Medical Benefits

The Plan pays the Reasonable and Customary charges incurred by you and your Eligible Dependents for Medically Necessary Covered Medical Expenses, in the amounts and subject to the conditions in the Schedule of Benefits. See your SPD for the Schedule of Benefits.

The Fund has partnered with Anthem Blue Cross/Blue Shield to provide medical benefits through a Preferred Provider Organization (PPO). The PPO benefits are for eligible Active Members, Pre-Medicare Retirees and their Eligible Dependents.

The PPO is made up of physicians, hospitals and other medical service providers who have agreed to charge discounted rates to the Fund. You may choose any provider you like, but Participating Providers or Network Providers will generally be less expensive for you and the Fund.

Pre-authorization is required for some services. Services that require pre-authorization are determined by Anthem and are subject to change from time to time. Please contact Anthem for the current list of services requiring pre-authorization. Also, please contact Anthem for a list of Participating Providers or Network Providers.

See your SPD for more detailed information about the Fund’s comprehensive medical benefits.

Transparency in Coverage Regulations

This link leads to the machine-readable files that are made available in response to the federal Transparency in Coverage Rule and includes negotiated rates with in-network providers for all covered items and services as well as historical payments to and billed charges from out-of-network providers. The machine-readable files are formatted to allow researchers, regulators, and application developers to access and analyze data more easily. A link to those machine-readable files can be found here:  https://www.anthem.com/machine-readable-file/search/ and the Fund’s EIN is 06-6078910.

Health Enhancement Program or HEP

One of the Fund’s primary goals is to encourage all Active and Pre-Medicare Retired Members and their Eligible Spouses, if applicable*, to adopt healthy lifestyles and to lead healthier lives. In order to encourage you to take control of your own health care, the Plan offers incentives to help you accomplish this goal. The Fund offers a number of preventive services, including annual physicals and blood tests, at no cost to you (provided you use an Anthem Network Provider).

* Since the Fund purchases coverage through Anthem under the Medicare Advantage PPO for its Medicare-Eligible Retirees and their Eligible Dependents, the Fund has no ability to control the terms of that program.

With the Health Enhancement Program (HEP), you (and your Spouse, if you are married) will be required to take certain steps while you have Fund coverage to avoid higher copays for covered health care. Here’s how HEP works.

You and your Spouse, if you are married, must complete three of the following four activities:

  • Choose a primary care physician (PCP). You can get a list of local Anthem PCPs online on Anthem's website or by calling Anthem. The Fund Office can also provide you with a list. (If you already have a PCP, you only need to complete two other activities.)
  • Have a routine physical exam with your PCP. If your PCP is a Network Provider, the exam will not cost you anything (no copay required).
  • Have the blood tests associated with your routine physical. If the tests are performed by a Network Provider, they will not cost you anything (no copay required).
  • If you smoke tobacco, enroll in a Fund-approved smoking cessation program. Contact the Fund Office for a list of approved programs.

If you (if you are not married), or you and your Spouse (if you are married), do not complete three of these requirements by the required due date, your copays will double. This means, for example, that you would pay $40 (instead of $20) for an office visit and $200 (instead of $100) for an emergency room visit. You will continue to pay double the amount for copays for at least six months, and until the July 1 or January 1 that follows your completion of the three requirements.

The Fund Office will send you a separate written notice regarding any applicable HEP due dates and requirements.

Physical Examination Benefit

The Plan will pay the Reasonable and Customary fees (including all x-ray or laboratory charges incurred as part of the routine physical examination) actually charged by a physician for a complete routine physical examination received by you and your Eligible Dependents each calendar year.

Pap Smear and Mammography Benefits

The Plan will pay the Reasonable and Customary fees for a Pap Smear once each calendar year, and for a routine Mammogram once for a covered woman between the ages of 35 and 39, and once each calendar year beginning in the year in which the covered woman reaches age 40. Of course, to be eligible for this benefit on a continuous basis from year to year, the woman must maintain her Fund eligibility.

Immunization Benefits

The Plan will pay the Reasonable and Customary charges for immunization benefits that are recommended by the Advisory Committee on Immunization Practices.

Disease Management Benefits

The Plan will pay the Reasonable and Customary fees for self-management training in connection with the treatment of a chronic disease, provided that the self-management training is Medically Necessary and is recommended in writing by your physician. The self-management training must be provided by a certified, registered or licensed health care professional who is trained in the care and management of your chronic disease. Chronic disease means a disease that is diagnosed by a physician, has no known cure, and is known to affect your long-term health.

Benefits payable for self-management training include:

  • initial training visits after you are initially diagnosed with a chronic disease that are Medically Necessary for the care and management of such chronic disease;
  • training and education that is Medically Necessary as a result of the diagnosis by a physician of a significant change in your symptoms or condition which requires modification of your program of self-management of the chronic disease; and
  • training and education that is Medically Necessary because of the development of new techniques and/or treatment for your chronic disease.

Prescription Drug Benefits

The Fund has partnered with Anthem to provide prescription drug benefits to you and your Eligible Dependents. The Plan covers the Reasonable and Customary charges for Medically Necessary prescription drugs for the care and treatment of an injury or illness, when prescribed by a physician and when filled at a Network pharmacy or through the mail-order program.

The maximum quantity of a prescription drug purchased at a pharmacy that will be covered is a 30-day supply or 100 tablets (whichever is less) through a retail Network pharmacy and 90 days for prescriptions filled through the mail-order program. Please contact Anthem for a list of Network pharmacies or for more information on how to enroll in the mail-order program.

Anthem determines the list of covered medications. The Plan does not cover over the counter drugs or drugs that are Experimental or Investigational (as defined by the Plan).

See your SPD for more detailed information about prescription drug benefits.