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