Active Health & Welfare – Plan A
You are eligible for Plan A Medical if your employer has negotiated Plan A medical benefits with your union.
Kaiser Permanente (HMO)
With an HMO, you must receive all your care through a Kaiser hospital or Kaiser physician contracted with the HMO in which you are enrolled. Non-Kaiser expenses will only be covered for emergency services. In general, care is provided to you after you pay a flat copayment per visit or service. You must live or work within the service area to enroll. Covered charges are not subject to a lifetime maximum.
If you enroll in Kaiser, you are encouraged to select a Primary Care Physician (PCP). You must use only Kaiser Permanente physicians and facilities. For Kaiser Permanente physicians & locations go to www.kp.org.
Direct Pay Medical Plan (PPO)
In the Direct Pay Plan, unlike an HMO, medically necessary care from any licensed provider that you select will be covered in accordance with Plan rules. The Plan has arrangements with Anthem Blue Cross under which various hospitals, laboratories, physicians and specialists agree to provide care to you at negotiated Preferred Provider Organization (PPO) rates. You will have less out-of-pocket expense when an Anthem Blue Cross PPO hospital, laboratory, physician, or specialist is used. In California, the Anthem Blue Cross network is called “Prudent Buyer.”
In all other states, the PPO is provided through the National Blue Cross /Blue Shield Association. For provider listings in California go to www.bluecrossca.com. For provider listings in all other states go to www.bluecares.com.
Health Reimbursement Account
The Health Reimbursement Account (HRA) is an account into which the Fund will contribute $600. Your HRA dollars can then be used by you and your dependents for deductibles and other eligible medical, prescription drug, dental and vision expenses that are not reimbursed from any other health plan. You must be covered under the Direct Pay Plan in order to qualify for the HRA account. Unspent funds on your HRA account will continue to accumulate and will remain available as long as you remain covered on the Direct Pay Plan. You are permitted to permanently opt out of and waive future reimbursements from the HRA at least annually, in a time and manner determined by the Fund Office. Upon your termination of employment, you may opt out and waive future reimbursements from the HRA.
You also receive greater benefits when you have an elective hospital stay pre-certified by Anthem Blue Cross before you are admitted. The toll-free number for California and all other states is (800) 274-7767. For emergency admissions, Anthem Blue Cross must be contacted within 48 hours.
Prescription Drug Coverage
Your prescription drug coverage will depend on the plan you are enrolled in.
Kaiser Permanente (HMO) Enrollees
If you are enrolled in Kaiser, you must obtain your drugs at Kaiser Pharmacies. Generic drugs are available with a $15 copayment and brand name drugs with a $30 copayment up to a 30-day supply at Kaiser Pharmacy. For mail order, the copayments are twice those at a retail pharmacy for a 90-day supply.
Direct Pay Medical Plan (PPO) Enrollees
These enrollees receive prescription drugs from the Trust Fund. You must use an OptumRx pharmacy. If you fill or refill prescriptions at a retail pharmacy, you will pay 20% of the charge plus $5 for up to a 30-day supply per formulary generic prescription or 20% of the charge per formulary brand name prescription or 20% of the charge plus $15 per non-formulary brand name prescription. The copayment is capped at $100 for certain formulary/non-formulary brand name prescriptions at retail. For mail order, prescriptions are covered in full after a $40 copayment for formulary generic drugs and a $60 copayment for brand name drugs, regardless of whether the drug is on the formulary, for a 90-day supply. The out-of-pocket limit for individual is $1,500 ($3,000 for 2 family members and $4,400 per family).
If your employer has negotiated for dental benefits with your union, dental coverage is available to you and your eligible dependents. Each of your dental care choices covers preventive, basic, and major care. Benefits depend on the plan in which you enroll. Newly eligible participants cannot enroll in Delta Dental (unless your employer has purchased the “Buy-Up Plan”) or the Scheduled Direct Pay Plan for the first 12 months of coverage. Therefore, during their first 12 months of coverage, you are limited to enroll in one of the DMOs shown below. Dental Plan Options include:
- Dental Maintenance Organization (DMO): The Newport Dental, MetLife, Dental, UnitedHealthcare Dental and United Concordia Dental Plans operate like HMOs, providing services only through participating dental offices. You will be responsible for small copayments for most covered services.
- Delta Dental Plan: Like the Direct Pay Medical Plan, the Delta Dental plan allows you to use any licensed dentist, but pays a higher benefit when you use Delta Preferred Option Dentists. For most participants, there is a $3,000 annual maximum benefit and you pay 20% of covered expenses when you use a Delta Preferred Option Dentist (30% of covered expenses when you do not). The maximum does not apply to pediatric dental services.
- Scheduled Direct Pay Dental Plan: The Scheduled Dental Plan also allows you to use any licensed dentist of your choice. The Plan pays 100% of a scheduled amount for covered dental treatment, not to exceed a $2,500 annual maximum per eligible person.
The maximum does not apply to pediatric dental services. However, the Plan offers members access to a dental PPO network, First Dental Health (FDH). FDH providers offer members treatment at discounted rates. Therefore, your annual maximum benefit goes farther by using a FDH dentist. For information on locating a FDH dentist, please contact FDH at (800) 334-7244 or www.firstdentalhealth.com.
If your employer has negotiated for self-funded orthodontic benefits with your union, Orthodontic coverage is available to you and your eligible dependents once you have been covered by the Plan for three months. If you are eligible for orthodontic coverage, orthodontic treatment will be covered in full up to a lifetime benefit of $2,500 per individual. If you enroll in a Dental Maintenance Organization, orthodontia may be available at discounted rates if you use a panel orthodontist. Regardless which dental plan option you have selected, orthodontic benefits are paid by the Fund Office once a claim is filed by your orthodontist.
If your employer has negotiated vision benefits with your union, whichever medical plan you choose, you may use Vision Service Plan’s (VSP) network of eye care professionals to receive exams, and purchase lenses and frames. HMOs also offer eye exams.
If you are entitled to medical coverage through the Fund, you are automatically entitled to the Burial Benefit. This benefit provides payment of $2,500 to your designated beneficiary upon the death of a covered Participant. Burial benefits are available to Active Employees and his or her covered Dependents.
If you are covered for Life Insurance, the amount available upon the death of you or your eligible dependents is dependent on your employer’s collective bargaining agreement with this Trust Fund.