Service Employees 32BJ North Health Fund

Plan B Summary Plan Description (SPD)

Table of Contents

Important Notice Eligibility and Participation When You Are Eligible When You Are No Longer Eligible Dependent Eligibility When Your dependents Are No Longer Eligible How to Enroll Your Notification Responsibility What Benefits Are Providided Hospital and Medical Benefits Overview of Eligible Expenses About the MagnaCare Networks In-Network Benefits Coverage When You Are Away From Home Benefit Maximums Conditions for Hospital and Medical Expense Reimbursement Covered Services In the Hospital and Outpatient treatment Centers Care in the Doctor's Office Preventative Medical Care Pregnancy and Maternity Care Durable Medical Equipment and Supplies Women's Health and Cancer Rights Act Excluded Hospital and Medical Expenses Presription Drug Benefits At the Pharmacy Through Mail Order Eligible Drugs Excluded Drugs Life Insurance and Accidental Death & Personal Loss Coverage Benefits Schedule of Life Insurance-Employees Schedule of Accidental Death and Personal Loss Coverage-Employees Retiree Health Benefits Eligibility Benefit How The HRA Works Annual and Lifetime Maximums Administrative Fees Termination Claims and Appeals Procedures Claims for Benefits Filing Hospital and Medical Claims Filing Pharmacy Claims Filing Life Insurance and Accidental Death & Personal Loss Coverage (AD&PLC) Claims Filing Retiree HRA Claims Where to Send Claim Forms Approval and Denial of Claims Health Service Claims (hospital/medical, pharmacy) Retiree HRA Claims Notice of Decision Appealing Denied Claims Filing an Appeal Where to File an Appeal Appeals Reviewers Time Frames for Decisions on Appeals Expeditied Appeals for Urgent Care Claims Pre-Service, Concurrent or Post-Service Medical or Hospital Claim Pre-Service or Concurrent Pharmacy Claim Appeal Post-Service Pharmacy Claim Appeal Voluntary Second Level Appeal of a Pahramacy Claim Notice of Appeal Denials Life and Accidental Death and Perseonal Loss Coverage (AD&PLC) Appeal Appeal Decision Notice Further Action Incompetence Mailing Address Coordination of Benefits Your Disclosure to The Fund Subrogation and Reimbursement Fraud Overpayments Continuted Group Health Coverage During a Family and Medical Leave During Military Leave Under COBRA COBRA Continuation of Coverage Other Health Plan Information Your Should Know Assignment of Plan Benefits No Liability for Practice of Medicine Privacy of Protected Health Information Certificate of Creditable Coverage Converting to Individual Coverage General Information Employer Contributions How Benefits May Be Reduced, Delayed or Lost Compliance with Federal Law Plan Amendment or Termination Plan Administration Statement if Rights under the Employee Retirement Income Security Act of 1974 as Amended Plan Facts Funding of Benefits and Type of Administration Plan Sponsor and Adminstrator Paricipating Employers Agent for Service of Legal Process Glossary Footnotes Contact Information

ALERT: 02/24/10 NEW Please click here for important benefit changes>>