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Downloadable Beneficiary Forms Are Available on Final, Based on the Divorce Decree

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Downloadable Beneficiary Forms Are Available on Final, Based on the Divorce Decree Central Pennsylvania Teamsters GUARDIAN Health and Welfare/Pension Guardian Newsletter ® Reading, Pennsylvania March 2010 What Benefits are Available for Immunizations and Injections under the Health and Welfare Fund? mmunization and injection dependent children are addressed in benefits are included as a Core a later section of this article. Benefit under all active and I Flu shot and pneumonia vaccine retired Central PA Teamsters Health benefits for adults & Welfare plans. Immunization and injection benefits for dependent If you use a network provider, children are paid differently than for the Fund provides full coverage for adults. The following is a description flu shots and pneumonia vaccines of how immunizations are covered. for adults. If you use a non-network Please contact the Health and Welfare provider, the Fund pays the UCR and Fund if you have questions. you will be responsible for any balance charged by the non-network provider. Immunization benefits for dependent children Other CDC recommended immunizations and injections for If you use a network provider, adults and non-CDC recommended the Fund provides full coverage for immunizations and injections for immunizations recommended by dependent children the Centers for Disease Control and Prevention (CDC) for eligible The following is a description dependent children and adolescents Usual, Reasonable and Customary of how other CDC recommended through age 23. If you use a non- (UCR) rate. Benefits for non-CDC immunizations for adults, as Network Provider, the Fund pays the recommended immunizations for (Continued on page 2) Are You Recently Married, Divorced or Widowed? lease notify both the Health and Welfare Fund and to change your beneficiary for Health and Welfare death your employer of any changes in your marital status benefits after marriage or divorce unless you wish to. P(married, divorced or widowed) so that the change However, you do need to complete a new beneficiary form can be reflected on their Health and Welfare billing for your Pension Benefits after your divorce is finalized. statement for proper reporting of dependent coverage. If you become widowed, please notify the Fund. The Please note: the Fund does not consider your ex-spouse Fund will request a copy of the death certificate. You will to be an eligible dependent under the Health and Welfare need to complete a new beneficiary form for your Pension Plan after the effective date of your divorce. Members are Benefits. You may also need to update your beneficiary required to reimburse the Fund for any claims paid on form for your Health and Welfare death benefits. behalf of an ex-spouse after the date a divorce becomes Downloadable beneficiary forms are available on final, based on the divorce decree. www.CentralPATeamsters.com (click on Pension or If you become divorced, please forward copies of Health and Welfare) or you can call the Pension or Health your divorce decree to both the Health and Welfare and Welfare Departments. There are separate beneficiary and Pension Departments. forms for Pension Benefits and for death benefits under Don’t forget to review your beneficiary designation the Health and Welfare Plan. following a change in your marital status. It is not necessary n What Benefits Are Available. What are the Current CDC Recommended (Continued from page 1) Childhood and Adolescent Immunizations? well as non-CDC recommended • Hepatitis B (HepB) immunizations for dependent • DTaP, DT (Diphtheria, tetanus, acellalur pertussis) children, are covered. • Td, Tdap (Tetanus, diphtheria, acellular pertussis) Active Plans • Polio (IPV) (Plans 13, 13Y, 14 and 16) • Human papilloma-virus (HPV) Network benefits for CDC • Varicella (Var) (Chickenpox) recommended immunizations • MMR (Measles, mumps, rubella) for adults and for non-CDC • Seasonal Influenza (TIV) (LAIV) recommended immunizations for • Rotavirus (RV) dependent children: If the network • Hib (Haemophilus, influenza type b) provider charges separately for a non- • Pneumococcal conjugate (PCV) specialist office visit, immunization • Pneumococcal polysaccharide (PPSV) or injection, the Plan will pay for the • Hepatitus A (HepA) office visit in accordance with the • Meningococcal conjugate (MCV4) Meningococcal contracted network rate, less a $15 polysaccharide (MPSV4) co-payment. If the office visit payment made by the Plan is less than $25, the For information on the vaccine schedules and contraindications Plan will pay the difference up to the and precautions, visit the CDC website, www.cdc.gov. $25 benefit toward the immunization or injection service. If the network Retired Plans toward the immunization or injection provider does not charge for an office (Plan R-2, R-4, R-5 and R-7) services. visit, the Plan will pay up to $25 toward the immunization or injection services. Network benefits for CDC Non-network benefits for CDC Non-network benefits for CDC recommended immunizations for recommended immunizations for recommended immunizations for adults as well as for non-CDC adults as well as for non-CDC adults as well as for non-CDC recommended immunizations for recommended immunizations for recommended immunizations for dependent children: If the network dependent children: If the non- dependent children: If the non- provider charges separately for an network provider charges separately network provider charges separately office visit, immunization or injection, for an office visit, immunization or for an office visit, immunization or the Plan will pay for the office visit to injection, the Plan will pay benefits for injection, the Plan will pay benefits a non-specialist in accordance with the service with a non-specialist as an for the office visit. If the office the contracted network rate, less a office visit to the non-network provider. visit payment to a non-specialist is $15 co-payment. If the Plan’s office If the Plan’s office visit payment is less than $25, the Plan will pay the visit payment is less than $15, the less than $15, the Plan will pay the difference up to the $25 benefit toward Plan will pay the difference up to the difference up to the $15 benefit toward the immunization. If the non-network $15 benefit toward the immunization the immunization. If the non-network provider does not charge for an office or injection service. If the network provider does not charge for an office visit, the Plan pays up to $25 toward provider does not charge for an office visit, the Plan pays up to $15 toward the the immunization or injection. visit, the Plan will pay up to $15 immunization or injection. n Visit Our Website Delta Dental Update Members and their families, as well as contributing employers, can Effective immediately, Delta Dental has a new access the Fund website, www.CentralPATeamsters.com, for benefits claims mailing address: information, announcements, reports and notices, investment reports, Delta Dental forms, wellness information and provider network links. P.O. Box 2105 Participants in the Retirement Income Plan (RIP) can view their Mechanicsburg, PA 17055-6999 account balances (updated monthly) by visiting the Pension Web The claims fax number remains the same: Portal page. You must register first before you can access your account 717-691-6653 information. Page 2 /March 2010 Health and Welfare / Pension Guardian Central Pennsylvania Teamsters Health and Welfare Fund Prescription Drug Benefits Prescription Plan Benefits Prescription Plan Benefits Prescription Plan Benefits Under Plans 13, R4, R5 and R7 Under Plans 14, 16 and R6 Under Plan 13Y If you are covered under Plan 13, R4 or R5 your If you are covered under Plan 14 or 16 your If you are covered under Plan 13Y your prescription information is listed below. prescription information is listed below. prescription information is listed below. Negative Formulary List* Plan 14, 16 and R6 Negative Formulary List* Aciphex Lamisil Sarafem Option Levels A, B & C Aciphex Lamisil Sarafem Advicor Lexapro Sonata** Negative Formulary List* Advicor Lexapro Sonata** Allegra Lipitor Sporanox Aciphex Lamisil Sarafem Allegra Lipitor Sporanox ** Altoprev Lunesta** Symbyax Advicor Lexapro Sonata Altoprev Lunesta** Symbyax Ambien** Luvox Tagamet Allegra Lipitor Sporanox Ambien** Luvox Tagamet ** Axid Mevacor Tamiflu Altoprev Lunesta Symbyax Axid Mevacor Tamiflu ** Bextra Nexium Trepadone Ambien Luvox Tagamet Bextra Nexium Trepadone Celebrex Paxil Trilipix Axid Mevacor Tamiflu Celebrex Paxil Trilipix Celexa Pepcid*** Valturna Bextra Nexium Trepadone Celexa Pepcid*** Valturna Clarinex Pexeva Vioxx Celebrex Paxil Trilipix Clarinex Pexeva Vioxx *** Crestor Pravachol Vytorin Celexa Pepcid Valturna Crestor Pravachol Vytorin Cymbalta Prevacid Xyzal Clarinex Pexeva Vioxx Cymbalta Prevacid Xyzal Daypro Prilosec**** Zantac*** Crestor Pravachol Vytorin Daypro Prilosec**** Zantac*** Diflucan Pristiq Zegerid Cymbalta Prevacid Xyzal Diflucan Pristiq Zegerid **** *** Edluar Protonix Zetia Daypro Prilosec Zantac Edluar Protonix Zetia Effexor Prozac Zipsor Diflucan Pristiq Zegerid Effexor Prozac Zipsor Fibricor Relenza Zocor Edluar Protonix Zetia Fibricor Relenza Zocor Kapidex Rozerem Zoloft Effexor Prozac Zipsor Kapidex Rozerem Zoloft Fibricor Relenza Zocor And All Injectables (excluding Insulin and Imitrex) And All Injectables (excluding Insulin and Imitrex) Kapidex Rozerem Zoloft *Please note that this listing is subject to *Please note that this listing is subject to And All Injectables (excluding Insulin and Imitrex) change. Participants will receive notifica- change. Participants will
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