Silver/Gold/Platinum Benefits Overview

See Platinum Plan A Highlights here

See Platinum Plan B Highlights here

See Silver Gold Plans A & B Highlights here

 

 

 

Silver/Gold/Platinum employees are offered the following health care benefits through the Benefit Fund:

 

Medical Benefits Provided through the Indemnity PPO Medical Plan. Be sure to check out the Health Reimbursement Account (HRA) benefit provided through the Indemnity PPO Medical Plan. You can earn funding for your account through the My Health/My Choices Incentive Program.
Prescription Drug Coverage Provided through UFCW Unions and Food Employers Network Pharmacy or the OptumRx 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).
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 HealthWorks.
Vision Care Provided through the Benefit Fund’s Vision Care Program.

 

 

Eligibility

Employees are eligible for Silver/Gold/Platinum benefits as follows:

 

Plan A Employees hired on or after
March 1, 2004

Plan B Employees hired on or after
October 4, 2004

Employees (other than Clerk’s Helpers) who work the Required Hours each month:

 

  • Employees and their eligible child(ren) become eligible on the first day of the seventh month of employment, where a minimum of 20 hours has been worked in each of the first four months and the full hours requirement has been worked in the fifth month.  The employee’s spouse or registered domestic partner becomes eligible on the first of the following month following 60 days after the employee works 1200 hours. Until the spouse would otherwise become eligible for subsidized coverage after the employee works 24 months, the spouse must pay for his or her coverage at premiums equal to 150% of the Plan’s COBRA rate.

 

Clerk’s Helpers who work the Required Hours each month:

 

  • Employees and their eligible child(ren) become eligible on first day of the 19th month of employment.

 

If promoted, credit is given for the purpose of medical plan eligibility from your original date of hire

Employees (other than Utility Clerks) who work the Required Hours each month:

 

  • Employees and their eligible child(ren) become eligible on the first day of the seventh month of employment, where a minimum of 20 hours has been worked in each of the first four months and the full hours requirement has been worked in the fifth month. The employee’s spouse or registered domestic partner becomes eligible on the first of the following month following 60 days after the employee works 1200 hours. Until the spouse would otherwise become eligible for subsidized coverage after the employee works 24 months, the spouse must pay for his or her coverage at premiums equal to 150% of the Plan’s COBRA rate.

 

  Utility Clerks who work the Required Hours each   month:

 

  • Employees and their eligible child(ren) become eligible on first day of the 19th month of employment.

 

If promoted, credit is given for the purpose of medical plan eligibility from your original date of hire

 

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 Silver/Gold/Platinum benefit level.

 

If you do not return to the Industry in less that 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 Silver/Gold/Platinum benefit level provided that you return to work at the same Employer within 12 months.

 

Refer to the FAQs for information regarding dependent eligibility.

 

 

Step Up Benefits

Employees (other than Clerk’s Helpers or Utility Clerks) earn upgrades to their benefits after reaching certain service milestones. You can progress from Silver to Gold to Platinum benefits levels, as follows:

 

Plan A Employees (other than Clerk’s Helpers)

 

Benefit Level

Hire Date

Months of Employment Covered under
Silver, Gold or Platinum Benefits Level

Silver On or after March 1, 2004 6 – 42 months
Gold Between March 1, 2004 and
July 21, 2007On or after July 22, 2007
43 – 66 months

 

43 – 78 months

Platinum Between March 1, 2004 and
July 21, 2007On or after July 22, 2007
67+ months

 

79+ months

 

Plan B Employees (other than Utility Clerks)

 

Benefit Level

Hire Date

Months of Employment Covered under
Silver, Gold or Platinum Benefits Level

Silver On or after October 4, 2004 6 – 42 months
Gold Between October 4, 2004 and
October 11, 2007On or after October 12, 2007
43 – 66 months

 

43 – 78 months

Platinum Between October 4, 2004 and
October 11, 2007On or after October 12, 2007
67+ months

 

79+ months

 

 

Indemnity PPO Medical Plan — Silver/Gold/Platinum

 

Indemnity PPO Medical Plan contact information

 

Coverage/Eligibility questions:
714-220-2297, 562-408-2715 or 877-284-2320 (Fund Office)

 

 

Anthem Blue Cross Provider Finder:
855-686-5613

 

Medical Preauthorization:
800-274-7767

 

Website:
www.anthem.com/ca

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 when you complete Healthy Activities through the My Health/My Choices Incentive Program.
  • 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

 

Platinum 80% of PPO charges or 50% of the Plan’s Allowed Amounts as determined by the Fund for non-PPO charges.
Silver/Gold 75% of PPO charges or 50% of the Plan’s Allowed Amounts as determined by the Fund for non-PPO charges.

 

Plan B Employees

 

Silver/Gold/Platinum 75% of PPO charges or 50% of the Plan’s Allowed Amounts as determined by the Fund for non-PPO charges.

 

 

  • 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

 

Platinum PPO coverage: $1,500 per person/$3,000 per family
Non-PPO coverage: $10,000 per person/$20,000 per family
Silver/Gold PPO coverage: $2,500 per person/$5,000 per family
Non-PPO coverage: $10,000 per person/$20,000 per family

 

Plan B Employees

 

Platinum PPO coverage: $2,000 per person/$4,000 per family
Non-PPO coverage: $10,000 per person/$20,000 per family
Silver/Gold PPO coverage: $2,500 per person/$5,000 per family
Non-PPO coverage: $10,000 per person/$20,000 per family

 

  • The annual in-network calendar year deductible is $1,000 per person/$2,000 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)—Silver/Gold/Platinum

                My Health/My Choices Incentive Program Guide

Indemnity PPO Medical Plan Health Reimbursement Account Contact Information

Phone: 714-220-2297, 562-408-2715 or 877-284-2320 (Fund Office)

 

The Indemnity PPO Medical Plan includes an important feature to help Participants pay their share of eligible medical and prescription drug expenses: a Health Reimbursement Account (HRA).

Your HRA is funded through the My Health/My Choices Incentive Program. 

This section describes how the HRA works, including:

 

 

 

HRA Funding

 

 

You receive funding for the HRA through the My Health/My Choices Incentive Program.

 

The program provides HRA funding in two ways:

 

1.     An automatic Base HRA Contribution.

  

2.     The ability to earn additional HRA contributions by completing certain “Healthy Activities.”

 

The level of funding you can receive for your Base HRA Contribution and Earned HRA Contributions depends on:

 

Ø  Your Indemnity Medical PPO Plan coverage (Platinum, Gold or Silver, and Plan A or Plan B)

 

Ø  Your coverage category (Single, Employee + Child(ren), Family)

  

Ø  The Healthy Activities you choose to complete.

 

 

 

Base HRA Contribution

 

The Base HRA Contribution is added to your account annually on January 1. Depending on your plan and coverage level, you receive the following Base HRA Contribution for the year:

 

Automatic Base HRA Contribution – Platinum Plan

 

Single

Employee + Child(ren)

Family

Plan A

$175

$500

$275

Plan B

$150

$425

$250

 

 

 

Automatic Base HRA Contribution – Gold and Silver Plans

 

Single

Employee + Child(ren)

Family

Plan A or Plan B

$125

$475

$250

 

 Earned HRA Contributions and Healthy Activities

 

You can complete the program’s Healthy Activities between June 1 and May 31 of the following year to earn additional HRA contributions to your account in the year in which that May 31 falls. The My Health/My Choices Incentive Program guide explains the Healthy Activities you can choose from and the money you receive for completing them.

 

You can earn up to the following, depending on your plan and coverage level:

 

Platinum Plan

 

Platinum Plan

 

Example: Complete Healthy Activities from June 1, 2016 through May 31, 2017 and receive your  2017 Earned HRA Contributions

Earn $150 for each activity completed, up to the maximum allowed each year.

 

 

 

Platinum Plan

 

Maximum Annual Earned Funding – the most  you can earn for completing  Healthy Activities

Plan A

$575

$750

$975

Plan B

$575

$750

$925

Number of Activities Needed to Earn Maximum HRA Contributions

4

5

7

 

 

 

Platinum Plan

 

Your Maximum Total Annual HRA Funding Opportunity =  Base HRA Contribution + Earned HRA Contributions

Plan A

$750

$1,250

$1,250

Plan B

$725

$1,175

$1,175

 

 

 

Gold and Silver Plans

 

Gold and Silver Plans

 

Example: Complete Healthy Activities from June 1, 2016 through May 31, 2017 and receive your  2016 Earned HRA Contributions

Earn $125 for each activity completed, up to the maximum allowed each year.

 

 

 

Gold and Silver Plans

 

Maximum Annual Earned Funding – the most  you can earn for completing  Healthy Activities

Plan A or Plan B

$425

$625

$850

Number of Activities Needed to Earn Maximum HRA Contributions

4

5

7

 

 

 

Gold and Silver Plan

 

Your Maximum Annual Total HRA Funding Opportunity =  Base HRA Contribution + Earned HRA Contributions

Plan A and Plan B

$550

$1,100

$1,100

 

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, 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.

 

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

 

 

Benefits Charts and Summaries of Benefits and Coverage

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

 

Benefits Charts

 

Summaries of Benefits and Coverage

 

 

 

 

 

 

 

 

 

 

 

 

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 of the site.

 

 

Dental and Orthodontic Benefits

Dental Plan Contact Information

 

Phone: 714-220-2297, 562-408-2715 or 877-248-2320 (Fund Office)

 

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

Platinum/Gold: $1,800 per person
Silver: $1,000 per person

 

 

Plan B Employees

Platinum/Gold: $1,400 per person
Silver: $1,150 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

 

For services included on the Benefit Fund’s Schedule of Allowances, the Plan pays 100% after your required copayment, which varies by service.

 

You are responsible for the cost of services that are not included on the Benefit Fund’s Schedule of Allowances.

Indemnity Dental Prepaid Clinics
Orthodontia Plan A Employees

 

Platinum/Gold: Plan pays 75% of usual, customary and reasonable (UCR) charges, up to a lifetime maximum benefit of $1,800 per person.

 

Silver: Plan pays 70% of usual, customary and reasonable (UCR) charges, up to a lifetime maximum benefit of $1,000 per person.

Plan A Employees

 

Platinum/Gold: Plan pays 100% of negotiated rate, up to a lifetime maximum benefit of $1,800 per person.

 

Silver: Plan pays 100% of negotiated rate, up to a lifetime maximum benefit of $1,000 per person.

 

Plan B Employees

 

Platinum/Gold: Plan pays 75% of usual, customary and reasonable (UCR) charges, up to a lifetime maximum benefit of $1,500 per person.

 

 

Plan B Employees

 

Platinum/Gold: Plan pays 100% of negotiated rate, up to a lifetime maximum benefit of $1,500 per person.

 

Silver: Plan pays 70% of usual, customary and reasonable (UCR) charges, up to a lifetime maximum benefit of $1,000 per person.

 

Silver: Plan pays 100% of negotiated rate, up to a lifetime maximum benefit of $1,000 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 BenefitChart.

 

Prescription Drugs

Market Priced Drug (“MPD”) Program Overview
How the MPD Program Works?
MPD Program Example-Drugs to Treat High Cholesterol
MPD Exception Request Process
MPD Program Resources
Categories of Prescription Drugs Covered Under the MPD Program
MPD Program FAQs

Q1: Why does UFCW have a Market Priced Drug (MPD) program?
Q2: How does the MPD program work?
Q3: What’s a Preferred Drug?
Q4: How are Preferred Drugs selected?
Q5: How is a Preferred Drug different from a generic equivalent?
Q6: The drug I take is more expensive, so that means it works better, right?
Q7: When will my costs change?
Q8: How much will I have to pay for my prescription?
Q9: What if the Preferred Drug doesn’t work for me?
Q10: How can my doctor file a request for an exception?
Q11: If my request for an exception was approved in the past, do I have to file a new request each time I refill or renew my prescription?
Q12: What should I do if I think a Preferred Drug might work for me?
Q13: Where can I find out more?

 

Market Priced Drug (“MPD”) Program Overview

The Market Priced Drug (MPD) program for Indemnity PPO and UHC Medical Plan Participants MPD helps you and your doctor identify lower cost prescription drugs for treating some very common health conditions. Lower cost drugs are called “Preferred” Drugs under the MPD program. When you use a Preferred Drug to treat a condition included in the MPD program, you will pay your current copayment. However, if you use a drug that is not on the Preferred Drug list (known as a “Non-Preferred” Drug), your out-of-pocket cost will be much higher.
(Note: The MPD program accounts for the possibility that a Participant or enrolled dependent may not be able to use a Preferred alternative.)
The MPD Program covers multiple medical conditions, including common, chronic medical conditions like high cholesterol, depression and high blood pressure. See a complete list [jump link to list, below] of all medical conditions covered under the MPD program.
The MPD program is designed to improve the Fund’s ability to manage prescription costs and encourage Participants and enrolled dependents to make cost-effective prescription drug choices by:

  • ==> Encouraging informed, active choices about filling prescriptions and how much those prescriptions cost
  • ==> Educating Participants and enrolled dependents about lower-cost prescription options of equal quality and safety
  • ==> Helping Participants control future health care premium increases.

The MPD Program applies to retail and mail order drugs.

How the MPD Program Works?

If a Participant or enrolled dependent currently uses a Non-Preferred Drug that is in one of the categories of prescription drugs covered under the MPD program [link to Market Priced Drug Program Preferred Categories chart] (for example, “Statins” for high cholesterol) he/she has three choices:

 

Choice Result
1. Continue to use the current, Non-Preferred Drug prescription Participant/dependent pays the regular copayment plus the difference between the full market prices of the Non-Preferred Drug and the Preferred Drug
Your out-of-pocket costs can change as market prices for these drugs change
2. Have his/her doctor prescribe a Preferred Drug alternative Participant/dependent pays the regular copayment (or less, if the price of the drug is less than the copayment amount) under the prescription drug coverage
3. Ask his/her doctor for an Exception to stay on the Non-Preferred medication Participant’s/dependent’s doctor can file an MPD Exception Request form. If the exception is approved, Participant/dependent pays the regular copayment for his/her Non-Preferred Drug

 

MPD Program Example-Drugs to Treat High Cholesterol

Health Condition Drug Category Non-Preferred Drug Preferred Drugs
High Cholesterol Statins Crestor® atorvastatin

This is not a full list of cholesterol drugs included in the MPD program.
In the following example, when you fill a prescription for the Non-Preferred Drug Tricor®, your old copayment of $20 per month will increase to $138.86 per month. If you switch to the Preferred Drug fenofibric acid, your copay will be only $10 per month.

Estimated Costs* (per 30 days, 1 tablet per day)
OPTION 1: Continue using Tricor® 145mg OPTION 2: Switch to fenofibric acid 105mg
Tricor® drug price $143.16 fenofibric acid drug price $24.30
Fenofibric acid drug price – $24.30
Member copayment + $20.00 Member copayment $10.00
Total member cost per month $138.86 Total member cost per month $10.00
Estimated member yearly cost $1,666.32 Estimated member yearly cost $120.00

* Costs and savings in the chart above are estimates only. Actual costs and savings may vary.

MPD Exception Request Process

If you are taking prescription drugs, be sure to tell your doctor about the MPD program right away. Under the MPD program, a Participant’s or dependent’s physician may request exemptions from the program for their patients for recognized medical reasons, such as the following:
=> The Participant or dependent tried the Preferred Drug and it doesn’t work as well as the Non-Preferred Drug.
=> The Preferred Drug won’t work with other medications the Participant or dependent takes.
To request an exception, the Participant’s or dependent’s physician must request a Market Priced Drug Exception Request form from OptumRx @ 888-715-7573, complete and submit it to OptumRx via fax: 1-800-527-0531. OptumRx will perform a review and then notify you and your doctor of the decision.
Always contact OptumRx first for questions about the MPD program before calling the Fund Office or a Union Local office.

MPD Program Resources

+ By phone. OptumRx call center representatives are available Monday through Friday, 7 a.m. – 7 p.m. PT to answer questions about the MPD Program. Call toll-free 888-715-7573.
+ Online. Visit OptumRx’s online Medicine Cabinet: www.optumrx.com. The Medicine Cabinet will help Participants/dependents make informed choices about preferred alternatives to Non-Preferred Drugs. There they can:
=> Review drug costs and find lower-cost alternatives.
=> Check for drug interactions and explore detailed drug information specific to a medical condition.
=> Calculate annual costs and savings.
=> Print information about MPD alternatives to discuss with a physician.
Have your medical plan ID card handy-you’ll need your member ID from the card to register for the site.

Categories of Prescription Drugs Covered Under the Market Priced Drug Program

The MPD Program covers multiple medical conditions, including common, chronic medical conditions like high cholesterol, depression and high blood pressure. The list is included below. This changes from time-to-time, so be sure to contact OptumRx to verify a drug’s status.

Market Priced Drug Program Preferred Categories
Allergy/Asthma High Blood Pressure
Corticosteroids Beta Blockers
Second Generation Antihistamines ARB’s
Anti-Allergic Agents Calcium Channel Blockers
Selective Beta-2 Adrenergic Agonists ACE Inhibitors
Aldosterone Blockers
Selective Alpha-1 Adrenergic Blocking Agents
Muscle Relaxants Diabetes
Genitourinary Smooth Muscle Relaxants Thiazolidediones
Centrally & Direct Acting Skeletal Relaxants Biguanides
Antimuscarinics/Antispasmodic Sulfonylurea’s
Meglitinides
DPP-4 Inhibitors
Thyroid High Cholesterol
Thyroid Agents Fibrates
Parathyroid Statins
Bile Acid Sequesterants
Various Inflammatory Conditions Acid Reflux
Adrenals PPI’s
Histamine H-2 Antagonists
Various Conditions Edema
Bone Resorption  Inhibitors Potassium-Sparing Diuretics
5-Alpha Reductase Inhibitors Loop Diuretics
Phosphodiesterase Type II inhibitors Thiazide-Like Diuretics
Depression/Anxiety Pain/Inflammation
SSNRI’s Opiate Agonists
SSRI’s NSAIDS
Antidepressants (Misc)
Anxiolytics & Hypnotics
Tricyclics
Benzodiazpines
Serotonin Modulators
Heart Rhythm/Chest Pain Hormone Replacement
Class III Antiarrhythmics Estrogens
Class Ic Antiarrhythmics
Nitrates and Nitrites
Parkinson’s Disease
Monoamine Oxidase Inhibitors
Nonergot Derivative Dopamine Receptor Agonists
Dopamine Precursors

 

MPD Program Frequently Asked Questions

Q1: Why does UFCW have a Market Priced Drug (MPD) program?
A: The UFCW Benefit Fund is committed to helping you and your family be healthier, and that includes providing access to competitively priced and high-quality health care. Prescription drugs are often an expensive part of your health care, but there are often many different ones available to treat the same medical conditions. The Benefit Fund’s MPD program helps you understand more about those drug options. It may also help you save money and keep the cost of your benefit coverage more manageable for the Fund.

Q2: How does the MPD program work?
A: The MPD program includes certain types of drugs where many different equivalent options are available to treat the same health conditions. Lower cost options are designated as “Preferred” Drugs. Higher-priced ones are “Non-Preferred” Drugs. Paying for a Preferred Drug:
=> You pay the applicable brand or generic copayment for the Preferred Drug.
Paying for a Non-Preferred Drug:
=> You pay the applicable brand or generic copayment for the Non-Preferred Drug.
=> You ALSO pay the price difference between the Non-Preferred and Preferred Drug. In some cases, the amount you pay can be a lot more than your copayment.

Q3: What’s a Preferred Drug?
A: All drugs – Preferred and Non-Preferred – must meet Food and Drug Administration (FDA) standards for safety and effectiveness before they can be sold to consumers. Although they treat the same condition, Preferred and Non-Preferred Drugs may have different active ingredients and vary in price. As an example, atorvastatin costs less than Crestor®, but both drugs are FDA approved to safely and effectively treat high cholesterol. Atorvastatin is a Preferred Drug and the regular copayment applies. Crestor® is a Non-Preferred Drug, so you pay the regular copayment plus the difference between the market prices of Crestor® and atorvastatin.

Q4: How are Preferred Drugs selected?
A: The Benefit Fund relies upon medical experts at DestinationRx who review real-world medication usage to select Preferred Drugs for the MPD program. DestinationRx uses scientific evidence, such as medical literature and national guidelines, to determine which drugs should be Preferred Drugs.

Q5: How is a Preferred Drug different from a generic equivalent?
A: A generic equivalent contains the same active ingredient as a brand drug. So, a generic equivalent is the generic version of a brand drug. A Preferred Drug may not have the same active ingredient as the Non-Preferred Drug, but both treat the same health condition. Preferred Drugs can be either brands or generics.

Q6: The drug I take is more expensive, so that means it works better, right?
A: Not necessarily. A drug is often more expensive because it can only be made by the company that has a patent for the active ingredient. During the 17 to 20 years that a patent typically lasts, the patent holder can set a high price for its drug. Other companies can only start making a generic version after the brand-name drug’s patent expires. This usually lowers the price of the drug even though the brand and its generic equivalent both work the same way in the body.

Q7: When will my costs change?
A: If you currently use a Non-Preferred Drug, you will pay more for it when you fill the prescription. You may avoid the cost increase by taking action and talking with your doctor about Preferred Drugs as alternatives to Non-Preferred Drugs. The www.optumrx.com website from OptumRx includes market-priced drug information. You can visit the site to find out how much your current prescription drugs cost and research Preferred Drugs.

Q8: How much will I have to pay for my prescription?
A: It depends on what you choose to do. You have three options:
=> If you choose a Non-Preferred Drug: You pay the regular copayment. You ALSO pay the difference between the full market prices of the Non-Preferred Drug and the Preferred Drug. Your out-of-pocket costs can change as market prices for these drugs change.
=> If you choose a Preferred Drug: You pay the regular copayment (or less, if the price of the drug is less than the copayment amount) under your prescription drug coverage.
=> If your doctor determines the Preferred Drug isn’t right for you: Your doctor can file a MPD Exception Request Form. If the exception is approved, you’ll pay the regular copay for a brand or generic medication.

Q9: What if the Preferred Drug doesn’t work for me?
A: Your doctor can file a Market Priced Drug Exception form to have you continue using a Non-Preferred Drug. Typically, exceptions are requested for recognized medical reasons like the following:
=> You’ve tried the Preferred Drug and it doesn’t work as well as the Non-Preferred Drug.
=> The Preferred Drug won’t work with other medications you take.
If the request is approved, you pay the applicable generic or brand copayment for the Non-Preferred Drug.

Q10: How can my doctor file a request for an exception?
A: Call OptumRx at 1-888-715-7573 (TTY 711) between 7 a.m. and 7 p.m. Pacific Time and ask them to send you or your doctor an MPD Exception Request Form by mail. Please note: your doctor must complete and submit the form to OptumRx via fax: 1-800-527-0531. OptumRx will perform a review and then notify you and your doctor of the decision. If you disagree with the decision from OptumRx, you have the right to file an appeal with OptumRx.

Q11: If my request for an exception was approved in the past, do I have to file a new request each time I refill or renew my prescription? A: No, if your exception request is approved, it will remain in effect for up to three years. If you continue using the Non-Preferred Drug after one year, your prescription will need to be reviewed again.

Q12: What should I do if I think a Preferred Drug might work for me?
A: Go to www.optumrx.com to research your options. That way you can make informed decisions and have more information to give your doctor. Then talk to your doctor about whether a Preferred Drug may be an effective, cost-saving solution for you.

Q13: Where can I find out more?
A: OptumRx, the Benefit Fund’s pharmacy benefit manager, is your first resource. You can call them with MPD program questions at 1-888-715-7573 (TTY 711) between 7 a.m. and 7 p.m. Pacific Time. Or visit the OptumRx website at www.optumrx.com to look up a list of Preferred Drugs and check current market prices for the MPD program. UFCW participating pharmacies are trained to assist you with any questions you have about the new MPD program.
If you have questions about your drug therapy, talk to your doctor.

Prescription Drug Program Contact Information

 

Phone: 714-220-2297, 562-408-2715 or 877-284-2320 (Fund Office)
Participating Pharmacies

 

Mail Order Drug Contact Information (OptumRx)

 

Phone: 800-797-9791
Web: www.optumrx.com

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

 

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 OptumRx Mail Order Program or any UFCW Unions and Food Employers Participating 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.

 

OptumRx Mail Order Program

 

If you take a maintenance medication, the OptumRx 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 OptumRx customer service at 800-797-9791 for more information regarding the mail order program. You can also visit the OptumRx web site, www.optumrx.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).

 

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

 

Plan A Employees

 

Platinum After meeting the Indemnity PPO Medical Plan calendar year deductible, the Plan pays 80% of covered expenses.
Silver/Gold After meeting the Indemnity PPO Medical Plan calendar year deductible, the Plan pays 75% of covered expenses.

 

 

Plan B Employees

 

Silver/Gold/Platinum After meeting the Indemnity PPO Medical Plan 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. To find a provider, click here: Podiatry Provider Directory or contact PPOC at 800-367-7762, or to ask if your current podiatrist can be added to the network.

 

 

Chiropractic/Acupunture Benefits

Indemnity PPO Medical Plan

Benefit Payments Plan A Employees

 

Platinum: After you meet the Indemnity PPO Medical Plan calendar year deductible, the Plan pays 80% of the scheduled allowance, up to $1,000 per calendar year.

 

Silver/Gold: After you meet the Indemnity PPO Medical Plan calendar year deductible, the Plan pays 75% of the scheduled allowance, up to $800 per calendar year.

 

Plan B Employees

 

Platinum: 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.

 

Silver/Gold: After you meet the Indemnity PPO Medical Plan calendar year deductible, the Plan pays 75% of the scheduled allowance, up to $800 per calendar year.

Note: Only those services listed on the Schedule of Allowances are covered.

 

 

 

Employee Member Assistance Program (EMAP)

EMAP Contact Information

 

Phone: 800-461-9179

The Employee Member Assistance Program (EMAP) covers mental health care and the treatment of chemical dependency through HMC HealthWorks. EMAP benefits are provided to Indemnity PPO Medical Plan participants and administered through HMC.

 

Under EMAP, all care and treatment must be pre-certified by HMC 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 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.