Member Name Address City, State, Zip Code
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November 1, 2019 Member Name Address City, State, Zip Code Dear Member, On behalf of the Board of Trustees, welcome to the Teamsters Health and Welfare Fund of Philadelphia and Vicinity. In addition to your medical benefits coverage, the Fund provides specialty programs and services that can help you save money on your medical expenses. The goal of these additional benefits is to help you take control of your health and support healthy outcomes for you and our Fund. In this new member packet, you will find detailed information on the carved-out programs and services available to you through the Fund’s medical benefits plan. This folder includes: ● Summary Plan Description ● Dental Fee Schedule ● Enhanced Benefits Guide ● Member Identification Card ● Dental Provider Booklet Please take the time to read the enclosed material as these programs and services are extremely valuable. If you have any questions in reference to the benefits information included in the Summary Plan Description or Enhanced Benefits Guide, please contact Member Services at 1-800-523-2846. Sincerely, TEAMSTERS HEALTH AND WELFARE FUND OF PHILADELPHIA AND VICINITY TEAMSTERS HEALTH AND WELFARE FUND OF PHILADELPHIA AND VICINITY Enhanced Benefits Guide A Summary of Your Health + Life Benefits Introduction The mission of Teamsters Health and Welfare Fund of Philadelphia and Vicinity and its Board of Trustees is to fulfi ll the Fund’s responsibility and commitment to excellence in providing and maintaining quality benefi ts in a cost-effi cient manner. In the spirit of this mission, the Fund has included in its medical plan specialty programs and services that can help members succeed in making positive lifestyle choices at no additional cost. In this Enhanced Benefits Guide you will fi nd valuable information on the carved-out programs and services available to you and your eligible dependents through the Fund’s medical benefi ts plan. The Fund off ers members a “dual option” medical program that includes a Platinum Plan and a Gold Plan. The Platinum Plan has lower out of pocket expenses compared to the Gold Plan. All of the medical benefi ts outlined on the following pages are subject to the eligibility schedule and provisions set forth in the Fund’s Summary Plan Description. If you are unsure as to what applies to you and/or your dependents, please call Member Services at 800-523-2846. TABLE OF Contents Medical Benefits Coverage .................................................2 No Cost Share Medical Services Pharmacy & Prescription Benefits Coverage Prescription Copays Group Term Life and AD&D Benefits Program Disability Enhanced Member Benefits ..............................................5 Dental Program Total Care Network TELADOC Health Care Solutions Corporation HealthCare Strategies National Vision Administrators Cancer Treatment Centers of America Fit Teamster Color Genomics WellTeam ...............................................................................................................13 Annual Wellness Screening Program Quick Reference Information ......................................14 Life Events Coordination of Benefits Medicare Definitions Important Contact Information HRA Information for YRC Employees ...........16 ENHANCED BENEFITS GUIDE: A SUMMARY OF YOUR HEALTH + LIFE BENEFITS 1 Medical Benefits Coverage Medical Horizon BCBS PPO Horizon BCBS PPO Aetna EPO Aetna EPO PLATINUM GOLD PLATINUM GOLD PCP Visit $20 Copay $30 Copay $15 Copay $25 Copay Specialist Visit $30 Copay $40 Copay $25 Copay $35 Copay Emergency $100 Copay $100 Copay $100 Copay $100 Copay Urgent Care $50 Copay $50 Copay $50 Copay $50 Copay In-Network $250 deductible per $500 deductible per $100 deductible per $350 deductible per Deductible & person, $500 per family, person, $1,000 per family, person, $200 per family, person, $700 per family, Coinsurance and 10% coinsurance up to and 10% coinsurance up to and 10% coinsurance up and 10% coinsurance up $500 per person $750 per person to $250 per person to $500 per person Out-of-Network $500 deductible per $1,000 deductible per NOT COVERED NOT COVERED Deductible & person, $1,000 per family, person, $2,000 per family, Coinsurance and 20% coinsurance up and 20% coinsurance up to $1,500 per person to $2,250 per person No Cost Share Medical Services The Aff ordable Care Act requires the Fund to cover certain preventive care services with no cost-sharing PREVENTIVE SERVICES INCLUDE, BUT ARE NOT LIMITED TO: (co-payment, deductibles, or • Annual physical exam • PSA screening coinsurance) to the member. To • Screening tests • Aortic aneurysm screening help members take control of their (cholesterol and lipid level, (ages 65-75) health and ensure their dependents blood pressure, type 2 • Bone density test are in the best of health, the Fund diabetes) • Colonoscopy will pay 100% of the cost of qualifi ed • Annual preventive (starting at age 45) preventive services, such as an dental exam • Depression screening annual routine physical exam. Please • Immunizations • Lung cancer screening note, cost-sharing requirements • Routine pelvic exam and (ages 55-80 who have a may still apply to preventive care Pap test history of smoking) services received from an out-of- • Mammogram network provider. 2 TEAMSTERS HEALTH AND WELFARE FUND OF PHILADELPHIA AND VICINITY Medical Benefits Coverage Pharmacy & Prescription Benefits Coverage As the Fund’s pharmacy and prescription benefits administrator, Capital Rx is dedicated to giving members the best services necessary to provide comprehensive prescription drug, specialty medications and mail order pharmacy coverage. MAIL ORDER PHARMACY SPECIALTY MEDICATIONS Capital Rx’s mail order pharmacy Capital Rx’s specialty medication provider is Magellan Rx Specialty provider is Magellan Rx Pharmacy. Pharmacy. Specialty medications are often given by injection or infused Magellan Rx provides a convenient to treat complex, chronic conditions and may require special handling, prescription mail order service including refrigeration. When you get a prescription from your doctor for that delivers medication right specialty medications, follow these three steps: to your home. There are three ways a member can submit their ➊ Have your doctor e-prescribe to Magellan Rx Pharmacy-Specialty, prescription to Capital Rx’s mail- Orlando, FL 32812 or fax your prescription to 866-364-2673. Make sure order pharmacy provider: your doctor includes your contact information. If prior authorization is required, your doctor may need to take extra steps to submit your prescription. E-PRESCRIBE ➋ A representative from Magellan Rx Specialty Pharmacy will contact you Have your doctor e-prescribe to to get additional information and schedule your delivery. Deliveries can Magellan Rx Pharmacy-Home. be made to your home or to your doctor’s office. Additionally, you may call 800-424-7491 to confirm the receipt of the prescription from the FAX prescriber. Have your doctor fax your ➌ Your prescription will arrive in private, tamper-resistant packaging prescription to 888-282-1349. when and where you’ve requested. Faxed prescriptions may only be sent by a doctor’s office and must Members can register online at www.cap-rx.com and gain access to their include patient information and online member profile. Once you register you will have the ability to view diagnosis for timely processing. and download pharmacy claims, access the precision drug lookup tool, locate a participating pharmacy and much more. MAIL Mail your prescription and completed order form to P.O. Box 620968, Orlando, FL 32862. The Capital Rx Member Help Desk is available 24/7 at 800-424-7491. ENHANCED BENEFITS GUIDE: A SUMMARY OF YOUR HEALTH + LIFE BENEFITS 3 Medical Benefits Coverage Prescription Prescription CAPITAL RX CAPITAL RX Copays PLATINUM GOLD By using the Teamsters Health & Tier 1 (Generic) $5 Copay $10 Copay Welfare Prescription Drug Card, members can fill prescriptions and Tier 2 (Preferred) $15 Copay $20 Copay 90-day maintenance medications Tier 3 (Non- Preferred) 50% with $30 Min./ 50% with $40 Min./ at any in-network retail pharmacy, $50 Max $60 Max with one copay, and receive generic Specialty $100 Copay $150 Copay medications for as low as $5. Group Term Life and AD&D Benefits Program All of the Group Term Life and Accidental Death and Dismemberment benefits noted within this guide are subject to the eligibility schedule set forth in the Fund’s Summary Plan Description. Unlike other plan benefits which are self-insured, Death and Dismemberment benefits are provided through a group life policy insured by Dearborn National. If you are unsure how this benefit applies to you and/or your dependents, please call the Fund office. Accidental Death and Dismemberment Death Benefits Benefits (Members Only) Death of Member $20,000 Loss of Life $20,000 Death of Spouse $1,500 Both hands or both feet $20,000 Sight of both eyes $20,000 DEATH OF DEPENDENT CHILD IN ACCORDANCE WITH AGE AS FOLLOWS: One hand and one foot $20,000 Over 14 days, but less than six months $300 One hand and sight of one eye $20,000 Six months, but less than two years $600 One foot and sight of one eye $20,000 Two years, but less than three years $1,200 One hand or one foot $10,000 Greater than three years $1,500 Sight of one eye $10,000 Disability Weekly Benefits $250 per week $50 per workday If you work for a New Jersey Employer covered under the New Jersey Temporary Disabilities Law, you will receive 1/2 (half) of the disability payment indicated above. Disability benefits will commence on the first work day if the disability results from an accident or hospitalization. Benefits will commence on the sixth work day if the disability is a result of a sickness or pregnancy. Weekly disability benefits are payable for a maximum of 26 weeks. The Fund will pay you weekly disability benefits upon the initial denial of a worker’s compensation claim if you execute a Fund approved subrogation agreement. 4 TEAMSTERS HEALTH AND WELFARE FUND OF PHILADELPHIA AND VICINITY Enhanced Member Benefits Enhanced member benefi ts are carved-out health benefi ts specifi cally designed for the Fund and are included in the Fund’s medical plan.