Health

Your health benefits are divided into two parts: medical and hospital coverage. Your medical plan is administered by the Fund Office and covers routine exams, tests, and preventive care. The hospital plan is administered by Empire Blue Cross Blue Shield and covers inpatient and outpatient hospital charges.

Hospital

You’ll pay a maximum of $1,500 each year for out-of-pocket, in-network hospital expenses. After that, the Plan covers the full cost of all in-network hospital expenses. However, there’s no out-of-pocket maximum for out-of-network hospital expenses. That means finding a hospital in Empire Blue Cross Blue Shield’s network saves you a lot of money.

If you’re having a medical emergency, go to the closest hospital. The Plan will cover it.

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Medical

You and your family have access to comprehensive and convenient medical coverage.

The Health Fund has an agreement with MagnaCare. When you receive care from doctors and facilities that participate in the MagnaCare network, you don’t have to pay a deductible, and you’re only responsible for copays and coinsurance. You can use out-of-network providers, but you’ll pay more.

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Coverage for Common Expenses

What you pay for common expenses:

* Applies to your Hospital Plan maximum of $1,500

For a complete list of covered services and a summary of what the Plan pays, review the Health Fund Summary Plan Description.

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No Surprises Act

The No Surprises Act will take effect on January 1, 2022. This law protects you from balance billing if you get treated by an out-of-network provider from an in-network hospital or emergency room. Balance billing happens when an out-of-network provider charges you the difference between the total cost of your care and what your health plan agreed to pay.

Sometimes, in-network emergency rooms and hospitals employ out-of-network doctors. In these cases, you might receive care from an out-of-network provider, through no fault of your own. Also, you might not have time to choose between an in- or out-of-network provider in a medical emergency. The No Surprises Act is designed to ensure that you aren’t balance billed if you receive care under these circumstances. It protects you from paying extra when the circumstances are beyond your control.

You should still use network providers whenever possible. Visit your insurance carrier’s website to find a list of network providers near you:

• Empire Blue Cross Blue Shield (hospital)
• MagnaCare (medical)
• OptumRx (prescription drug)

If you believe that you’ve been wrongly billed, contact the Employee Benefits Security Administration (EBSA) at 866-444-3272 or through their website.

The above summary is not a complete description of your rights under the No Surprises Act. For more detailed information about the No Surprises Act, read this notice from your Health Fund.

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Coverage for OTC At-Home COVID-19 Tests

Starting January 15, 2022, group health plans are required to cover over-the-counter (OTC) at-home COVID-19 tests without participant cost-sharing, preauthorization, or medical management, even if no health care provider was involved in ordering the test.

As this requirement has just been announced, the Health Fund and our insurance carriers are in the process of determining how to administer the benefit. At this time, we have not determined whether health providers and/or pharmacies will be reimbursed directly, or whether participants will need to purchase the tests and submit claims for reimbursement. We are hopeful that OptumRx will provide a way to cover the tests through the prescription drug program so you can purchase them at no cost. However, we do not know for sure if that program will meet all the government requirements.

As soon as we know how the new OTC at-home test reimbursement will be administered, we will send out a letter with more information. In addition, we will post the information on the Fund Office’s newly launched website: www.iwusf.net.

In the meantime, if you purchase any OTC COVID-19 tests on or after January 15, 2022, please save your receipt and packaging (in the event you need the box or the information on it to receive reimbursement).

The links below have the most recent information about free tests available from the federal government.

• https://www.covidtests.gov
• www.usps.com/covidtest

Currently, Medicare does not pay for over-the-counter COVID-19 tests. Our covered participants who are on Medicare can pick up free at-home tests from community health centers and Medicare-certified health clinics, as well.

If you have any additional questions, please do not hesitate to contact the Fund Office at 212-684-1586.

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Prescription Drugs

Your prescription drug coverage, administered by OptumRx, offers you convenient and affordable access to the medications you need.

When you enroll in the medical plan, you’re also eligible for prescription drug coverage. OptumRx will send you an ID card. Present your ID card when you fill a prescription at a network pharmacy.

Coverage

Details

The amount you pay out of pocket for prescriptions depends on a few things. Here’s how you can limit your out-of-pocket costs:

• Fill your prescriptions at OptumRx network pharmacies
• Use the OptumRx mail-order pharmacy.
• Take generic versions of the drugs prescribed to you when possible.

As you can see in the chart above, OptumRx separates drugs into three categories: generic, formulary, and non-formulary. Generic drugs are lower-cost, chemically equivalent alternatives to more expensive brand-name drugs. Formulary drugs are non-generic drugs that OptumRx covers at discounted rates. Non-formulary drugs aren’t discounted and cost you the most out of pocket.

For all types of drugs, but especially for drugs you take regularly, it’s cost-effective for you to fill your prescriptions via the OptumRx mail-order pharmacy. Retail pharmacies like Walgreens and CVS only give you a 30-day supply of your prescription. With the OptumRx mail-order pharmacy, you can get a 90-day supply for the cost of two 30-day supplies.

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Dental

Dental health is an important part of your overall health. You become eligible for dental benefits through the Health Fund once you’ve maintained medical and hospital coverage for 24 consecutive months.

Highlights

The Health Fund has an agreement with Metrodent Premier and CPS Dental. When you receive care from dentists who participate in the Metrodent and CPS network, you pay less. You can receive care from out-of-network dentists, but you’ll pay more.

Most in-network dental services are 100% covered after you pay a copay. Preventive and diagnostic dental care are 100% covered without a copay. You can view a schedule of dental benefits for a complete list of maximum fees allowed for services under the plan.

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Optical

See clearly with optical benefits through the Health Fund. You become eligible for optical benefits once you’ve maintained medical and hospital coverage for 24 consecutive months.

Highlights

Optical coverage provides you with an allowance of $300 per year to spend on eye care: $25 for an optical exam and $275 for glasses or contact lenses.

The Health Fund has an agreement with four different optical care networks: Vision Screening, Davis Vision, General Vision Services, and Comprehensive Professional Systems (CPS). When you use eye care providers who participate in one of these networks, you pay less. You’re allowed to use any eye care provider, but you may pay more out of pocket if your provider doesn’t participate in one of the networks.

Coverage

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Member’s Assistance Program

If you or a family member is struggling with substance abuse, we’re here to help. The Member’s Assistance Program is a 100% confidential program with access to trained substance abuse counselors. You and your dependents are eligible to participate in the Member’s Assistance Program after you’ve maintained medical and hospital coverage for 36 consecutive months.

Call the Member’s Assistance Program coordinator, Jim Dufficy, at 212-679-1513 to get started.

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Hearing

The Health Fund helps you pay for hearing expenses up to a maximum of $1,800 per ear every three years.

Hearing expenses include the cost of hearing aids, hearing analysis, and tests and exams performed by a physician or an otologist. The Health Fund has an agreement with HearUSA to provide you with discounted hearing aids. You can visit any provider, but the cost of your hearing aids may be covered in full if you choose a provider who participates in the HearUSA discount program. You’ll be required to pay HearUSA directly and submit a claim to the Fund Office for reimbursement.

Contact HearUSA at 877-664-9353, or visit their website for a list of HearUSA participating providers.

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Life and AD&D Insurance

You’re eligible for life and accidental death and dismemberment (AD&D) coverage after you work at least 1,000 hours in covered employment in a 12-month period. This coverage helps to give your family financial security in the event you’re in a serious accident or you die.

Coverage

Life insurance coverage pays a benefit to your beneficiary in the event of your death. The amount of the benefit is $50,000 if you’re an active employee at the time of your death and $4,000 if you’re a retiree. You may also request an accelerated death benefit if you’re diagnosed with a terminal illness.

AD&D coverage pays a benefit to you or to your beneficiary in the event of your death, when you’re in an accident and lose a limb, sight, speech, hearing, or become paralyzed. The amount of the benefit depends on the type of injury you sustained.

See your Summary Plan Description for more details.

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