Your General Medical Reimbursement Benefit

What is the General Medical Reimbursement Benefit?
When Is Coverage Provided?
Expenses Are Covered By The General Medical Reimbursement Benefit?
Retirees, Spouse and/or dependents with MEDICARE PART D Plan
Getting Your Benefit
What's Not Covered?


What is the General Medical Reimbursement Benefit?

The Fund will provide you, your spouse and eligible children up to a maximum benefit of $1200 per family, per calendar year for certain unreimbursed medical, dental, prescription drug and Medicare expenses.

When Is Coverage Provided?
Coverage is provided when:

  • Services are received in accordance with the procedures described in this Benefit Summary Plan Description.
  • Services are obtained while you, your spouse or your children are eligible for coverage (See the section entitled “Eligibility”).
  • Services are medically necessary and covered hereunder.
  • Services are not otherwise excluded.

What Expenses Are Covered By The General Medical Reimbursement Benefit?
The Fund will reimburse your out-of-pocket expenses, not otherwise reimbursed under any plan of insurance or other benefit plan provided by this Fund, up to the maximum annual family limit, for:

  • Unreimbursed premium payments, deductibles and co-payments under any plan of medical and/or hospital insurance (including prescription drug riders) covering you, your spouse and eligible children .
  • Unreimbursed Medicare Part B deductibles paid by you and your spouse.
  • Where you do not have the Optional Drug Rider to your City Health plan and you, your spouse and eligible children are enrolled in the EnvisionRxOptions prescription drug program, any covered prescription drug expenses you incur in excess of the $1,500 per family per calendar year benefit provided by the Fund’s Prescription Drug Cost Reimbursement Benefit will automatically be covered by the General Medical Reimbursement Benefit until you reach the $1,200 per family annual maximum benefit.
  • If you are covered by the Fund’s Scheduled Dental Benefit Plan and you have reached the $2,000 per person per calendar year maximum benefit and you require additional covered dental services, you will be reimbursed the cost of the additional covered dental services in accordance with the Plan’s allowances for such dental services as provided in the Schedule of Dental Allowances up to the $1,200 per family annual maximum benefit.
  • Any out-of-pocket expenses you incur for covered dental services provided by the Fund’s Dentcare program will be covered up to the maximum benefit of $1200 per family per calendar year.

Retirees, Spouse and/or dependents with MEDICARE PART D Plan

  • If you have elected to receive your prescription coverage under Medicare Part D, the CWA Local 1180 Retirees Benefits Fund will, on application consider reimbursement of out of pocket expenses that you incur for premiums, co-payments and deductibles under your Medicare Part D prescription coverage up to the family limit of $2700 per year ($1500 Prescription Drug Benefit plus $1200 General Medical Benefit). However, you may only claim your dependent(s) out-of-pocket expenses as they pertain to co-payments and, deductibles (not premiums) and only under your shared $1200 General Medical Benefit.
  • If your spouse and/or your eligible dependent(s) elects to receive their prescription coverage under Medicare Part D, you may claim your dependent(s) out-of-pocket expenses as they pertain to co-payments and, deductibles (not premiums) under your shared $1200 General Medical Benefit.

Getting Your Benefit
If you are submitting claims for unreimbursed premium payments, deductibles or co-payments under your City Health Plan, your Optional Drug Rider under the City Health Plan or any other medical, hospital and/or prescription drug plan covering you, your spouse and your eligible children:

  • Save your health plan statements showing that you have met your deductibles, incurred premium payments for which you have not been reimbursed and had co-payment expenses for covered medical procedures, hospital charges, dental charges and prescription drugs.
  • Submit photocopies of your health plan statements to the Fund Office once each calendar year no later than June 30th following the end of the prior year. Claims submitted after that date will be denied.

If you are submitting claims for unreimbursed Medicare Part B deductibles for you and/or your spouse:

  • Save your Medicare statement showing that you have met the Part B deductible for the year.
  • Submit photocopies of your Medicare statement(s) to the Fund Office, together with any additional covered medical expenses you incurred once each calendar year, no later than June 30th following the end of the prior year. Claims submitted after that date will be denied.

If you are enrolled in the EnvisionRxOptions prescription drug program and exceed the $1,500 per family per calendar year maximum benefit provided by the CWA Local 1180 Prescription Drug Cost Reimbursement Benefit, you will automatically continue to be covered for prescription drugs covered by the Benefit until you reach the $1,200 per family per calendar year maximum benefit provided by the General Medical Reimbursement Benefit. EnvisionRxOptions will inform you when you have reached your maximum annual benefit. You do not need to file claims for this benefit with the Fund Office.

What's Not Covered?
Benefits are not provided for:

  • Optical, Podiatry or Mental Health Benefits
  • Expenses otherwise covered by any other benefit provided by the Fund
  • Expenses for which you have been reimbursed or are entitled to reimbursement under any other plan of insurance
  • Expenses for procedures and treatments that are not medically necessary
  • Cosmetic drugs, surgery or treatment
  • Expenses not covered by any medical, hospital, dental or prescription drug plan of insurance in which you, your spouse or eligible dependents are enrolled
  • Services by a provider whose office is attached to, or a dental school which is a part of, certain hospitals within New York State (call the Fund Office for a list of such providers).
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