Northwest Carpenters Health and Security Plan
Summary Plan Description
- Notice
- Statement of Purpose
- Participant Eligibility and Enrollment
- Continuation Coverage
- Dependent Eligibility and Enrollment
- Retiree Eligibility and Enrollment
- Preferred Provider Organization
- Medical Review Programs
- Schedule of Benefits
- Medical Benefits
- Acupuncture
- Alternative Care
- Ambulance Transportation
- Anesthesia
- Autism Spectrum Disorder/Pervasive Developmental Disorder
- Bariatric Surgery
- Behavioral Health Services
- Blood
- Chiropractic Care
- Dental Accidents
- Diabetic Care
- Diagnostic X-Ray and Laboratory Services
- Durable Medical Equipment
- Erectile Dysfunction
- Habilitative Care
- Hearing Aids
- Home Health Care
- Home Phototherapy
- Hospice Care
- Hospital Services and Supplies
- Infusion Therapy
- Kidney Dialysis
- Medical Supplies
- Oral Surgery
- Orthognathic Surgery
- Orthotics
- Physician Services
- Pregnancy Care
- Preventive Health Services
- Prosthetic Devices and Artificial Limbs
- Reconstructive Surgery
- Rehabilitative Care
- Skilled Nursing Facility
- Sleep Studies
- Sterilization
- Telehealth Consultations
- TMJ and MPDS Treatment
- Transplants
- Prescription Drug Benefits
- Introduction
- Formulary
- Express Scripts Retail Pharmacy Program
- Express Scripts By Mail
- Out-of-Pocket Maximum
- Nonparticipating Pharmacies
- Express Scripts Medicare Prescription Plan
- Step Therapy Program
- Retail Refill Allowance Program
- Specialty Medications
- SaveOnSP
- Claims Issue
- Limitations and Exclusions
- Summary of the Prescription Drug Programs
- Dental Benefits
- Vision Benefits
- Time Loss Benefits
- Life Insurance and Accidental Death and Dismemberment Benefits
- Retiree Health Reimbursement Accounts
- Claims Process
- How to File a Medical Claim
- Claims for Prescription, Dental, Vision, Time Loss, Life Insurance, and Accidental Death and Dismemberment
- Timely Filing Requirement
- Coordination of Benefits (COB)
- Facility of Payment
- Trust's Right to Reimbursement
- Right to Receive and Release Necessary Information
- No Waiver of Claim Paid in Error – Recovery by Trust
- Misrepresentation
- Assignment
- Glossary
- General Limitations and Exclusions
- Important Information
- Claims and Appeals Rules
- Life Insurance and Accidental Death and Dismemberment Claims Appeal Procedure
- Interpretation
- Rights Under the Employee Retirement Income Security Act (ERISA)
- HIPAA Privacy Plan Amendment
- Notice of Privacy Practices
- Amendment and Termination
- Benefits Not Guaranteed
- Nondiscrimination
- Administrative Information
- Names, Titles and Addresses of the Board of Trustees
Related Content
Partner Websites
Northwest Carpenters Health and Security Plan
Out-of-pocket Maximum
Each person covered under the plan has his or her own $2,850 out-of-pocket maximum. The following expenses accumulate towards the prescription out-of-pocket maximum:
- Retail pharmacy copayments.
- Mail order copayments.
- Retail Refill Allowance (RRA) coinsurance.
When you and your dependents have paid a combined out-of-pocket maximum of $5,700 in a calendar year for the out-of-pocket expenses listed above, no further out-of-pocket payment for these expenses is required for any family member during that calendar year.
Last Updated: 04/25/2023