Health Care Benefits Silver/Gold/Platinum

Silver/Gold/Platinum Benefits Overview

• Benefits Overview
• Eligibility
• Step Up Benefits

 

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) and Life Balance Health Risk Questionnaire (HRQ) plan benefits provided through the 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).
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.
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 dependent child(ren) become eligible on the first day of the seventh month of employment. The employee’s spouse or registered domestic partner becomes eligible after the employee completes his/her 24th month of employment   Clerk’s Helpers who work the Required Hours each month:   Employees become eligible on first day of the 19th month of employment; dependents are not eligible for coverage.   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 dependent child(ren) become eligible on the first day of the seventh month of employment. The employee’s spouse or registered domestic partner becomes eligible after the employee completes his/her 24th month of employment   Utility Clerks who work the Required Hours each month:   Employees become eligible on first day of the 19th month of employment; dependents are not eligible for coverage.   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, 2007 On or after July 22, 2007	43 – 66 months   43 – 78 months
Platinum	Between March 1, 2004 and July 21, 2007 On 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, 2007 On or after October 12, 2007	43 – 66 months   43 – 78 months
Platinum	Between March 1, 2004 and October 11, 2007 On or after October 12, 2007	67+ months   79+ months

 

 

Indemnity PPO Medical Plan — Silver/Gold/Platinum

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

 

Platinum	80% of PPO charges or 50% of the non-PPO usual, customary and reasonable (UCR) allowance
Silver/Gold	75% of PPO charges or 50% of the non-PPO usual, customary and reasonable (UCR) allowance

 

Plan B Employees

 

Silver/Gold/Platinum

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

 

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

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

 

 

HRA Funding

 

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

 

Plan A Employees

 

Platinum	$550 per member or $1,000 per family
Silver/Gold	$500 per member or $1,000 per family

 

Plan B Employees

 

Platinum	$525 per member or $925 per family
Silver/Gold	$500 per member or $1,000 per family

 

You will receive additional funding for your HRA if you complete a Life Balance Health Risk Questionnaire (HRQ), as follows:

 

Plan A Employees

Platinum	$200 if you complete the HRQ or $250 if you and your covered spouse/registered domestic partner complete the HRQ
Silver/Gold	$50 if you complete the HRQ or $100 if you and your covered spouse/registered domestic partner complete the HRQ

 

Plan B Employees

 

Platinum	$200 if you complete the HRQ or $250 if you and your covered spouse/registered domestic partner complete the HRQ
Silver/Gold	$50 if you complete the HRQ or $100 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, 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)—Silver/Gold/Platinum

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.2010hrq.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

 

 

Benefits Chart

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	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 Plan Claim Forms

You can download medical plan claim forms through Forms & Publications. The name of the specific forms and their purpose are included in this section of the site.

 

 

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 Platinum/Gold: $1,800 per person Silver: $1,000 per person     Plan B Employees Platinum/Gold: $1,250 per person Silver: $1,000 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

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 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.

 

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).

 

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. 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/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)

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 participants and administered through HMC/APS.

 

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.