Overview
The BOLR Part-Time and Weekend Worker Plan offers you and your eligible dependents dental and vision benefits. You also have access to Life and Accidental Death and Dismemberment (AD&D) insurance, in addition to disability income protection.
Vision Care Program
The BOLR Part-Time and Weekend Worker Plan offers complete vision care for routine eye exams, glasses, or contact lenses through the National Vision Administrator (NVA) participating provider network of ophthalmologists, optometrists, and opticians. If you don’t use participating NVA providers, you’ll be reimbursed for a portion of the cost of eye exams, glasses, or contact lenses.
| Vision Benefit Summary | ||
| Service | NVA Provider | Non-NVA Provider |
| Eye exam | 1 free exam every 24 months (12 months for children under age 19) | $30 allowance for one exam every 24 months (12 months for children under age 19) |
| Lenses and frames | $120 allowance every 24 months (12 months for children under age 19) | $60 allowance for lenses and $60 allowance for frames every 24 months (12 months for children under age 19) |
| Contact lenses | $120 allowance every 24 months (12 months for children under age 19) | $60 allowance every 24 months (12 months for children under age 19) |
Dental Benefits
Our dental plan, provided through Delta Dental, covers a wide range of dental services, including diagnostic and preventive care. This chart gives you a quick look at the Dental Benefits. Please refer to your Summary Plan Description for complete information about the benefits.
| Deductible | In Network | Out of Network |
|---|---|---|
| Annual Maximum Benefit1 | $3,000 per person, per year | $3,000 per person, per year |
| Preventive and Diagnostic Care Oral exam, cleaning, bitewing X-rays (twice a year); full-mouth X-rays every 36 months Fluoride treatments up to age 19 (limits apply) Sealants or space maintainers (age limits apply) | 100% | 100% (allowed amount) |
| Basic Restorative Fillings | 100% | 100% (allowed amount) |
| Major Restorative Repairs of existing crowns Inlays, onlays, crowns, cast restorations Bridges and dentures | 100% | 100% (allowed amount) |
| Orthodontia Children only, subject to a lifetime maximum of $4,500, except for medically appropriate orthodontia | 100% $1,000 lifetime maximum | 100% (allowed amount) |
1 Annual maximum for dental is a combined maximum for both in- and out-of-network care. Under the Affordable Care Act (ACA) guidelines, pediatric dental care is not subject to the annual maximums.
Life Insurance and Accidental Death & Dismemberment Insurance (Death Benefit—Participant Only)
Life insurance is designed to protect your family, or anyone who relies upon your income, in the event of your death. Accidental Death and Dismemberment (AD&D) insurance pays a benefit to you if you suffer an accidental loss of a limb or your eyesight, and pays a benefit to your beneficiaries if you die as a result of a covered accident. The Fund pays for $25,000 of life and AD&D coverage for you. The specific amount of dismemberment coverage is determined by your loss.
Dependents are not eligible for life or AD&D coverage, but you may designate one or more dependents as your beneficiary. Contact the Fund Office if you need to update your Beneficiary Information Form.
Disability Benefits
Disability benefits provide you and your family with a supplemental weekly payment if you become disabled and cannot work due to a non-work-related illness or injury.
The specific time allowance for disability is determined by the diagnosis and established disability guidelines. However, no disability can exceed the maximum benefit of 26 weeks due to illness. For disability benefits to be considered, you must complete a disability claim form, and you must provide documentation from a legally qualified doctor certifying that you are disabled and unable to perform your normal work duties.
Part-time and weekend employees are eligible for a benefit of $30 per week (or per weekend) for illness or injury while you are disabled and remain under the direct, regular care of a legally qualified doctor.
The form for your disability claim must be filed in a timely manner. See the form for more information about timing and deadlines. Contact the Fund Office to get a form.
Your disability claim begins on the seventh working day after you visit your doctor as a result of your disability. Disability benefits will not be paid for any period in which you missed work before you visited your doctor.
For more information about disability benefits, see your Summary Plan Description or call the Fund Office at (215) 568-3262 or (800) 338-9025 outside the local calling area.
