covered under this Plan or after termination of eligibility, except as provided under any extension or continuation of benefits provisions of this Plan
  • private-duty nursing care, medical care or treatment, or performance of surgical procedures, dental care or physical therapy when those services are rendered by a nurse, physician, dentist, or physiotherapist that ordinarily resides in the patient’s home or who is a member of the patient’s immediate family
  • travel and non-patient living expenses, whether or not recommended by a physician
  • hearing aids or examinations for their prescription or fitting other than what’s provided in the hearing aid benefit (see here)
  • eyeglasses or eye exams other than what’s provided in the vision benefit (see here)
  • dental services or prosthetics, or the fitting of these items, unless required due to an accidental injury. (For dental services that are covered, see the Dental Benefits section on here.)
  • regarding a second surgical opinion, the following charges will not be covered:
    • a consultation with anyone who is not board certified to perform the proposed surgery
    • more than two consultations with a surgeon, after the initial determination, in connection with the proposed surgery
    • any consultation with a physician who performs the surgery or has a financial interest in the outcome of the recommendation
    • any consultation in connection with a proposed surgery for which a surgical expense benefit would not be payable under this Plan
    • any consultation unless the patient is examined in person by the surgeon rendering the second opinion
  • charges for an organ donor covered by this plan if the charges are not directly related to the organ transplant procedure itself
  • medical, dental and vision services or supplies determined by the Board of Trustees as not medically appropriate or clinically eligible for the care or treatment of any injury or illness
  • cosmetic, plastic or reconstructive surgery including surgery to correct developmental malformations, or as a result of earlier cosmetic, plastic or reconstructive surgery, unless the surgery is appropriate for the repair of damage caused by an accidental injury or congenital defect; however, benefits are payable for breast reconstructive surgery in accordance with the Women’s Health and Cancer Rights Act of 1998
  • treatment by any method of jaw joint problems including tempromandibular joint (TMJ) syndrome, craniomandibular disorders, and/or other jaw joint conditions, except for surgery specifically determined in advance to meet clinical guidelines for medical appropriateness and up to specified limits set by the Trustees in consultation with the Fund’s dental and/or medical consultant
  • treatment of obesity, or weight reduction or physical fitness programs, including aquatherapy and surgical treatment unless specifically provided elsewhere in these rules
  • surgery, implants or other treatment or devices or drugs to enhance sexual performance
  • trans-sexual or gender change operations or any care or services associated with this type of surgery
  • confinement for more than one day preceding the date of surgery, unless justified as medically appropriate by the attending physician
  • any charges in excess of actual expenses, such as may be provided under a diagnostic related group (DRG) program
  • hospital charges in connection with extraction of teeth or other dental process, unless justified as medically appropriate by the attending physician
  • charges for any individual not covered by this Plan
  • abortions, unless justified by a physician as medically appropriate to protect the life of the patient, or with prior written approval of the Fund Office, when certified in writing by a physician who is board certified in obstetrics and gynecology prior to performing the procedure, that the fetus suffers from a severe performing disability which is likely to affect seriously the quality of life of the child if the pregnancy were carried to term
  • charges incurred by a dependent child in connection with pregnancy, childbirth, miscarriage or related medical condition
  • drugs, medicines and supplies intended for personal hygiene use, such as toothpaste and cleaning devices
  • biofeedback and aquatic therapy
  • wigs
  • hot and cold packs
  • therapeutic devices such as support garments, hypodermic needles, or syringes, except if used for insulin

Prescription Drug Exclusions

The following exclusions apply:

  • any drug removed from the formulary list by the pharmacy benefit manager
  • any drug not requiring a prescription, unless the drug is a compound of two or more drugs which may only be compounded by prescription
  • blood or blood plasma, biologicals or vaccinations
  • any experimental or investigational drug
  • fees for administration of a drug or insulin
  • medication to be taken at the place it is dispensed
  • medication taken while hospitalized or a patient in an approved facility (The cost of some medication taken while in a nursing home may qualify for reimbursement. For more information, contact the Fund Office.)
  • refills exceeding five in a six-month period, or the number specified by the prescribing doctor
  • refills more than six months from the date of the original prescription
  • medication otherwise available free under a local, state or federal program (e.g., workers’ compensation)
  • fertility drugs
  • erectile dysfunction drugs
  • laetrile, enzymes, vitamins, minerals and dietary supplements (except as specifically covered under this Plan)
  • drugs to enhance sexual performance
  • take-home drugs or medicines, except when provided as part of emergency room treatment under special urgent circumstances which do not permit use of the regular prescription drug benefit procedures

Dental Exclusions

The dental care benefits are not available to Active Employees and/or dependents that are self-paying for coverage or are predominantly (more than 50%) utilizing a credit of hours received under the Plan’s disability benefit. In addition, no dental care benefits are provided for:

  • any dental care, treatment or supply not prescribed by or under the direction of a dentist
  • replacement of a lost, stolen, or broken prosthetic device
  • appliances or restoration for the purpose of splinting, increasing vertical dimension or restoring occlusion
  • dental services and supplies rendered solely for cosmetic purposes, unless required as a result of accidental injury sustained while covered under this Plan or unless specifically provided under another provision of this Plan
  • an appliance or its modification, a crown, bridge, or gold restoration, or root canal therapy for which the impression was made, the tooth was prepared, or the pulp chamber was opened before the patient was covered under the Plan
  • replacement of an existing partial or full denture, splint or fixed bridgework, crowns and/or inlays installed as multiple abutments; splints for periodontal treatment or prosthetic appliances, fixed or removable, used as an adjunct to periodontal treatment, unless satisfactory evidence is presented to the Fund that the existing denture or bridgework was installed at least 36 months prior to its replacement and the prosthetic appliance, fixed or removable, is required to replace a natural tooth lost
  • orthodontics or other treatment or procedure designed to prevent or correct malocclusion of the teeth

Vision Exclusions

The vision care benefits are not available to H Plan Employees or to Active Employees and/or dependents that are self-paying for coverage or are receiving credit of hours. In addition, no vision care benefits are provided for:

  • non-prescription glasses
  • sunglasses
  • photosensitive, plastic, cosmetic tinted (other than pink 1 or 2) or oversized lenses, although you have the option of paying the difference in cost between these lenses and the cost of clear, standard size lenses
  • replacement or repair of lost or broken lenses or frames
  • orthoptics, vision training, or vision aids for anisekonia
  • medical or surgical treatments, as these may be provided for under other provisions of the Plan such as post-cataract lenses or implants
  • eye surgery for conditions which routinely can be corrected through corrective lenses
  • any eye examinations or the fitting of glasses except as provided here