Eligibility Rules

 

Who is Eligible for Coverage?
All participants covered by a Collective Bargaining Agreement between their Employer and the Enterprise Association Metal Trades Branch Local Union 638 will be eligible to participate in the Plan.  

When Does My Coverage Become Effective?
Participants will become eligible for coverage in the Welfare Fund on the first day of the second month following the first month his/her employer makes the required contractual contribution.  

Example: You are hired by an employer in September 2014 and reported on the employer’s September report with sufficient contributions.  Your coverage would start on November 1, 2014.

 
The contractual contributions levels required to obtain coverage are as follows:

• - MCA Service Contractors/Independent Contractors
  • - at least 100 hours per month
• - Parkchester North, Parkchester South, Parkchester Management and Peter Cooper Village/Tishman Speyer
  • - at least 130 hours per month
• - Reciprocal

• - Within Local 638’s jurisdiction
  • - at least 100 hours per month
• - Outside Local 638’s jurisdiction
  • - at least 130 hours per month

How Often Is My Coverage Reviewed?  
Eligibility for coverage in the Welfare Fund is reviewed on a monthly basis.

How Do I Maintain Coverage?
Participants will continue to be covered as long as their employers make the required monthly contributions on the participant’s behalf (see necessary contribution levels in answer to “When Does My Coverage Become Effective?”).

When Will a Participant’s Coverage Terminate?
A participant’s coverage in the Welfare Fund will terminate on the last day of the second month after the last month for which you are reported. 

Example: You are last reported by an employer for the month of September 2014.  Your coverage would end on November 30,  2014.

What Happens If I Lose Coverage?
A federal law, commonly referred to as COBRA, requires that group health plans offer participants and their families whose coverage would otherwise end, the opportunity for a temporary extension of health coverage called "Continuation Coverage" at their own expense. The Federal laws allow a plan to charge a 2% surcharge for continuation coverage.  The Welfare Fund will charge those electing COBRA coverage 102 percent of the Fund’s cost of coverage.

If your loss of coverage is due to insufficient hours, you and your qualifying dependents may continue coverage for up to 36 months.  Participants considering COBRA coverage must request the extended coverage in writing within 60 days from the date the participant is notified of the right to continue coverage.

If a spouse and dependents lose coverage due to the death of an active or retired participant, COBRA continuation coverage is available for up to 36 months.  

Divorced or legally separated spouses and dependent children who are no longer covered when they reach the age specified in the Plan may extend coverage for up to 36 months.  If you become either divorced, legally separated or your children no longer qualify as dependents, you must notify the Fund Office in writing within 60 days to protect their COBRA rights.

For more details about COBRA, please see the section entitled “Continuation of Coverage - COBRA” that appears later in this booklet.  Complete details concerning the COBRA coverage are available from the Fund Office.  The government website for general information is as follows: http://www.dol.gov/ebsa/faqs/faq-consumer-cobra.html.

It is mandatory that you report a divorce to the Fund Office immediately upon entry of a divorce decree or judgment.  You will be instructed to submit a full copy of your divorce decree or judgment. If your divorce decree or judgment is not yet available from the court or municipal clerk, you will be required to complete a pre-printed affidavit.  The Fund Office cannot accept your verbal notification; you must submit your divorce decree or judgment or complete an affidavit for the divorce to be recognized by the Fund Office.  

Please note:  You will be financially liable for the costs the Welfare Fund should incur due to your non-timely notification or failure to notify the Fund of your divorce.   

How Can I Become Covered Again?
Once your coverage terminates, in order to become covered again, you must satisfy the requirements set forth in the answer to the question, “When Does My Coverage Become Effective?”

What Happens If An Active Participant Becomes Temporarily or Partially Disabled and Unable to Work?
If an active participant, while covered under the Welfare Fund, becomes temporarily or partially disabled and unable to work, the participant and all eligible dependents will continue to be covered during the period in which the participant is disabled up to a maximum of twelve months so long as the participant’s disability continues and the participant applies for and meets all of the necessary requirements. This is called the Disability Status Program (DSP). As a prerequisite to the DSP application process;

• - You must be covered in the Welfare Fund at the time of your injury or illness.
• - You must have a minimum of 10 Years of Credited Service in the Metal Trades Branch Local 638 Pension Fund at the time of injury or illness.
• - You must be covered in the Welfare Fund for no less than 48 months of the 60 months prior to the date of injury or illness.
• - Your completed DSP application must be received within thirty (30) days of the injury or illness.
• - You must provide proof of Disability.  The application must be accompanied by a letter from the attending physician detailing the injury or illness.  Proof of disability may include copies of Disability or Workers’ Compensation payments and/or an Independent Medical Examiner (IME) conducted at the request of the Welfare Fund by Professional Evaluation Group (PEG).

If the participant is still disabled after twelve months, the participant may continue health benefits for themselves and their dependents by making the required COBRA payment for a maximum period of up to thirty-six months. (Please refer to the COBRA section of this booklet for details.)

Disabled participants who elected to continue their health benefit by making the required COBRA payment, and who subsequently qualify for Medicare during such thirty-six month period, shall lose their coverage under COBRA rules.  However, they will be permitted to continue to make COBRA payments for their dependents for the remainder of the self-payment period. 

Please contact the Fund Office at (212) 465-8888 option no. 4 for more information.  


What Happens If I Enter the Uniformed Services?
The Uniformed Services Employment and Reemployment Rights Act of 1994 (“USERRA”) applies to a person who performs duty, voluntarily or involuntarily, in the Uniformed Services as well as the reserve components of the Uniformed Services.  If you are drafted, activated from reserve status or enlist into the Uniformed Services of the United States (which includes the Army, Navy, Marine Corps, Air Force, Coast Guard, Public Health Service Commissioned Corps, the Army National Guard, and the Air National Guard or any other category designated by the President in time of war or national emergency), your coverage as an active participant will terminate in accordance with regular eligibility rules (see “When Will a Participant’s Coverage Terminate?”).

Your qualified dependents will maintain coverage in the Welfare Fund throughout your service as long as you were covered the day before your service commenced.  Although this dependent coverage is not required under USERRA, the Trustees have extended coverage as an additional benefit.

As a participant, if you worked 1 hour within 90 days immediately prior to entry into service as a covered participant on the date of your entry, the following is applicable:

• - If you are on active military duty for 30 days or less, you will continue to receive medical coverage under this Plan.  
• - If you are on active duty for more than 30 days, USERRA permits you to continue medical, prescription and dental coverage for you and your dependents at your own expense for up to 24 months provided you enroll for coverage.  This continuation of coverage operates in the same way as COBRA.  (Please refer to the COBRA section of this booklet for details.)  In addition, your dependents may be eligible for health care under the Civilian Health & Medical Program of the Uniformed Services (TRICARE).  This Plan will coordinate coverage with TRICARE if your dependents are enrolled in COBRA with the Welfare Fund (see the “Coordination of Benefits” section of this booklet).
• - You should carefully review the benefits, costs, provider networks, and restrictions of the TRICARE plan as compared to USERRA or COBRA to determine whether TRICARE coverage alone is sufficient or if temporarily continuing the Plan’s benefits under USERRA or COBRA is the best choice.  
• - When you return to work after receiving an honorable discharge (you must provide proof of such including Form DD-214), your full eligibility will be reinstated on the day you return to work with a participating employer for no less than two calendar quarters plus the quarter in which you return to active employment provided that you comply with the time limits set forth herein.  The time limits for returning to work are as follows:     
  • - Less than 31 days of Service:  1 day after discharge (allowing for 8 hours of travel).
  • - 31 to 180 days:  14 days from the date of discharge, if the period of military service was 31 days or more, but less than 181 days (provided that you either returned to work or applied for employment with a participating employer).
  • - 181 days or more:  90 days from the date of discharge, if the period of military service is more than 180 days (provided that you either returned to work or applied for employment with a participating employer).

If you are hospitalized or convalescing from an injury resulting from active duty, these time limits may be extended for up to two years.  Please contact the Fund Office for more details.

Please note:  You must provide oral or written advance notice to the Welfare Fund that you are leaving your job for service in the Uniformed Services (unless such notice was precluded by military necessity or otherwise impossible or unreasonable.)

 

 

COBRA (Self Payment) Rules

COBRA Eligibility

If you cease to be an active participant for any reason other than gross misconduct, you have the right to continue your Health Benefits for a period of up to 36 months, starting from the date your employer terminates Welfare Contributions on your behalf. Immediate notification of termination must be given the Fund Office in order to maintain your health insurance benefits through direct payments.

• Your spouse (husband or wife) may also continue his or her Health Benefits on a direct payment basis under any of the following circumstances:
• upon your death (providing you were eligible at the time of death).
• upon divorce or legal separation from you.
• upon your termination of employment for retirement or any reason other than gross misconduct.

Your dependent children (as defined in the plan) may also continue their health benefits on a direct payment basis under any of the following circumstances:

• upon your death (providing you and such dependent child were covered for benefits at the time of your death).
• upon termination of your employment (providing your child was covered at the time of such termination or was born or placed for adoption while the COBRA provisions were in effect.
• upon your divorce or separation.
• upon the date your eligibility ceases due to retirement or any reason other than gross misconduct.
• the date your dependent child ceases to be a dependent (due to age, change in student status, etc. – see definition on page 1).
• Your spouse and your dependent children (where applicable) will have the option to continue their Group Health Benefits for a period up to 36 months.

Termination of COBRA Benefits

The Group Health coverage under COBRA will automatically cease if:

Self payments are not received when due.

You or any of your dependents become covered under another Group Health Plan (including Medicare).

A divorced spouse or widow remarries and becomes covered under another Group Health Plan.

You return to work for an Employer who is obligated to make contributions on your behalf.

Notification and Filings

In the event your employment is terminated for any reason other than gross misconduct, you should immediately notify the Fund Office if you wish to continue your Group Health Benefits. You will then be furnished with the forms and instructions as to how to continue your health benefits on a direct payment basis.

You (or any family member) must also notify the Fund Office of any divorce, legal separation, or change in a dependent’s child’s status (i.e. attainment of maximum age, change in student classification, marriage) which might result in loss of Group Health Benefits.

Under the new law, you or one of the family members have up to 60 days to file your election with the Fund Administrator for continuation of Group Health Coverage on a direct payment basis and another 45 days to make the required self payments.

Group Health Benefits

You or an eligible dependent, who qualified under the direct payment provisions set forth above, will be covered for Empire Blue Cross Blue Shield Hospital and Medical Benefits, plus supplemental Comprehensive Medical, Prescription Drug, Dental and Vision Benefits in effect on the date such coverage was scheduled to be terminated. There will be no continuation of the Employee Group Life Insurance, or Employee Weekly Supplemental Disability Benefits under this section of the Plan.

The amount of the direct payment will be based on the group rate for your particular class of benefits. These costs may change from time to time, based on the actual claim experience of the group. In any event, the amount of the monthly Direct Payment required to maintain your Health Benefits or that of your dependents will be furnished upon request.

Termination of COBRA Due To Coverage Under Another Plan

As you may know, COBRA coverage may be terminated for any participant when he or she becomes covered under another group health plan, even when that plan contains a preexisting condition exclusion or limitation. However, under the provisions of the Health Insurance Portability and Accountability of 1996, those plans that do have preexisting condition limitations must now conform to regulations which limit the circumstances under which plan s can apply the exclusions for a preexisting condition. This new law limits the preexisting condition exclusion period to a maximum period of twelve months, and also requires all plans to give credit for any prior period of continuous health coverage under another plan. A period of prior coverage is not considered continuous if the individual had no health coverage for a 63 day period between his or her "old plan" and the new plan. Where coverage is not continuous, no credit for prior coverage is required. Where coverage is continuous, the period of coverage under the old plan will be credited to satisfy the waiting period for pre existing conditions.

Example

Joe Participant has been covered under the group health plan for 20 months. When he terminates employment, he elects COBRA continuation coverage under the plan. At the time that he elects COBRA coverage, he has a specific health problem. At the end of the fifth month of his COBRA continuation coverage period, he gets a new job and enrolls in his new employer’s group health plan. As permitted by law, the new plan excludes coverage for preexisting conditions, including Joe’s specific health problem, for 12 months. In determining whether Joe is subject to the 12 month preexisting condition exclusion period, his new employer must credit him with the 25 months of coverage he had under his prior employer’s plan (because there is no break in coverage of 63 days). Since Joe had been covered under his first employer’s group health plan for at least 12 months immediately prior to becoming covered under his new employer’s plan, he is not subject to the preexisting condition exclusion. For this reason, Joe’s prior plan may terminate his COBRA coverage.

Schedule of Benefits

The Metal Trades Branch Local 638 Welfare Fund provides several types of health care benefits:

Hospital and Medical Benefits

Dental Care Benefits

Prescription Drug Benefits

Vision Care Benefits

Disability Status Program

Group Life Insurance Benefits

The above benefits are administered by either the Welfare Fund or by outside organizations designated by the Trustees.

 Employee Group Life Insurance

Who Provides Our Life Insurance Benefits?

MetLife Life Insurance Company has been designated by the Trustees to provide group life insurance benefits for any participant who is eligible for coverage under the Welfare Fund. If you are an active covered participant and you die from any cause, your designated beneficiary will be paid $50,000.

Does Our Life Insurance Include Accelerated Death Benefits?

Yes, while covered under the Welfare Fund for Life Insurance you become terminally ill, you may request that MetLife pay an Accelerated Death Benefit (herein call ADB). Upon MetLife's approval of any such request, they will pay you up to 37,500 (75% of the life benefit of $50,000).

The benefit will also allow the participant to apply for this benefit if diagnosed with amyotrophic lateral sclerosis (a/k/a Lou Gehrig's Disease); end stage heart, 6, liver and/or pancreatic organ failure wherein the person is not a transplant candidate; a medical condition requiring artificial life support, without which the person would die; or a permanent neurological deficit resulting from a cerebral vascular accident (eg., stroke) or a traumatic brain injury which are both expected to result in life-long confinement in a Hospital or Skilled Nursing Facility. A terminal illness diagnosis requires the life expectancy must be no longer than 24 months. For the aforementioned named medical diagnoses, the life expectancy requirement does not apply.

The ADB program is very complicated. Contact the Fund Office for specific details regarding this benefit.

Can I Continue Life Insurance If I Fail To Remain Covered Under The Group Plan?

If your Welfare Fund coverage terminates, you may apply, without medical examination or other evidence of insurability, for an individual life insurance policy through MetLife Life Insurance Company. Your application for conversion and premium payment must be made within 31 days after the termination of your insurance. Contact the Fund Office for complete details.

Your group life insurance is payable if you die within the 31-day period following termination of insurance, whether or not you have applied for conversion to an individual policy.

What Is Accidental Death Or Dismemberment Insurance?

If, while you are insured, you are injured in a non-employment related accident and the accident is the sole cause of the injury, the injury is the sole cause of the covered loss and the covered loss occurs within one year of the date of accident, you or your beneficiary will receive the following benefits:

Benefit		Payable For
$20,000 $50,000 $50,000 $50,000 $20,000 $25,000 $25,000 $25,000 $25,000 $10,000 $12,500 $5,000		loss of life. loss of both hands, both feet, or both eyes loss of both hearing and speech. quadriplegia. third degree burns covering 75% or more of the body. loss of either hearing or speech. loss of a hand, loss of a foot, or loss of an eye. paraplegia. hemiplegia. third degree burns covering 50% to 74% of the body. loss of the thumb and index finger of the same hand. uniplegia.

The Loss Must Result From And Occur Within One Year Of The Accident.

Accidental dismemberment benefits are payable to the participant, but life insurance and accidental death benefits will be paid to your designated beneficiary.

Only one of the above amounts, the largest, will be paid on an Accidental Death or Dismemberment claim which results from one accident. No more than $50,000 is payable for all losses resulting from the same accident. The benefit for Accidental Death is in addition to your basic life insurance benefit.

Additional Accidental Death Benefits

The following are additional benefits and will be payable if, while insured, a participant suffers a bodily injury by accident and if, within 365 days after accident, he or she suffers a loss of life solely as a direct result of the accident.

1. Passenger Restraint and Airbag Benefit:
   If a covered loss of life of the participant occurs as a direct result of a motor vehicle accident and the insured is properly using a passenger restraint and (if the driver) is properly licensed, a benefit will be payable. If an airbag is activated as a result of the same accident, an additional benefit will be payable. Passenger restraint and airbag usage will require verification. The benefit provides for $10,000 for use of a passenger restraint and an additional $5,000 if an airbag is activated.
2. Education Benefit for Dependent Child and/or Spouse:
   If a loss of life of the participant occurs as a direct result of an accident, an education benefit will be payable on behalf of each dependent child and/or a surviving spouse for a maximum of 4 years from the date of death, with verification of continued entitlement. The benefit provides for an annual maximum of $1,000.
   
   A dependent child means a child who is, your biological child, or your adopted child, or your stepchild, any other child you support that lives with you in a parent-child relationship, and, for the purpose of this benefit, is an unmarried, full-time student and is attending school, up to and including the last grade of high school, or is under the age of 23 and attending college or trade school on a regular basis at the time or your death, or enrolls in college or trade school within 365 days after the claim has been approved.
   
   The Education Benefit will be payable to the dependent child if that child has attained the age of majority. Otherwise, the Education Benefit will be payable to the guardian of the estate of the minor, or to the Custodian under the Uniform Transfer to Minors Act, or an adult caretaker, when permitted under applicable state law.
3. Child Care Benefit:
   If you suffer a loss of life solely as a direct result of an accident, a Child Care Benefit may be payable with respect to any dependent child enrolled in a legally licensed child care center. The benefit, not to exceed $600 per year, is payable for a maximum of 4 years from the date of death.
   
   For the purposes of this benefit, a dependent child means a child who is under age 13 and is enrolled in a legally licensed child care center on the date of the accident or subsequently enrolled in a legally licensed child care center within 90 calendar days after the date the claim is approved and is either your biological child, or your adopted child, or your stepchild, or any other child you support who lives with you in a parent-child relationship.
   
   The Child Care Benefit will be payable to the guardian of the estate of the minor, or to the Custodian under the Uniform Transfers to Minors Act, or an adult caretaker, when permitted under applicable state law.
4. Repatriation of Remains Benefit:
   This Plan pays a Repatriation of Remains Benefit for the actual expenses incurred to prepare a person's body for transportation to a mortuary if, as a direct result of an accident for which a benefit is payable under this section, he or she suffers loss of life while outside a 200 mile radius from his or her principal place of residence. The maximum benefit payable is $5,000.
5. Coma Benefit:
   If a covered participant suffers a bodily injury caused by an accident and as a direct result becomes comatose, a monthly benefit of $1,000 of the Principal Sum less any benefit amount paid or payable because of the same accident will be payable for 11 months after the person has been continually comatose for at least 30 consecutive days. After 12 months of continuous coma, the full Principal Sum less any benefit amount paid or payable because of the same accident is payable.

Exclusions

Accidental Death or Dismemberment insurance benefits will not be paid for any covered loss which in any way resulted from, or was caused or contributed to by, any of the following:

• a bodily or mental infirmity.
• a disease or bacterial infection.*
• medical or surgical treatment.*
• suicide or attempted suicide.
• an intentionally self-inflicted injury.
• a war or any act of war (declared or not declared).
• commission of or attempt to commit a felony.
• use of alcohol, intoxicants, or drugs, except as prescribed by a physician. An accident in which the blood alcohol level of the operator of a motor vehicle meets or exceeds the level at which intoxication would be presumed under the law of the state where the accident occurred shall be deemed to be caused by the use of alcohol.
• air or space travel. This does not apply if a person is a passenger, with no duties at all, on an aircraft being used only to carry passengers (with or without cargo).
• These do not apply if the loss is caused by:
  • An infection which results directly from the injury.
  • Surgery needed because of the injury.
  • Medical malpractice

The injury must not be one which is excluded by the terms of this section.

 
It is essential that you keep your beneficiary information current. Contact the Fund Office if you wish to change or update your beneficiary information.

Failure to do so can delay or prevent payment of your group life and accidental death insurance benefits or result in payment which is not what you wished.

In the event that you die while covered in the Welfare Fund, your named beneficiary will receive $50,000 in Employee Group Life Insurance. The Employee Group Life Insurance is administered through MetLife.

The proceeds will be paid to your named beneficiary, as designated and recorded on the beneficiary card in the Fund Office.

Beneficiary: You may name anyone you wish as your named beneficiary and you may change your beneficiary at any time by filling out a new beneficiary form. These forms may be obtained by calling or writing the Fund Office or via the forms section of this website.

Conversion Privilege: If your insurance: (1) terminates because: (a) you are no longer a member of the classes eligible; or (b) your employment terminates; or (2) is reduced on or after your attainment of age 60 in any increment or series of increments aggregating twenty percent or more of the amount of coverage in force before the first reduction on account of such age, you may convert to an individual contract of life insurance.

You must make written application for such contract and pay the first premium within 31 days after insurance ceases. A medical examination is not required. You may choose to convert to an amount equal to, or less than, the amount which terminated under this Plan. Such insurance will be on one of the forms then being written by ULLICO, except term or disability insurance.

The premium for such contract will be based on: (1) your age; (2) the class of risk to which you belong; and (3) the amount of insurance.

The covered contract may, if you choose, be preceded by term insurance for not more than one year. You may also convert to an individual contract of life insurance if your insurance terminates because: (1) this Plan terminates; or (2) the insurance on the class to which you belong terminates. You will have the right to convert under the same conditions and limitations as set forth above. However, the amount of such individual contract will not be more than the amount of the insurance on your life on the date of termination less any amount of life insurance for which you may become eligible under any group contract within 45 days after the date insurance ends. The individual life insurance contract will be effective at the end of the 31 day period; the premium must be paid before that period ends.

Limitation: A Person who holds an individual contract of life insurance obtained through exercise of this conversion privilege will not be entitled to exercise the conversion privilege a second time, even if he is otherwise eligible, as long as such individual contract of life insurance remains in force, unless he provides evidence of good health satisfactory to the Company. The effective date of such individual contract shall be designated by the Company.

Extension of Coverage upon Termination: If you die within such 31 days from the date your group coverage is terminated the company will pay your Life Insurance Benefits as though you were still insured under the group plan.

Filing for Benefits: To obtain benefits hereunder, a claimant must contact the Fund to obtain the required claim forms. The claim form must be completed and then returned to the Fund Office together with proof of death or disability within 12 months of the date of death. Failure to file with prescribed period may be grounds for denying the claim unless the claimant can show good cause for non compliance within the prescribed time period.

Claims Appeal Procedure: If you disagree with the disposition of a claim, you may request a review. Please refer to the Claims Appeal Procedure described in this booklet.

Accidental Death And Dismemberment Insurance

Upon receipt of proper proof of loss, Accidental Death and Dismemberment (AD&D) benefits will be paid if: a participant, while covered, suffers a non-employment related accidental injury as a direct result of the accident, and independent of all other causes, suffers a "covered loss" within 365 days after the accident.

A "covered loss" is defined as a permanent loss of: life, a hand by severance at or above the wrist joint, a foot by severance at or above the ankle joint, an eye involving irrecoverable and complete loss of sight, two or more phalanges of both the thumb and index finger from one hand, hearing involving irrecoverable and complete loss of hearing in both ears, speech involving irrecoverable loss of speech, quadriplegia involving irrecoverable and complete loss of use in all four limbs, paraplegia involving irrecoverable and complete loss in both legs and lower trunk, or hemiplegia involving irrecoverable and complete loss of use of one side of the body.

The amount of benefit to be paid for a "covered loss" is as follows:

• Life: 20,000
• Two Hands: 50,000
• Two Feet: 50,000
• Sight of Two Eyes: 50,000
• One Hand and One Foot: 50,000
• One Hand and Sight of One Eye: 50,000
• One Foot and Sight of One Eye: 50,000
• One Hand or One Foot: 25,000
• Sight of One Eye: 25,000
• Thumb and Index Finger of Same Hand: 12,500
• Speech and Hearing: 50,000
• Speech or Hearing in Both Ears: 25,000
• Quadriplegia: 50,000
• Paraplegia: 25,000
• Hemiplegia: 25,000

If a covered participant suffers more than one loss in any one accident, the benefit shall be made for the loss for which the largest amount is payable.

In-Network Medical Benefits

Hospital and Medical Benefits are provided by Anthem BlueCross BlueShield. A full and complete description of the hospital and medical benefits available are contained in the Anthem Blue Access EPO Guide in the Summary Plan Description tab.

Disability Status Program
Helps with Your Health Coverage

Effective July 1, 2012 the Trustees have established a Disability Status Program (DSP) which is designed to help covered participants maintain eligibility if they are unable to work due to a medical condition. The DSP can protect you from losing coverage if your illness or injury prevents you from working. As a prerequisite to the DSP application process, you must be covered in the Welfare Fund at the time of your injury or illness.

You must have a minimum of 10 Years of Credited Service in the Pension Fund at the time of injury or illness. You must be covered in the Welfare Fund for no less than 48 months of the 60 months prior to the date of injury or illness.

Under the rules of the Welfare Fund, you must report any injury on or off the job which will effect your ability to work to the Fund Office as soon as possible. Your completed DSP application must be received within thirty (30) days of the injury or illness and must be accompanied by a letter from the attending physician detailing the injury or illness. Proof of disability may include copies of Disability or Workers' Compensation payments and/or an Independent Medical Examiner (IME) conducted at the request of the Welfare Fund by Professional Evaluation Group (PEG).

Participation in the DSP cannot  exceed 12 months and includes coverage for all dependents. Upon returning to work (or being deemed physically able to return to work), a participant would remain covered for two months (when regular eligibility rules would normally reestablish welfare coverage).

 

Hospital Benefits

Hospital and Medical Benefits are provided by Anthem BlueCross BlueShield. A full and complete description of the hospital and medical benefits available are contained in the Empire PPO Guide above.

Dental Expense Benefits

Metlife Preferred Dentist Program Plus

The following benefits are provided to all eligible Welfare Fund participants and their qualifying dependents subject to the provisions of the program.

Schedule Of Benefits

Deductible Amount

For Services of Network Providers...........................  None
For Services of Non-Network Providers
Type A, B, C and/or D Expenses Combined  
Individual.............................................................      $200
Family..................................................................       $500

Covered Percentage

For Services of Network Providers  
Type A Expenses...................................................  100%
Type B Expenses...................................................  100%
Type C Expenses...................................................  100%
Type D Expenses...................................................  75%

 
For Services of Non-Network Providers  
Type A Expenses....................................................  80%
Type B Expenses....................................................  80%
Type C Expenses....................................................  60%
Type D Expenses...................................................  50%

[When a Non-Network Provider is used, the covered expenses are based on the MetLife PDP Plus network schedule of benefits.]

Maximums

For Orthodontic Treatment
Aggregate Maximum Benefit  
Lifetime per covered dependent child.......................  $4,000

 
For Other Covered Dental Expenses
Maximum Benefit  
Per Calendar Year...................................................  $4,000

Please Note:

• Expenses for orthodontia, including any procedures necessary for such treatment, will be considered covered dental expenses only if the dependent child has not reached age 19.
• Covered dental expenses for orthodontia are not included in the Maximum Benefit per calendar year.
• The maximums for both orthodontic treatment and all other covered dental expenses apply to all expenses incurred whether treatment is provided by a Network Provider, a Non-Network Provider or a combination thereof.
• If a dental bill is expected to be $300 or more, see section F, Predetermination of Benefits.

Dental Expense Benefits

A. Definitons

Covered Dental Expense means the charges based on the Preferred Dentist Program Plus Schedule of Maximum Payments for the types of dental services shown in section C. These services must be:

1. performed or prescribed by a dentist who is:
   1. a Network Provider; or
   2. a Non-Network Provider; and
2. necessary in terms of generally accepted dental standards.

There may be more than one way to treat a dental problems. If, in MetLife's view, an adequate method or material which costs less could have been used, the dental expense benefits will be based on the method or material which costs less. The balance of the cost will not be a covered dental expense. See section E for examples that show how this works.

Dentist means a person licensed by law to practice dentistry. A type of dental service which is performed or prescribed by a doctor will be considered for dental expense benefits as if it were performed or prescribed by a dentist.

Deductible Amount means the amount shown in the Schedule Of Benefits. The deductible amount during any one calendar year will apply to covered dental expenses after:

1. you incur covered dental expenses for covered persons in your family; and
2. those expenses, when applied to the deductible amount, equal the family deductible amount.

Covered Percentage means the percentage shown in the Schedule Of Benefits.

Preferred Dentist Program Plus Schedule of Maximum Payments means MetLife's fee agreement with a Network Provider in which such Network Provider has agreed to accept a schedule of maximum fees as payment in full for services rendered.

Preferred Dentist Program Plus means MetLife's program to offer a covered person the opportunity to receive dental care from dentists who are designated by MetLife as Network Providers. When dental care is given by Network Providers, the covered person will generally incur less out-of-pocket cost for the services rendered.

Network Provider means a dentist who has been selected by MetLife for inclusion in the Preferred Dentist Program. These Network Providers agree to accept the Preferred Dentist Program Schedule of Maximum Payments as payment in full for services rendered.

Non-Network Provider means a dentist who is not a Network Provider.

Preferred Dentist Program Plus Directory means the list which consists of selected dentists who:

• are located in the covered person's area; and
• have been selected by MetLife to be Network Providers and part of the Preferred Dentist Program. These Network Providers agree to accept our Preferred Dentist Program Schedule of Maximum Payments as payment in full for services rendered.

B. Coverage

1. When Benefits May Be Payable

MetLife will pay dental expense beneftis if you incur covered dental expenses:

• for a covered person during any calendar year; and
• while you are covered for the dental expense benefits for that covered person; and
• the covered dental expenses are more than the deductible amount when using Non-Network Providers.

An expense is "incurred" on the date the dental service is completed.

2. How Benefits Are Determined

Benefits will be equal to the covered percentage of those covered dental expenses which are more than the deductible amount. However:

• The sum of all benefits for all covered dental expenses incurred for a covered person during any calendar year will not be more than the maximum benefit per calendar year; and
• The sum of all benefits for all covered dental expenses incurred for a covered person for orthodontic treatment during all calendar years will not be more than the applicable Aggregate Maximum Benefit.

In order to determine the amounts of covered dental expenses, MetLife may ask for x-rays and other diagnostic and evaluative materials. If they are not submitted, MetLife will determine covered dental expenses on the basis of the information which is available. This may reduce the amount of benefits which otherwise would have been payable.

3. How the Preferred Dentist Program Plus Works

A covered person is always free to choose the services of a dentist who is either:

• a Network Provider; or
• a Non-Network Provider.

Benefits will be determined and paid in either case, except that the covered person will generally incur less out-of-pocket cost if a Network Provider is chosen.

C. Dental Services Which May Be Covered Dental Expenses

1. Type A Expenses

    a. Oral exams
b. X-rays:
a. full mouth x-rays but not more than once every 36 months
b. bitewing x-rays but not more than twice in any calendar year (every 183 days).
c. Preventive treatment:
a. cleaning and scaling of teeth (oral prophylaxis) but not more than twice in any calendar year; and
b. topical fluoride treatment for a dependent child until their 19th birthday, but not more than twice  in any calendar year.
d. Space maintainers for a dependent child through the year in which they turn 19 (age 23 if a full-time student).
e. Two applications of sealant material for each molar tooth of a dependent child under age 16 not more than twice in a lifetime.
f. Emergency palliative treatment

2. Type B Expenses

    a. Fillings - amalgam, silicate, acrylic, synthetic porcelain or composite fillings.
b. Extractions
c. Root canal treatment
d. Treatment of periodontal disease and other diseases of the gums and tissues of the mouth.
e. Oral surgery
f. Injections of antibiotice drugs
g. Administration of general anesthesia, when medically necessary in connection with oral surgery, extractions, or other covered dental services.
h. Relinings and rebasings of existing removable dentures, but not more than once in any 36 month period.
i. Repair or re-cementing of crowns; inlays or onlays; dentures; or bridgework.

3. Type C Expenses

    a. Those services needed to replace one or more natural teeth which are lost while dental expense benefits for the covered person are in effect for:
a. Installation of fixed bridgework done for the first time.
b. Installation for the first time of a partial removable denture or a full removable denture.
b. Replacing an existing removable denture or fixed bridgework if it is needed because of the loss of one or more natural teeth after the existing denture or bridgework was installed or it is needed because the existing denture or bridgework can no longer be used and the existing denture or fixed bridgework was installed at least 60 months prior to its replacement.
c. Replacing an existing immediate temporary full denture by a new permanent full denture when the existing denture cannot be made permanent; and the permanet denture is installed within 12 months after the existing denture was installed.
d. Adding teeth to an existing partial removable denture or to bridgework when needed to replace one or more natural teeth removed after the existing denture or bridgework was installed.
e. Inlays, onlays, and crown restorations, but not more than one such restoration to the same tooth surface within 60 months of the prior restoration.

4. Type D Expenses

Orthodontia, including appliance therapy for dependent children through the year in which they turn age 19. The Aggregate Maximum Benefit for orthodontia is shown in the Schedule Of Benefits.

D. Exclusions: Services Which Are Not Covered Dental Expenses

1. Services or supplies received by a covered person before the dental expense benefits start for that person.
2. Services not performed by a dentist except for those services of a licensed dental hyienist which are supervised and billed by a dentist and which are for:
   1. cleaning and scaling of teeth; or
   2. fluoride treatments.
3. Cosmetic surgery or supplies. However, any such surgery or supply will be covered if:
   1. it otherwise is a covered dental expense; and
   2. it is required for reconstructive surgery which is incidental to or follows surgery which results from a trauma, an infection or other disease of the involved part; or
   3. it is required for reconstructive surgery because of a congenital disease or anomaly of a dependent child which has resulted in a functional defect.
4. Replacement of a lost, missing or stolen crown, bridge or denture.
5. Repair or replacement of an orthodontic appliance.
6. Services or supplies which are covered by any workers' compensation laws or occupational disease laws.
7. Services or supplies which are covered by any employers' liability laws.
8. Services or supplies which any employer is required by law to furnish in whole or in part.
9. Services or supplies received through a medical department or similar facility which is maintained by the covered person's employer.
10. Services or supplies received by a covered person for which no charge would have been made in the absence of dental expense benefits for that covered person.
11. Services or supplies for which a covered person is not required to pay.
12. Services or supplies which are deemed experimental in terms of generally accepted dental standards.
13. Services or supplies received as a result of dental disease, defect or injury due to an act of war, or a warlike act in time of peace, which occurs while the dental expense benefits for the covered person are in effect.
14. Adjustment of a denture or bridgework which is made within 6 months after installation by the same dentist who installed it.
15. Any duplicate appliance or prosthetic device.
16. Use of materials to prevent decay other than fluorides and sealant material for the molar teeth of a dependent child under age 16.
17. Instruction for oral care such as hygiene or diet.
18. Periodontal splinting.
19. Services or supplies to the extent that benefits are otherwise provided under this plan or under any other plan which the employer (or an affiliate) contributes to or sponsors.
20. Myofunctional therapy or correction of harmful habits
21. Implantology.
22. Initial installation of a denture or bridgework to replace one or more natural teeth lost before the dental expense benefits started for the covered person.
23. Charges for broken appointments.
24. Charges by the dentist for completing dental forms.
25. Sterilization supplies.
26. Services or supplies furnished by a family member.
27. Treatment of temporomandibular joint disorders.

Dental expenses will be based on the materials and method of treatment which cost the least and which, in MetLife's view, meet generally accepted dental standards.

E. Examples Of Alternate Benefits

1. Fillings: Inlays, Onlays and Crowns

If a tooth can be repaired by a less costly method than an inlay, onlay or crown, dental expense benefits will be based on the adequate method of repair which costs the least.

2. Crowns, Pontics and Abutments

Veneer materials may be used for front teeth or bicuspids. However, dental expense benefits will be based on the adequate veneer materials with cost the least.

3. Bridgework and Dentures

Dental expense benefits will be based on the adequate method of treating the dental arch which costs the least. In some cases removable dentures may serve as well as fixed bridgework. If dentures are replaced by fixed bridgework, the dental expense benefits will be based on the cost of a replacemetn denture unless adequate results can only be achieved with fixed bridgework.

These are not the only examples of alternate benefits. To find out how much your dental expense benefits will be, see section F.

F. Predetermination Of Benefits

If a dental bill is expected to be $300 or more, before the dentist starts the treatment, a covered person can find out what dental expense benefits will be paid by MetLife. To do this, the covered person should send a claim form to MetLife in which the dentist states:

• the work to be done; and
• what the cost will be.

MetLife will then tell the covered person what the dental expense benefits schedule is. The predetermination does not review eligibility for services which have time limitations, ex. dentures cannot be replaced within 5 years of installation. If the covered person does not use this method to find out what dental expense benefits MetLife will pay, the decision will be final and binding with regard to what are covered dental expenses and what dental expense benefits will be paid.

This method should not be used for:

• emergency treatment; or
• routine oral exams; or
• x-rays, cleaning and scaling, and fluoride treatments: or
• dental services which cost less than $300.

G. Impact Of Government Plans On Dental Expense Benefits

To the extent that services or supplies, or benefits for them, are available to a covered person under a government plan, as defined below, they will not be considered for dental expense benefits under this benefit program. This provision will apply whether or not the covered person is enrolled for all government benefits for which they are eligible. This provision will not apply to a government plan if it requires that dental expense benefits under this benefit program be paid first.

A government plan is any plan, program or coverage, other than Medicare:

• which is established under the laws or the regulations of any government; or
• in which any government participates other than as an employer.

H. Dental Expense Coverage After Benefits End

No benefits will be payable for covered dental expenses incurred by a covered person after the dental expense benefits for that person end. This will apply even if we have per-determined benefits for dental services. However, benefits for covered dental expenses incurred for a covered person for the following services will be paid after dental expense benefits end:

1. For a prosthetic device if:
   1. the dentist prepared the abutment teeth and made impressions while dental expense benefits for the covered person were in effect; and
   2. the device is installed within 60 days after the date dental expense benefits end; or
2. For a crown if:
   1. the dentist prepared the tooth for the crown while the dental expense benefits for the covered person were in effect; and
   2. the crown is installed within 60 days after the date the dental expense benefits end; or
3. For root canal therapy; if
   1. the dentist opened the tooth while the dental expense benefits for the covered person were in effect; and
   2. the treatment is finished with 60 days after the date the dental expense benefits end.

I. Payment Of Benefits

MetLife will send payment directly to your Network Provider. When a Non-Network provider is used, dental expense benefits will be paid to you. MetLife will pay benefits when it receives satisfactory written proof of your claim. Proof must be submitted no later than 90 days after the end of the calendar year in which the covered dental expenses were incurred. If proof is not given on time, the delay will not cause a claim to be denied or reduced as long as the proof is given as soon as possible.

When Benefits End

• All of your benefits will end on the date your coverage in the Welfare Fund ends. Your coverage ends when you fail to maintain eligibility. Please refer to the ELIGIBILITY section for details.
• If this benefit program ends in whole or in part, your benefits which are affected will end.
• All benefits on account of a qualifying dependent will end on the last day of the calendar year in which that qualifying dependent ceases to be your dependent.

The end of any type of benefits on account of a covered person will not affect a claim which is incurred before those benefits ended.

The dental expense benefits for a covered person may be continued in accordance with the federal law called COBRA. Please refer to the answer to the question "What Happens If I Lose Coverage?" under the ELIGIBILITY section of this booklet for details.

Prescription Drug Benefits

Who Administers The Prescription Drug Benefits?

Prescription drug benefits are available to all participants and their qualifying dependents who meet the Welfare Fund eligibility requirements. Your prescription drug benefits are administered by Express Scripts which covers almost all drugs prescribed by a licensed medical doctor, osteopath, dentist or podiatrist for their generally accepted medical use.

This benefit includes both a Card Program and a Home Delivery/Mail Service Program. This benefit program was instituted in an effort to increase benefits, alleviate the claim filing burden and reduce costs when you or your dependents require prescription drugs. At the time your coverage becomes effective you will receive a plastic identification drug card and home delivery/mail service order forms.

How Does The Prescription Drug Benefit Program Work?

Express Scripts Drug Program

Prescriptions filled at a local, retail pharmacy will have the following co-payments:

Generic Brand Controlled Substances

$10 for a 21 day fill or re-fill (one re-fill limit) $30 for a 21 day fill or re-fill (one re-fill limit) $43 for a 30 day fill or re-fill (no limit)

Prescriptions filled through the Express Scripts Home Delivery mail order program will have a $40 co-payment for a 90 day fill or re-fill.

Both retail and mail order prescriptions must be filed generically if a generic equivalent drug is available. If you have a prescription filled with a brand name drug when a generic is available FOR ANY REASON you will pay the brand name co-payment plus the difference between the cost to the Welfare Fund for the generic and the brand. Using a brand name drug when a generic is available will cost you a great deal of out-of-pocket expense.

Please keep in mind that if you have a prescription filled with a brand name drug when a generic is available the difference which you must pay does not accrue towards your annual deductible.

• Direct Reimbursement Program
  Should there arise an occasion that the retail or home delivery/mail service program is not used, a direct reimbursement claim process has been established between the Welfare Fund and Express Scripts. Your reimbursement under this program may be significantly less than your purchase price of the prescription. Participants are permitted to use the direct reimbursement claim procedure only once during their lifetime coverage.
  
  Contact the Fund Office [(212) 465-8888 extension 244] to obtain a Direct Reimbursement Claim form. The claim form must be filled out by the patient as well as the pharmacist. Along with the complete claim form, you must submit a letter explaining why you were unable to use the card or the home delivery/mail service program to the Fund Office. Upon the approval of the Fund, your claim will be submitted to Express Scripts for processing.

What Prescription Drugs Are Covered In This Program?

Prescription drugs available under both the Card and the Home Delivery/Mail Service Programs include:

• Federal Legend Drugs
• State-Restricted Drugs
• Compounded Medications
• Insulin and insulin syringes only
• Narcotic painkillers (considered controlled substances)
• A.D.D. drugs (considered controlled substances)

Each state establishes its own legal list of controlled substances. Typically, under state laws, a controlled substance cannot have more than a 30 day fill.

Are There Any Exclusions in This Program?

The following are the excluded items to the prescription plan:

• Contraceptives, oral or other, whether medication or devices, regardless of intended use.
• Non-Federal Legend Drugs including all "over the counter" items, regardless of whether they are prescribed.
• Charges for the administration or injection of any drug.
• Needles and syringes, support garments, and other non-medical substances (such items may be covered under your medical benefits coverage).
• Prescriptions which you are entitled to receive without charge under any Workers' Compensation Laws or any municipal, state or federal program.
• Medication taken by, or administered to, a person while an inpatient in a licensed hospital, hospice, rest home, sanitarium, extended care facility, nursing home or similar institution which operates on its premises, or allows to be operated on its premises, a facility for dispensing pharmaceutical products.
• Drugs labeled "Caution - limited by federal use to investigational use" or experimental drugs.
• Blood, blood plasma or biological sera.
• Vitamins; except those, which by law, require a prescription.
• Any prescription filled, except controlled substances, in excess of the number specified by the physician, or any refill dispensed after one year from the physician's original order.

What Programs Have Been Instituted to Insure Proper Drug Use?

The Welfare Fund is committed to providing quality prescription drug benefits. With this goal in mind, we use a set of Utilization Management Programs, administered by Express Scripts, to determine how you prescription drug plan will cover certain medications. The goal of these programs is to alleviate inappropriate and potentially harmful use of prescription drugs while simultaneously assuring the proper utilization of benefit dollars. Member health, safety, and satisfaction remain the primary objectives of the prescription drug coverage.

These programs are Coverage Review, Step Therapy, Quantity Duration and Retrospective Drug Utilization Review (RDUR) health and safety program.

Coverage Review

For some medications, you must obtain approval through a review process in order to obtain coverage. When you use Express Scripts By Mail, we will call your doctor to start the coverage review. If you submit a prescription to a participating retail pharmacy for a medication that requires coverage review, you, your doctor, or your pharmacist can initiate the review by calling (800) 753-2851.

If coverage is not approved, either at a retail or mail-order basis, you will be responsible for the full cost of the medication. You have the right to appeal the decision. Information on how to request the appeal will be included in the letter that you receive.

The following medications are subject to a Coverage Review:

Androgens and anabolic steriods (androgens: methyltestosterone tablets and capsules, fluoxymesterone tablets, testosterone gel, testosterone patches, testosterone lozenges, injectable testosterone, and injectable methyltestosterone; anabolic steroids: Anadrol-50®, Winstrol®, Oxandrin®, Deca-Durabolin®, and Kabolin®)
Growth hormones (Humatrope®, Nutropin®, Serostim®, Saizen®, Norditropin®, Genotropin®, Tev-Tropin®, Zorbtive™, Protropin®, Increlex™)
Appetite and weight loss (Meridia®, Xenical®, Didrex®, diethylporpion, Tenuate®, phentermine, Ionamin®)
Miscellaneous pulmonary agents (Xolair®)
Hepatitis medications: interferons (Infergon®, Roferon®, Intron-®A, Alferon®, PEG-Intron®, Pegasys®); ribavirin (Rebetol®, Copegus®)
Antinarcoleptic agents (Provigil®)
Antineoplastic agents (Iressa®)
Contraceptive agents (various)
Erythroid stimulant (Epogen®, Procrit®, Aranesp®)
Miscellaneous dermatologicals (Retin-A®, Tazorac® cream)
Mutliple sclerosis therapy (Avonex®, Rebif®, Betaseron®, Copaxone®)
Myeloid stimulants (Neupogen®, Leukine®, Neumega®, Neulasta®)

Step Therapy

Step Therapy looks at a patient's prescription history and determines whether he or she is eligible for a given medication without a coverage review. If there is not enough information in the history, a coverage review may be necessary. The following medications are subject to a Step Therapy Review:

Miscellaneous rheumatologicals (Enbrel®, Arava®, Kineret®, Humira®, Orencia®, Remicade®)
Pain (Oxycontin®, Actiq®)
Dermatologicals (Protopic®, Elidel®)
Allergy (Singulair®, Accolate®, Zyflo®)
Cancer Therapy (Tarceva®)
COX 2 inhibitors (Celebrex®)
Ribavirin therapy (Rebetol®, Copegus®)

Quantity Duration

Your prescription drug plan provides coverage for a quantity of medication and duration of treatment sufficient to meet the needs of most patients. If a greater quantity or longer course of treatment is needed, a coverage review process is required.

The following medications are subject to a Quantity Duration Review:

Sleep therapy (Lunesta®, Ambien®, Sonata®, Prosom®, Doral®, Restoril®, Dalmane®, Halcion®, temazepam, flurazepam, triazolam)
Erectile dysfunction agents (Cialis®, Levitra®, Viagra®, Caverject®, Edex®, and Muse®)
Migraine therapy (Imitrex®, Zomig®, Axert®, Amerge®, Frova®, Relpax®, Maxalt®, Migranal®)
Anti-influenza (Relenza®, Tamiflu®)

Quantity Duration - no review

Your plan will cover the following 8 pills of the medications listed below within a 21-day period. Prescriptions that exceed that amount will not be covered by the plan. Your retail pharmacist or your mail-order pharmacy may reduce the quantity of medication dispensed to an amount covered by your plan. If you choose to obtain additional quantities, you will be responsible for the full cost of the medication at your retail pharmacy.

Erectile dysfunction agents (Cialis®, Levitra®, Viagra®, Caverject®, Edex®, and Muse®)

Vision Care Benefits

Vision care benefits are available for you and your qualifying dependents. This benefit will reimburse you for the cost of eye examinations, frames, and/or lenses, including contact lenses.

Vision care benefits are available in the maximum amount of $400 per person each year. You must be covered under the Welfare Fund on the date of service or the purchase date. In addition, the date of service or the purchase date will determine whether you have reached the maximum benefit for the year.

Coordination Of Benefits

Coordination of Benefits (COB) is a provision in group health and group dental contracts that prevent duplicate payments for the same covered medical or dental expenses. The COB provision applies only when a participant or eligible dependent is covered under more than one group health or dental program. When that is the case, the Welfare Fund will coordinate benefit payments with the other group plan. One group will pay its full benefit as the primary plan and the other group will pay secondary benefits (if necessary) to cover some or all of the remaining expenses. This COB provision prevents duplicate payments and overpayments. In no case should the benefits received from the two group plans in total be greater than the medical or dental allowed charges.

The rules to determine the order of payment under Welfare Fund coverage in those cases where there is coverage under more than one group plan are as follows:

1. If the other group plan does not have a COB provision similar to the Welfare Fund's, then that group will be primary.
2. If both groups have a COB provision, the group covering the person as a participant is primary.
3. If a dependent child is covered under both parents' gourp plan and the parents are not separated or divorced, the plan of the parent whose birthday falls earlier in the year will be primary. For purposes of determining the earlier birthday only the month and day are considered; the year of birth has no significance. If both parents have the same birthday, the plan which covered the parent longer will be primary. However, if the other group plan does not use the "birthday rule;" but instead uses a rule based on the gender of the parent and as a result the two plans do not agree on which is primary, then the father's group plan shall be primary.
4. If a dependent child is covered under both parents' group plan, the parents are separated or divorced, there is no court decree which establishes financial responsibility for the child's coverage, the plan of the parent who has custody (the custodial parent) shall be primary. However, if the custodial parent has remarried and the child is also covered as a dependent under the step-parent's plan, the custodial parent's plan will pay first, the step-parent's plan second and the non-custodial parent's plan third.
5. If a court decree specifies which parent is to be responsible for the child's coverage and that parent's plan has actual knowledge of the decree, then that parent's plan will be primary.
6. If a person is covered under one group as an active participant or as the dependent of an active participant and is also covered under another group as a retired participant or as the dependent of a retired participant, the group which covers that person as an active participant is primary. If the other group plan does not have this rule, and as a result the two plans do not agree on which is primary, then this rule will be ignored.
7. If none of the above rules determine which group plan is primary, the group plan covering the person for the longer period of time is primary.