Active Members Back to Health & Welfare Active Members Most Frequently Asked Questions How Do I Find a PPO Provider in my area For California Residents: Contact www.bluecrossca.com or contact the Trust Office at (800) 527-4613, extension 2155. Effective December 1, 2002, a new and larger network of hospitals, physicians and other health care professionals replaced the CCN network we used to have. The name of the new contract provider network is the Blue Cross Prudent Buyer Plan. You will find that most of the hospitals and physicians in the current network also participate in the Prudent Buyer network. The list of participating providers is often updated; you should check with your provider before obtaining services to verify that the provider is in the network, or you may contact the Fund Office to obtain more information on the Prudent Buyer network. You may also access the Prudent Buyer network via the Blue Cross website at www.bluecrossca.com. The providers in the new network have agreed to better pricing than we currently have which means greater savings for you. In addition to greater savings, you will enjoy other advantages under the new Prudent Buyer network that will make the program easier for you. When you are seen by a Prudent Buyer provider, the provider will obtain any necessary information from you and will bill the Fund for you. Your out-of-pocket expenses will be greatly reduced when you use contract providers. Remember, your coinsurance is lower for services obtained from a contract provider. In addition, payments to contract providers are based on negotiated rates, and contracts do not permit these providers to charge more than their negotiated rate. The Prudent Buyer Plan will also replace First Health Network's Utilization Review services. Utilization Review is integrated with the Prudent Buyer program and automatic when you use a contract hospital. When a non-contract hospital is used, you should verify with the hospital that pre-certification is being obtained. Show your identification card (see below) even if you are using a non-contract hospital so the hospital can obtain the pre-certification. Your provider should use the Prudent Buyer toll free Utilization Review and Pre-certification telephone number: 1-800-274-7767. For residents outside of California: Simply select a provider from the First Health Network Directory, or go their website at www.firsthealth.com , or contact the Trust Office at (800) 527-4613, extension 2155. How Does The Ironworkers Fee For Service Plan Work? For Active members and their dependents enrolled in the California Ironworkers Fee-For-Service Plan, you have the freedom to go to the doctors and hospitals of your choice; however, there is a difference in your benefits when you use PPO providers also known as Preferred Provider Organization versus NON-PPO providers. When you choose a PPO or Blue Cross Prudent Buyer Provider provider, your calendar year deductible is $250 per person/ $750 per family as opposed to $500 per person/ $750 per family if you use a non-contracted provider. See the following "Active Fee-For-Service Benefit Summary" for more basic information. If you have additional questions, please contact the Claims Department at (800) 527-4613 Ext 2155 How does the Prescription Drug Program work? Prescription Solutions is the new pharmacy benefit administrator for the Welfare Plan effective January 1, 2003. We have taken this action to save on the Fund's prescription drug benefit costs. The new Prescription Solutions program will offer the Fund competitive discounts on drug prices and reduced administrative costs. This will allow us to continue providing you and your eligible dependents with the excellent prescription drug coverage you now have. You will probably not have to change pharmacies. Prescription Solutions contracts with all of the major pharmacy chains. There are also many independent pharmacies in the Prescription Solutions network. If you want to find out if a pharmacy is in the network, please call Prescription Solutions Customer Service at 1-800-797-9791, or visit their website at www.rxsolutions.com . The program is easy to use. All you have to do is show your new Prescription Solutions ID card when you fill a prescription at a participating pharmacy. The pharmacist will check your eligibility on line, fill your prescription, and charge you the applicable co-payment for each prescription or refill. Prescription Drug Benefit Changes · The following are benefit changes that you will need to be aware of effective January 1, 2003: · If you are using maintenance medication and you obtain your prescriptions at a retail pharmacy instead of the mail-order program, you will be charged two times the retail co-payment on your fourth and subsequent presentations of that prescription at a retail pharmacy. If you use the mail-order program, you can receive a 90-day supply for two times the retail co-payment. · Medications prescribed on or after January 1, 2003 that are not on the Prescription Solutions formulary will require prior authorization from Prescription Solutions. Exception: If you have already received a prescription for a specific medication prior to January 1, 2003, and it is not on the Prescription Solutions formulary, then no prior authorization will be required. Non-formulary brand name drugs are charged a $30 co-payment. How Do I Use The Mail Order Program? Request a Plan Prescription Mail Order Form and envelope from the Fund Office. Complete the section indicated and have your doctor complete the prescription on the form enclose your prescription (s) in the postage paid envelope. Use the postage paid, self-addressed envelope to mail the form to Prescription Solutions. Be sure to enclose your check for the applicable co-payment(s) amount made out to Prescription Solutions. Your prescription will be filled by a licensed pharmacist exactly as written by your doctor and will be delivered to your home either by UPS or by first class mail. Please allow 7 to 14 days for delivery. Should you have any questions on your medication, call Prescription Solutions toll-free at (800) 562-6223. How Do I Order Refills? You will receive a refill form with your initial medication. Simply mail the refill form and your check to Prescription Solutions. You may also order your refills over the telephone using the toll-free number provided above. If your doctor requires that a prescription be taken for more than six to twelve months (an initial three month supply plus one three refills), you must have a new Plan Prescription Form completed by you and your doctor must submit a new prescription to Prescription Solutions. What Drugs Are Covered? Drugs which, under state or federal laws, require the written or oral prescription of a licensed doctor or dentist. Insulin & supplies. What Is Not Covered? In addition to the General Exclusions and Limitations listed in the Health and Welfare Manual, the following items are not covered: Drugs obtained from a hospital or extended care facility. Drugs or medications not requiring a prescription. Appliances, devices, prosthetics, bandages, heat lamps, braces, splints, non-drug items. Injectable drugs (except insulin), blood and blood plasma, immunization agents. Multiple and non-therapeutic vitamins, cosmetics, dietary supplements, health and beauty aids. Drugs or medications in connection with mental and nervous disorders, including anxiety, stress and the like (i.e., Valium, Lithium). Drugs or medications not reasonably necessary for the care or treatment of bodily injuries or sicknesses. Drugs or medications in connection with occupational injuries or sicknesses; Drugs for which reimbursement is provided by any Federal Government, State, County, Municipality or any special Districts or Medicare; Smoking deterrents (e.g., Nicorette gum, patches); Retin-A (for anyone over 25 years of age); Rogaine Sol (Minoxidil); Drugs or medications not Medically Necessary. What Are The Benefits of the Dental Plan? The Plan will pay your dentist the amount of eligible dental expense incurred, but not to exceed the amount listed in the Schedule of Dental Allowances in Appendix A. The maximum amount payable for covered dental services rendered to each eligible person in any calendar year is $3,000. Preferred Dentists have agreed to charge specific fees which are lower than usual and customary fees, thereby reducing your out-of-pocket expense. Calendar year deductible is $100.00 per person. Is pre-determination necessary for any dental benefits? Please Note: Your Dental Plan requires that a pre-determination of benefits be obtained for charges of $200 or more. This means your dentist must complete a dental claim form indicating the treatment plan and submit it to the Fund Office along with the supporting x-rays before the services are performed. The Fund will then advise your dentist whether or not the services are covered under the Plan. Who is eligible for Vision care Benefits? These benefits are available to Active Employees and their eligible dependents who are not covered under the Kaiser Foundation Health Plans. If you are enrolled in the Kaiser Plans you will receive your vision care from that plan. What kind of vision care do I and/or my dependents receive under the plan? Click on this link to get more information on VSP Benefits Click on this link to get more benefits information on Spectera Benefits. For more information on Spectera Click on the following link Spectera Website Why a Member Assistance and Chemical Dependency Benefits Program (MAP) The Board of Trustees of the California Field Ironworkers Welfare Plan has established an integrated Member Assistance and Managed Chemical Dependency Benefits Program (MAP) to assist the Plan's eligible Active Employees in dealing with difficult situations that cause stress and can result in challenges to you health and well being. The MAP provides the Plan's Eligible Active Employees with professional evaluation, consultation, referral, and treatment services for personal and chemical dependency (drug or alcohol) related problems. It is designed to make it as easy as possible for you to get help with your problems. The Plan has retained Managed Health Network, dba Health Management Center (HMC), a well-respected national provider of health care services, to provide and administer the MAP effective June 1, 2001. The MAP is based on a private professional relationship between you and a counselor. Advice given to anyone who uses the MAP is strictly CONFIDENTIAL. No information can be released without written permission, unless required by court order of subpoena. The Trustees cannot take responsibility for the results of the counseling received nor interfere in the professional relationship. We urge you to read this information carefully. THE BOARD OF TRUSTEES CALIFORNIA FIELD IRONWORKERS WELFARE PLAN WHO IS ELIGIBLE? The MAP covers the Plan's Eligible Active Employees, as defined in the eligibility provisions set forth in the Plan's Summary Plan Description (SPD). Dependents and Retirees are not covered under the MAP. HOW DOES THE MAP WORK? The integrated Member Assistance and Managed Chemical Dependency Benefits Program (MAP) has two basic components: 1. A Member Assistance Program that provides each Eligible Active Employee with up to a maximum of 3 MAP outpatient assessment sessions per calendar year for the assessment of personal and chemical dependency (drug or alcohol) related problems at no cost to the employee. It is designed to assist you in identifying and effectively dealing with these problems in their early stages. Many employees will receive the help they need in these sessions. However, if more specialized or extensive care of services are needed, the MAP will provide an employee with the following assistance: · Employees experiencing personal problems such as legal, financial, elder care, childcare, etc. will be referred to an appropriate Community Service Program that can provide the needed care of services. · Employees experiencing Mental Health problems will be referred to their Medical Plan for the required care or services. In cases in which an Employee's Medical Plan does not provide the required care of services, the Employee will be referred to an appropriate Community Service Program that can provide the needed care of services. · Employees experiencing Chemical Dependency (drug or alcohol) related problems that require more specialized or extensive care beyond that provided by the MAP will be referred to the MAP's Comprehensive Managed Chemical Dependency Benefits Program described under 2. below for the needed care of services. 2. A Managed Chemical Dependency Benefits Program that provides you with a full continuum of geographically convenient, medically necessary and clinically appropriate chemical dependency care and services, including Detoxification, Acute and Rehabilitation Hospital Treatment, Residential Treatment, Partial Treatment, Day/Night Treatment and structured intensive Outpatient Treatment Programs, for chemical dependency problems that cannot be effectively resolved or treated under the MAP. There are three (3) different ways for you to get involved with the MAP: 1. An employee may call MAP's nation-wide toll free Hotline directly at 1-800-977-7962 twenty-four hours a day, seven days a week. A specially trained MAP staff member will always be there to take you call. 2. Your employer and/or business agent may suggest or direct you to contact MAP and may offer assistance in arranging an appointment. 3. Employees who fail an alcohol or drug test may be directed to contact the MAP for an appropriate chemical dependency assessment and referral. During the initial call, a MAP counselor will discuss the nature of your problem with you and outline a plan of action for you to consider. This plan may include a referral to a clinical specialist or facility in your area for a MAP assessment or to appropriate Community Service Programs for personal problems such as legal, financial, elder care, childcare, etc. Whenever a chemical dependency referral is necessary, the MAP counselor stays personally involved and monitors the individual's progress and care. You MUST call the MAP to access your benefits under this Program. No benefits are payable under the MAP for care or services that are received on or after June 1, 2001 that have not been both authorized by HMC and provided by an HMC contracted Network Provider or Facility. HOW DO I KNOW I'LL GET QUALITY HELP? The MAP is managed by Health Management Center (HMC). HMC is a national provider of health services specializing in administering program like ours. HMC's MAP staff consists of licensed or certified health professional, counselors, psychologist, social workers, and psychiatrist. HMC has also selected an exclusive contracted panel of chemical dependency providers and facilities located throughout your area, ready to offer a full continuum of care. These health care providers and facilities were chosen based on their demonstrated ability to provide you with clinically appropriate care that meets your specific medical needs. IMPORTANT BENEFITS INFORMATION Member Assistance Program: The MAP provides each of the Plan's eligible active employees with up to a maximum of 3 HMC authorized outpatient assessment sessions with an HMC contracted Network Provider per calendar year for the assessment of personal and chemical dependency (drug and alcohol) related problems at no cost to the employee. Chemical Dependency Benefits: HMC authorized MAP Chemical Dependency Inpatient/Alternate Care and Outpatient Treatment that is provided by an HMC contracted Network Facility or Provider is reimbursed in accordance with the schedule of Chemical Dependency Benefits set forth in the MAP's "Combined Evidence of Coverage and Disclosure". All Inpatient/Alternate Care Treatment at a hospital or facility must be pre-authorized prior to admission. Emergency admissions require authorization within 48 hours of the admission. No Benefits are payable under the MAP for care or treatment that has not been both pre-authorized by HMC and provided by an HMC contracted Network Facility or Provider. HOW IS PRIVACY PROTECTED? None of your personal or clinical information will be disclosed to anyone without your written permission except by a court order or a subpoena. If you are referred by your employer or business agent, you may request that the MAP counselor supply general information that will help your employer or business agent understand what they can do to be of help. REMEMBER ACT EARLY. Don't wait. Problems rarely go away by themselves. Self-referral is encouraged and the earlier the better. The success rate is directly affected by how soon you get help. SIZE. Don't think your problem has to be large or complex. Contacting the MAP for an evaluation is wise. It could make a very big difference in you health and well being. RISK. Your job is not jeopardized in any way by using the MAP. In fact, it can only be enhanced. CONVENIENCE. Your appointments are scheduled to meet your needs. Appointments can be made after work or before work and on Saturdays. GUIDANCE. The Map professional will help you map out a course of action. PRIVACY. Confidentiality is absolutely assured, unless otherwise compelled by law (court orders) or released in writing by you. FOR MORE INFORMATION OR TO MAKE AN APPOINTMENT CALL THE MAP OFFICE: TOLL FREE: 1-800-977-7962 The MAP is a 24 hour, 7 day a week service Other Important Information This information generally outlines the type of help that may be potentially available to you under the Plan's Member Assistance and Managed Chemical Dependency Benefits Program (MAP). You must refer to the Plan's "Summary Plan Description (SPD)" for specific information regarding the MAP's eligibility rules and the MAP's "Combined Evidence Of Coverage And Disclosure" for specific information regarding the MAP's benefits, services, definitions, limitations, exclusions, etc. In case of conflict between the provisions of this information and the Plan's SPD or "Combined Evidence Of Coverage And Disclosure," the applicable provisions of the Plan's SPD and the MAP's "Combined Evidence Of Coverage And Disclosure" will govern.