Platinum Plus Benefits Overview

 

Platinum Plus eligible Participants are offered the following health care benefits through the Benefit Fund:

 

Medical Benefits	Choose coverage under the Indemnity PPO Medical Plan, Kaiser HMO or UHC SignatureValue Flex HMO. Be sure to check out the Health Reimbursement Account (HRA) and Health Risk Questionnaire (HRQ) plan benefits provided through the Indemnity PPO Medical Plan.
Prescription Drug Coverage	Provided through UFCW Unions and Food Employers Network Pharmacy or the Prescription Solutions Mail Order Pharmacy.
Dental/Orthodontic Benefits	Provided through the Indemnity Dental Plan or the Prepaid Dental Plan.
Podiatry Services	Provided through the Podiatry Plan of California (PPOC) for Indemnity PPO Medical Plan participants, or through the Kaiser or UHC Flex HMO for HMO participants.
Chiropractic/Acupuncture	Covered in accordance with the Plan’s Schedule of Allowances.
Employee Member Assistance Program (EMAP)	Covers mental health care and treatment of chemical dependency through HMC/APS. (EMAP benefits are provided to Indemnity PPO Medical and UHC participants only; mental health and chemical dependency benefits for Kaiser HMO participants are provided through the Kaiser HMO.)
Vision Care	Provided through the Benefit Fund’s Vision Care Program.

 

 

Eligibility

Participants are eligible for Platinum Plus benefits as follows:

 

• Plan A employees hired prior to March 1, 2004, who meet the Platinum Plus “continuing eligibility” requirements

 

• Plan B employees hired prior to October 4, 2004, who meet the Platinum Plus “continuing eligibility” requirements
   

“Continuing eligibility” is earned on a “skip-month” basis. You are eligible for benefits during the second month following the month in which you earn the Required Hours. Your eligibility ceases in the event you fail to earn the Required Hours, if you are terminated, or if you are laid off. If you return to the Industry less than 120 days following termination or lay-off, you will:

 

• Reestablish eligibility on a “skip-month” basis, and
• Retain your Platinum Plus status.

 

If you do not return to the Iindustry in less than 120 days following termination, you will be considered a New Hire and will be subject to all new hire eligibility provisions. However, if you respond to a recall from a lay-off, you will maintain your Platinum Plus status provided that you return to work at the same Employer within 12 months.

 

Refer to the FAQs for information regarding dependent eligibility.

 

 

Medical Benefits – Platinum Plus

 

A summary of the benefits offered under the Platinum Plus plan is included in the table below. Refer to your Plan’s Benefits Chart for more details.

 

Plan Choice	Choose one of three medical plans—the Indemnity PPO Medical Plan (With Health Reimbursement Account (HRA)), the Kaiser Permanente HMO, or the UHC HMO. You must live in an HMO service area to elect HMO coverage.   You are required to pay premiums for coverage for yourself and your dependents.
	Indemnity PPO Medical Plan	HMOs
In-network Calendar Year Deductible	$1,000 per person / $2,000 per family Your deductible is offset by the Fund’s contribution to your Health Reimbursement Account (HRA) and an additional incentive if you participate in the Life Balance Health Risk Questionnaire (HRQ).	None
Annual Maximum	$2,000,000	None
In-network Annual Out-of-Pocket Maximum	Plan A employees: $1,500 per person / $3,000 per family Plan B employees: $2,000 per person / $4,000 per family	Refer to HMO Evidence of Coverage
Coinsurance or Copayment	Plan A employees: After you meet your deductible, the Plan pays coinsurance of 80% of PPO charges or 50% of the non-PPO usual, customary and reasonable (UCR) allowance.   Plan B employees: After you meet your deductible, the Plan pays coinsurance of 75% of PPO charges or 50% of the non-PPO usual, customary and reasonable (UCR) allowance.	$25 copayment for office visits; $100 copayment for hospital care; refer to HMO Evidence of Coverage for copayments required for other services
Find a Doctor	You can choose any licensed health care provider. If you choose a PPO provider, you will have the lowest possible out-of-pocket expense.	You need to use an HMO provider when you seek care. Generally, care from non-HMO providers is not covered except for emergency care.

 

 

Indemnity PPO Medical Plan – Platinum Plus

 

The Indemnity PPO Medical Plan is a preferred provider organization (PPO) plan that combines a Health Reimbursement Account (HRA) with comprehensive medical coverage. In addition to paying benefits when you and your family need medical care, this plan is designed to help prevent illness and promote wellness.

 

The Indemnity PPO Medical Plan gives you:

 

• 100% coverage for preventive care services specified in the Plan’s Preventive Care Guidelines when you use PPO providers. This means the Plan pays the full cost without dipping into your HRA balance.
   
• Annual HRA funding, which is used to pay for eligible out-of-pocket expenses, including your prescription drug copayments, calendar-year deductible and coinsurance.
   
• Extra HRA funding if you complete a confidential Life Balance Health Risk Questionnaire (HRQ).
   
• The freedom to choose the health care providers you want. If you choose a PPO doctor, hospital or other health care provider, you will have the lowest possible out-of-pocket expense. The Plan does not require you to have your care coordinated through a primary care physician. You do not need a referral to see a specialist.
   
• Comprehensive medical coverage that pays a percentage of covered charges after you meet your calendar year deductible, as follows:

   

  Plan A Employees	80% of PPO charges or 50% of the non-PPO usual, customary and reasonable (UCR) allowance
  Plan B Employees	75% of PPO charges or 50% of the non-PPO usual, customary and reasonable (UCR) allowance

 

• An out-of-pocket maximum expense limit that protects you from catastrophic health care expenses. After you meet your deductible and annual out-of-pocket maximum, the Plan will pay 100% of your covered medical expenses for the remainder of the calendar year. The out-of-pocket maximum varies depending on single, family, PPO and non-PPO coverage levels, as follows:

   

  Plan A Employees	PPO coverage: $1,500 per person / $3,000 per family Non-PPO coverage: $10,000 per person / $20,000 per family
  Plan B Employees	PPO coverage: $2,000 per person / $4,000 per family Non-PPO coverage: $10,000 per person / $20,000 per family

 

• The lifetime maximum benefit provided under the Plan is $2,000,000 per person.

 

Refer to your Plan’s Benefits Chart for more detailed information regarding the benefits covered under the Plan.

 

 

Health Reimbursement Account (HRA) – Platinum Plus

 

The Indemnity PPO Medical Plan includes a Health Reimbursement Account, through which the Fund pays Participant’s eligible expenses, including the Plan’s deductible, coinsurance and prescription drug copayments.

 

• HRA Funding
• Using Your HRA Funds
• Ineligible HRA Expenses

 

 

Health Reimbursement Account (HRA) Funding

 

The Benefit Fund provides annual funding for your HRA, as follows:

 

Plan A Employees	$550 per member or $1,000 per family
Plan B Employees	$525 per member or $925 per family

 

You will receive additional funding for your HRA if you complete a Life Balance Health Risk Questionnaire (HRQ): $200 if you complete the HRQ or $250 if you and your covered spouse/registered domestic partner complete the HRQ.

 

You are not allowed to make deposits into the account. Also, you are not allowed to “cash out” your account if you stop participating in the Plan.

 

Using Your HRA Funds

 

When you go to the doctor or hospital, the Benefit Fund uses the money in your HRA to pay your portion (deductible and coinsurance) of your claims. When your HRA funding is used up, you are responsible for meeting the rest of the deductible, coinsurance and prescription drug copays out of your own pocket. After your deductible is met, the Indemnity PPO Medical Plan’s coverage kicks in to pay a percentage of your covered expenses.

 

If all of your HRA funds are not used in one year, the unused balance rolls over to the following year. This means the funds will be used for your future medical needs – as long as you remain enrolled in the Plan. In addition, once you retire, if you are eligible for Retiree Health and Welfare and enroll in the Indemnity PPO Medical Plan, your HRA account balance (if any) will continue to be used until it is gone.

 

Ineligible HRA Expenses

Your HRA can be used to pay many out-of-pocket medical expenses, but it cannot be used to pay employee, retiree, or COBRA premiums; non-PPO provider charges that exceed the usual, customary, and reasonable (UCR) allowance; and expenses that are excluded from the medical and prescription drug programs such as the cost of over-the-counter drugs, mental health treatment by a non-contract provider, dental care, orthodontic services, vision services and eyeglasses or contacts.

 

 

Life Balance Health Risk Questionnaire (HRQ)

 

To promote the good health of everyone enrolled in the Indemnity PPO Medical Plan, the Trustees encourage (and reward) Plan Participants for completing a confidential Life Balance Health Risk Questionnaire (HRQ).

 

The HRQ is administered through HMC Companies (HMC). You can access and complete the HRQ through http://www.2012hrq.com.

 

The HRQ is designed to help you identify and provide confidential feedback on health areas where you might be at risk (e.g., issues with heart disease, high blood pressure, or diabetes). The HRQ asks you questions about your personal and family health history, your lifestyle, and about health issues that are relevant to men and women individually.

 

The HRQ is strictly confidential, and only you will receive the results and related recommendations. Your Employer, the Fund Office, your Union, and your doctor will not be given or have access to any of the health information you provide through the HRQ. If you want to take action to address the findings of the HRQ, it’s up to you to contact your health care provider and share that information.

 

When you complete your HRQ, you will receive extra funding for your HRA.

 

 

Preventive Care Guidelines

 

The Indemnity PPO Medical Plan pays 100% of the allowable charges for many preventive care services, when you receive these services from PPO providers. These services are not subject to the Plan’s calendar year deductible – which means you pay no money out of your pocket or your HRA for this care.

 

The following chart provides a brief overview of some of the preventive services that the Plan covers at 100% with no deductible. Refer to the Plan’s Preventive Care Guidelines for more detailed coverage information.

 

 

Overview of Preventive Care Guidelines
Covered Service	When Covered
Childhood and adult immunizations Well baby care	Age-appropriate per the Plan’s Preventive Care Guidelines
Routine physical exam (adult)	Annually
PAP smear and pelvic exam (female)	Annually
Sigmoidoscopy or colonoscopy screening for colorectal cancer	For average risk individuals, every five years starting at age 50
Mammogram	For average risk women, every one to two years starting at age 40
Prostate specific antigen (PSA) test (male)	For average risk men, annually starting at age 50

 

 

HMO Plans—Platinum Plus

 

In addition to the Indemnity PPO Medical Plan, two HMO medical plans are available to Platinum Plus Participants who live in the HMO’s service areas:

 

• The Kaiser Permanente HMO, or
• The UHC Flex HMO

 

This section provides general information regarding the HMO plans. Refer to your Plan’s Benefits Chart as well as to the separate brochures and the Evidence of Coverage provided by the HMO for more information.

 

• What is an HMO?
• HMO Plan Benefits
• Ancillary Benefits for HMO Participants
• HMO Mental Health/Chemical Dependency Benefits

 

 

What is an HMO?

 

An HMO is a medical plan with a network of providers who have agreed to provide their services at a contracted rate. To receive benefits, you must see a provider who is affiliated with your HMO’s network. Except in the case of eligible emergency care, services received from a non-HMO provider are not covered.

 

 

HMO Plan Benefits

 

If you are enrolled in an HMO, most covered services are paid in full after you pay the required copayment. Covered services and required copayments are explained in each HMO’s Evidence of Coverage. In general, HMO covered services include:

 

• Doctor office visits
• Surgery
• Hospital Care
• Family planning
• Physical exams
• Immunizations
• PSA testing
• Speech therapy
• Hearing aids
• Durable medical equipment and medical supplies

 

Refer to your Plan’s Benefits Chart for a comparison of key features of the Kaiser and UHC HMO plans.

 

 

Ancillary Benefits for HMO Participants

 

Some Indemnity PPO Medical Plan benefits are available as ancillary benefits to HMO participants. These benefits include the Benefit Fund’s Prescription Drug Program, acupuncture, chiropractic, Vision Care Program, and injectable drug benefits. Refer to your Plan’s Benefits Chart for details.

 

 

HMO Mental Health/Chemical Dependency Benefits

 

UHC Flex HMO
If you are enrolled in the UHC Flex HMO and you or a family member needs mental health or chemical dependency treatment, you must call HMC/APS at 800-461-9179 to receive benefits. Lab work authorized by HMC/APS will be provided through the Indemnity PPO Medical Plan.

 

Benefits for AB88 diagnoses are provided through HMC/APS in compliance with California law. HMO copayments apply.

 

Kaiser Permanente HMO

Kaiser’s mental health/chemical dependency benefits are provided through Kaiser. Members are not eligible for EMAP benefits through HMC/APS.

 

 

Benefits Charts

 

Refer to your Plan’s Benefits Chart for more detailed information regarding the benefits covered under your Plan.

English version	Spanish Version
Plan A Employees   Plan A Silver/Gold Benefits Chart Plan A Platinum Benefits Chart Plan A Platinum Plus Benefits Chart   Plan B Employees   Plan B Silver/Gold Benefits Chart Plan B Platinum Benefits Chart Plan B Platinum Plus Benefits Chart Updates to Platinum Plus Plan B Dental Updates for Plan B	Plan A Employees   Plan A Silver/Gold Benefits Chart Plan A Platinum Benefits Chart Plan A Platinum Plus Benefits Chart   Plan B Employees   Plan B Silver/Gold Benefits Chart Plan B Platinum Benefits Chart Plan B Platinum Plus Benefits Chart

 

 

 

Medical, Dental, Orthodontic Pre-Authorization, Vision, and Hearing Aid Claim Forms

 

You can download each of these claim forms, found in the Forms & Publications section. 

 

 

Dental and Orthodontic Benefits

 

The Benefit Fund’s dental program offers dental and orthodontic coverage through the Indemnity Dental Plan or the Prepaid Dental Plan. The plans cover preventive, basic and major services and orthodontia.

 

You may enroll in the Indemnity Dental Plan or the Prepaid Dental Plan when you become eligible for benefits, and can change your plan election during the annual Open Enrollment period.

 

A summary of each Plan’s benefits is included in the table below. Refer to your Plan’s Benefits Chart for more detailed information.

 

	Indemnity Dental Plan	Prepaid Dental Plan
Dental Provider Choice	You may seek care from any licensed dental provider.	When you enroll in the Prepaid Dental Plan, you must select a Prepaid Dental Clinic, which provides your dental care. If you do not visit this clinic, you are responsible for the full cost of your care.   A list of Prepaid Dental Clinics is provided with your plan enrollment materials; contact the Fund Office for a copy.
Calendar Year Deductible	$50 per person/$150 per family   Deductible waived for preventive and diagnostic procedures.	None
Calendar Year Benefit Maximum	Plan A employees: $1,800 per person   Plan B employees: $1,250 per person	None
Plan Payments	Payments are based on the Benefit Fund’s Schedule of Allowances, and each procedure has an allowance. The Plan pays its percentage of your dentist’s fee, provided the fee is not higher than the allowance. If your dentist charges a higher fee, you are responsible for paying the difference between your dentist’s fees and what the Plan pays. To request a copy of the Schedule of Allowances, contact the Fund Office.   Preventive/Diagnostic Care: 100% of scheduled allowance   Basic Restorative Care: 80% of scheduled allowance   Major Restorative Care: 70% of scheduled allowance	The Plan pays 100% after your required copayments, which vary by service. You are responsible for the cost of services that are not included on the Benefit Fund’s Schedule of Allowances.
	Indemnity Dental Plan	Prepaid Dental Plan
Orthodontia	Plan A employees: Plan pays 75% of usual, customary and reasonable (UCR) charges, up to a lifetime maximum benefit of $1,800 per person.	Plan A employees: Plan pays 100% of negotiated rate, up to a lifetime maximum benefit of $1,800 per person.
	Plan B employees: Plan pays 75% of usual, customary and reasonable (UCR) charges, up to a lifetime maximum benefit of $1,500 per person.	Plan B employees: Plan pays 100% of negotiated rate, up to a lifetime maximum benefit of $1,500 per person.
	You are responsible for provider’s fee for service after Plan payment.	You may be responsible for additional costs, as outlined on your Plan’s Benefit Chart.

 

 

Prescription Drugs

 

The Benefit Fund offers a Prescription Drug Program as a part of the benefits package provided to employees. The program helps to cover the cost of medically necessary drugs prescribed by your doctor to treat illness or injury. Participants must use the Benefit Fund’s Prescription Drug Program—coverage is not provided through your medical plan.

 

• Prescription Drug Benefit Summary
• Participating Pharmacies
• Prescription Solutions Mail Order Program

 

Prescription Drug Benefit Summary

 

Copayments and coverage levels vary, based on your eligibility for Plan A and Plan B Silver, Gold, Platinum or Platinum Plus benefits. The amount of your copayment will also depend on whether your prescription is filled with a formulary generic, formulary brand name, or non-formulary drug. You will pay the lowest copayment when you use generic medications. You pay the applicable copayment at the time your prescription is filled.

 

Refer to your Plan’s Benefits Chart for details about the program’s prescription drug coverage levels.

 

Participating Pharmacies

 

For a 30-day supply of prescription medication, you may use any UFCW Unions and Food Employers Participating Network Pharmacy. For a 90-day supply, you may use the Prescription Solutions Mail Order Program or any Network Pharmacy that has joined the plan’s 90-day maintenance program. Check with your pharmacy to see if they participate in this program.

 

A list of participating pharmacies is available here or on request from the Fund Office.

 

Prescription Solutions Mail Order Program

 

If you take a maintenance medication, the Prescription Solutions Mail Order Program provides a convenient and cost-effective way to fill your prescription. Through the mail order prescription service, a 90-day supply of your prescription is mailed to your home for the cost of a 60-day retail pharmacy supply.

 

Call Prescription Solutions customer service at 800-797-9791 for more information regarding the mail order program. You can also visit the Prescription Solutions web site, www.prescriptionsolutions.com, to order and refill your prescriptions online.

 

 

Podiatry Benefits

Participants in the Indemnity PPO Medical Plan have access to podiatry services, including medical care of the foot, ankle and lower leg, through the Podiatry Plan of California (PPOC). Note: Participants in an HMO plan receive podiatric services through the HMO. Refer to the plan’s Evidence of Coverage for details about plan benefits.

 

Benefits for Plan A and Plan B employees participating in the Indemnity PPO Medical Plan (PPO) are covered as follows:

 

Plan A	After meeting the Indemnity PPO Medical Plan (PPO) calendar year deductible, the Plan pays 80% of covered expenses.
Plan B	After meeting the Indemnity PPO Medical Plan (PPO) calendar year deductible, the Plan pays 75% of covered expenses.

 

Services must be authorized by PPOC and rendered by a PPOC network provider. If you seek care through a non-PPOC provider, you will be responsible for the full cost of your services. Contact the Fund Office or PPOC at 800-367-7762 to find a network provider, or to ask if your current podiatrist can be added to the network.

 

 

Chiropractic/Acupuncture Benefits

The Benefit Fund offers chiropractic benefits through the Indemnity PPO Medical Plan. Chiropractic benefits are offered also to HMO Plan Participants as ancillary benefits. Benefit coverage levels are based on the following Schedule of Allowances:

 

	Indemnity PPO Medical Plan	HMO Plans
Benefit Payments	Plan A Employees: After you meet the Indemnity PPO Medical Plan (PPO) calendar year deductible, the Plan pays 80% of the scheduled allowance, up to $1,000 per calendar year.   Plan B Employees: After you meet the Indemnity PPO Medical Plan calendar year deductible, the Plan pays 75% of the scheduled allowance, up to $1,000 per calendar year.   Only those services listed on the Schedule of Allowances are covered.	Plan A Employees: After you pay a $25 office visit copayment, the Plan pays 100% of the scheduled allowance, or 80% of the scheduled allowance for x-rays, up to $1,000 per calendar year.   Plan B Employees: After you pay a $25 office visit copayment, the Plan pays 100% of the scheduled allowance, or 75% of the scheduled allowance for x-rays, up to $1,000 per calendar year.   Only those services listed on the Schedule of Allowances are covered.

 

 

Employee Member Assistance Program (EMAP)

The Employee Member Assistance Program (EMAP) covers mental health care and the treatment of chemical dependency through HMC/APS. EMAP benefits are provided to Indemnity PPO Medical Plan and UHC HMO participants and administered through HMC/APS. Mental health and chemical dependency benefits for Kaiser HMO participants are provided through the Kaiser HMO.

 

Under EMAP, all care and treatment must be pre-certified by HMC/APS and obtained from an EMAP provider. EMAP providers include therapists and counselors, such as psychiatrists, psychologists and marriage family counselors, acute care facilities and rehabilitation centers.

 

You can reach HMC/APS 24 hours a day, seven days a week at 800-461-9179. All contact with EMAP is confidential.

Refer to your Plan’s Benefits Chart for a summary of the benefits provided through EMAP.