Health Care FAQS

In most cases, when you visit a network provider, the provider will take care of the claims process—no claim forms are required. However, if you visit a non-network provider, or if your provider will not file a claim on your behalf, you may have to pay that provider up front and submit a claim to the Fund Office for reimbursement of the covered amount.

You can find claim forms here.

You may appeal a claim denial by submitting your appeal to the Fund Office. Review the claims and appeals procedures booklet for specific instructions. You can request a paper appeal form from the Fund Office or your Union Local.

Keep in mind that you have a limited period of time to file your appeal (generally 180 days from the denial of a medical claim).

Under the Indemnity PPO Medical Plan, a deductible is a specific amount that you must pay each calendar year before the plan begins to pay for most benefits. You satisfy the deductible as you pay for eligible health care expenses. The funds available in your HRA may be used to help pay your deductible. Once you satisfy the deductible, the plan’s coinsurance benefits begin.

Under the Indemnity PPO Medical Plan, coinsurance is the percentage of the allowed amount for medical services that you pay. For example, under the Silver Plan, the plan pays 75% of the allowed amount for an in-network doctor’s visit; you pay the remaining 25% as coinsurance.

An annual medical out-of-pocket expense maximum protects you from catastrophic health care expenses. After you meet this maximum, the plan will pay 100% of your covered medical expenses for the remainder of the calendar year. The annual medical out-of-pocket maximum amount offered under your medical plan depends on whether you cover yourself only or yourself and your family.

Indemnity PPO Medical Plan Participants take note: There is no out-of-pocket maximum on services you receive from providers outside the Anthem Blue Cross Preferred Provider network, unless you qualify for out-of-area benefits.

Precertification is required for all surgeries (except for emergency services and childbirth),

Indemnity PPO Medical Plan Participants should contact Anthem Blue Cross prior to surgery to ensure authorization (precertification) of the surgery and related procedures. While in-network PPO providers will process precertification’s for you, you are responsible for ensuring that you obtain precertification if you are using out-of-network or out-of-area providers. Failure to obtain precertification will result in a 20% benefit reduction for hospitalization related to surgery services provided by out-of-network and out-of-area providers.

If you need surgery, it is a good practice to discuss surgical procedures with your doctor to help ensure you understand the risks and costs of surgery. The plan will cover second opinions if you choose to obtain one.

You can expect to pay more out of your pocket if you use out-of-network providers.  Benefits are covered at lower levels when you use an out-of-network provider, and you are not protected through the annual medical out-of-pocket maximum for services received out-of-network.  In addition, the Fund’s allowed amount for services from an out-of-network provider may be less than what the provider charges, and you will be responsible for the difference.  For these reasons, the Fund encourages you to use a network provider whenever possible. See the question below for details on finding a network provider.

To find an Anthem Blue Cross provider, call 855-686-5613 or go to www.anthem.com/ca. When prompted to select a network, be sure to choose Blue Cross PPO (Prudent Buyer) – Large Group

When you visit a health care provider, you will need to present your medical plan ID card at the time you seek care. You should receive your ID card after you enroll. To request a replacement card, or if you do not receive your ID card in the mail, contact the Fund Office (if you are enrolled in the Indemnity PPO Medical Plan) or your HMO directly (if you are enrolled in the Kaiser HMO).

PPO Plan Participants should contact the Fund with claims questions. They can contact Anthem to locate a provider or request preauthorization, but all other participant calls should be directed to the Fund.

The best way to contact your medical plan carrier is through its toll free customer service number or web site. Contact information is as follows:

Anthem Blue Cross

800-227-3641

www.anthem.com/ca

Kaiser Permanente:

800-464-4000

www.kp.org

Kaiser Senior Advantage:

800-443-0815

www.kp.org/medicare

“HRA” stands for “Health Reimbursement Account.” The HRA is offered as a part of the Indemnity PPO Medical Plan for active Participants. Through the HRA, the Fund provides you with funding each year to pay for part of you and your family members’ eligible medical and other health care expenses, such as deductibles and coinsurance. Once you retire, if you are eligible for retiree health benefits, and you enroll in the Indemnity PPO Medical Plan for retirees, your HRA account balance (if any) will continue to be used until it is gone.
The Fund administers the HRA on your behalf. You may contact the Fund Office, or refer to the “Health Reimbursement Account” section for additional information.

Each year the Fund makes an automatic “Base” contribution to your HRA. Also, you can complete “Healthy Activities” to earn HRA funding and increase your HRA balance. If you’re enrolled in family coverage, your covered spouse or domestic partner can complete Healthy Activities, too, which will add even more to your account.

There are seven different types of activities; you choose the activities that make sense for you.

Refer to the “Health Reimbursement Account”  section for more details.

Your HRA will receive funding for Healthy Activities processed between June 1 and December 31, during the first week of the following January. The Fund will add contributions for activities completed between January 1 and May 31, as they are processed.

After the Fund credits a Healthy Activity to your HRA, your additional funds become available to pay your eligible expenses.

The balance on hand is available only to pay your share of claims that have not previously been processed. HRA funds cannot be used to pay for previously processed claims.

To use your HRA funds to pay prescription drug copays, you must “opt in” by returning an Rx-HRA Option Form to the Fund Office. You can get the form here or on request from the Fund Office.

The Fund sends quarterly statements that show the Healthy Activities processed, the contributions made to your HRA, and the amounts paid from your HRA for your eligible expenses.

If you don’t use your entire HRA balance during the calendar year, it rolls over for use in future years, as long as you stay enrolled in and eligible for the Indemnity PPO Medical Plan.

No, this is not allowed.

Caremark will be your plan’s pharmacy benefit manager (“PBM”). Their goal is to provide safe, easy and cost-effective ways for you to get the medication you need.

There will be no change to your current pharmacy network.

As in the past, choose a participating pharmacy and present your member ID card at the pharmacy counter.

To see a list of network pharmacies in your area, use the CVS Caremark app, visit the website on your member ID card and call Customer Care at 1-855-311-3162.

There may be some changes in prescription drugs covered. Some medication may not be covered unless Caremark prior-authorizes the prescription. Some medication may require a different copay, higher or lower than what you currently pay. Caremark will write to you if your medication will be affected. You will have 90 days to work with your doctor to determine the appropriate action, such as whether switching to another drug is an option or if your doctor should try to prior authorization on your behalf.

If you are taking a specialty medication, Caremark will work with you and your physician. Look out for the Caremark letter in the mail.

If you have any questions about the cost of coverage of your medication, please contact Caremark at 1-855-311-3162. Register for your own account on Caremark.com or the CVS Caremark app to get personalized information.

Beginning March 22, 2021 Caremark Customer Service is available 24/7 to answer any of your prescription benefit questions. Please contact a Caremark representative at 1-85-311-3162.

Register to create your personal account on Caremark.com to find cost information for your medications.

A formulary is a list of generic and brand-name prescription drugs selected by a panel of expert pharmacists and physicians. The panel of experts select drugs that are both clinically and cost effective.

• Drugs on the formulary are preferred drugs or “formulary generic” and “formulary brand-name.”
• Drugs not on the formulary are non-preferred drugs or “non-formulary.” Your copays are lower for formulary generic and formulary brand-name drugs.

Beginning March 22, 2021, to learn if your medication is covered, you can call Caremark at 1-855-311-3162.

Caremark will continue to look for ways to help make getting your medications more affordable. What you pay for your medication could change for several reasons, including:

• Medications could change tier on the formulary
• Medications may no longer be covered
• Some medications may be required to have prior authorizations (pre-approval for benefit coverage)
• Some medications may only be covered for a limited quantity per fill or within a specified time period

Existing approvals will carry forward to Caremark. Caremark will advise you in writing if your medication will need to go through the prior authorization process.

There will be some changes to the diabetic medications and supplies covered by Caremark. Members who are impacted by formulary changes will receive letters from Caremark. The Caremark letter will let you know the alternative medications or supplies that will be covered. You will have up to three months to transition to the medication on the new formulary drug list.

You an use the following resources to learn your coverage options.

Call the Customer Care at 1-855-311-3162
Use the CVS Caremark app
Visit Caremark.com

CVS Specialty is Caremark’s pharmacy dedicated to servicing members who take specialty medications. Our patient care coordinators and pharmacists are highly trained to understand your special therapy needs. You can continue to fill at your current pharmacy. However, if you like, you can utilize CVS Specialty to have your medication delivered to your home.

When CVS Specialty is the provider of your specialty medications, you’ll have the access to experienced pharmacists and nurses who can help you understand why your medication was prescribed, how it works, and how to administer and store it. They’re also available to help you manage any side effects and to answer any questions or concerns you may have.

We ship your medication wherever you need it — in safe, temperature-controlled and tested packaging. Shipping is at no cost to you.

CVS Specialty representatives will contact you and your doctor to discuss how CVS Specialty can help you manage your specialty medication prescription. Starting April, 1 2021, you can register online at CVSspecialty.com or by calling CVS Specialty at 1-800-237-2767 to enroll.