teamsters local 1932 health & welfare trust enrollment ... · initial here section 4: elect...

Teamsters Local 1932 Health & Welfare Trust Enrollment Changes – Qualifying Life Event(s)

Dear Member: Visit the Trust website at https://teamsters1932.zenith-american.com to complete your enrollment updates/changes online and for access to additional plan information. For your convenience, attached are the following documents to assist you with enrollment changes due to qualifying life events: Premium Deduction Election Form Enrollment Form Online Enrollment Instructions Plan Comparison of Benefits Cost Comparison

If you prefer to complete the enclosed enrollment form, please choose from the options below to submit your completed enrollment form:

• Secure Upload: Upload your Enrollment Form and supporting documentation on the website at https://teamsters1932.zenith-american.com

• E-mail: [email protected] • Fax: (909) 789-1311 • Mail: Teamsters Local 1932 Health & Welfare Trust

P.O. Box 571 San Bernardino, CA 92402-0571

Should you have any questions or need assistance with your enrollment updates/changes, contact your dedicated Customer Service Department at (909) 494-2916 or (866) 484-1337. Customer Service is available Monday through Friday 8am to 5pm PDT.

https://teamsters1932.zenith-american.com/


mailto:[email protected]

REV. 8/09/2016 1 of 2 (Premium Deduction Election)

Ensure the most current form is submitted. Refer to EMACS Forms/Procedures website.

PREMIUM DEDUCTION ELECTION Must print in Black or Blue ink ONLY

Employee ID Rcd No. Last Name, First Name

Department Department ID Telephone

REASON FOR ELECTION AGREEMENT Date Event Date Event

New Hire Moved in/out of the HMO area

Adoption/Guardianship* Needles Subsidy/Change in Subsidy Eligibility

Birth* Open Enrollment

Death* Reduction in Hours for Employee or Spouse/Domestic Partner*

Disabled Over-Age Dependent (Please provide required Disabled Dependent Certification form)

Return from Unpaid Leave of Absence

Divorce/Dissolution of Domestic Partnership*(Please provide required mailing address of ex-spouse/domestic partner)

Mailing Address:

City, State, Zip:

Unpaid Leave of Absence Taken by Employee or Spouse/Domestic Partner*

Gain/Loss Spouse’s/Domestic Partner’s EEEmployment or Other Group Coverage*

Other:

Marriage/Domestic Partnership*

*Documentation is required for evidence of qualifying event (i.e.; Birth Certificate, Certificate of Marriage/Domestic Partnership, CourtOrders, Final Divorce Decree, Benefit Confirmation Statement, COBRA Notice, Loss of Coverage Letter, and Termination Notice)

BENEFIT ELECTIONS Check the appropriate tax elections and list all dependents you wish to enroll in benefits.

Plan Before Tax Name of Dependent

Tax Dependent

Yes No

Domestic Partner/Domestic Partner’s

ChildBefore Tax After Tax

Medical Dental

Voluntary Life AD&D Vision*

*Tax election for vision coverage applies only to Firefighters, Nurses, Probation, Specialized Peace Officer - Supervisory units

HR Use Only Comments

Enroll: Vision Life

DISTRIBUTION: Original - EBSD-HR (0440) Reviewed By(Employee ID)

Date Keyed By(Employee ID)

Date

Update AD&D from Employee + Spouse to Employee Only

AfterTax

REV. 8/09/2016 2 of 2 (Premium Deduction Election)

Authorization and Certification Employee signature is required for all qualifying events

I understand my share of the plan coverage cost may be adjusted to reflect any rate change. I acknowledge that my election is irrevocable unless there is a qualifying event in my family status and that in the absence of a family status change, my next opportunity to change this election will be during Open Enrollment. If I do not complete and return a new election form during Open Enrollment, the elections specified on page one of this Premium Deduction Election form will be maintained for the new plan year.

I hereby authorize the County of San Bernardino to obtain eligibility dates of coverage from previous Medical Plans for the exclusive purpose of determining my eligibility for the County of San Bernardino’s Premium Conversion Benefit Plan as required under Internal Revenue Code Section 125. I understand this authorization is only in effect for 60 days from the date of my signature.

Needles Subsidy Eligible Employees: I understand that my eligibility for the “Needles Subsidy” is entirely contingent upon being assigned to Needles, Trona, or Baker as my work location. I understand that it is my responsibility to notify the Employee Benefits and Services Division (EBSD) should my assigned work location change to an area other than Needles, Trona, or Baker. I further understand that should it be discovered that the Needles Subsidy has been paid to me in error, that the County will collect, through payroll deduction, any amount of subsidy for which I received and was not eligible.

________________________________ _____________________________________ Signature of Employee Print Employee Name

_______________________ Date

I understand my options in the Benefit Plan. I understand the County will reduce my salary in the amount of the plan coverage cost on either a before tax or after tax basis.

I understand that if at any time my or my family’s eligibility changes, I will notify EBSD or department payroll specialist within 60 days of the change in order to make the appropriate changes to my benefit deductions. For example, if I get divorced I am required to remove my ex-spouse from County sponsored Benefit Plans.

I understand that I will be taxed on the fair market value of any benefits for any individual who is not my Federal/State tax dependent.

Employee Signature Date

Payroll Specialist (Print & Sign) Telephone Date

Office Use Only

Approved Authorized Representative Signature Date

Denied

2020-2021 Enrollment Change Form – Life Event - Teamsters Local 1932 Health and Welfare Trust Page 1 of 4

ENROLLMENT CHANGE FORM – LIFE EVENT 2020-2021 PLAN YEAR TEAMSTERS LOCAL 1932 HEALTH AND WELFARE TRUST

Teamsters Trust Fund Administrative Office: 433 N. Sierra Way, San Bernardino, CA 92419-4831 P 909-494-2916 | P 866-484-1337 | Fax 909-789-1311

SECTION 1: EMPLOYEE INFORMATION

Employee ID Last Name, First Name, Middle Initial □ Male

□ Female

Date of Birth

/ / Social Security Number

Home Address City State Zip Code Telephone

( )

Mailing Address □ Same as Home Address City State Zip Code Date of Hire

/ /

County of San Bernardino - Department Email Address

Qualifying Life Event

□ Add □ Change □ Remove

Eligibility requires proof of dependency, such a copy of the certified birth or marriage certificate or domestic partnership, adoption or placement paperwork, complete requirements are found in the Summary Plan Description located on the Trust’s website at https://Teamsters1932.zenith-american.com.

SECTION 2: ENROLLMENT DECISION - TEAMSTERS LOCAL 1932 HEALTH PLAN

□ As a dues paying member of Teamster’s Local 1932, I “Elect to Enroll” in the Teamsters Local 1932 Health and Welfare Trust. I previously opted out of coverage and my other coverage recently (within the last 60 days) terminated. Proof of the termination of coverage is enclosed with my Enrollment Form.

SECTION 3: ELECT MEDICAL AND DENTAL COVERAGE | SELECT ONE : ■ Pre-Tax or ■ Post-Tax

BLUE SHIELD HMO KAISER HMO BLUE SHIELD PPO OPT-OUT/WAIVER

□ HMO Platinum Plan $10 copay $0/admit; no charge Network: Access+

□ HMO Platinum Plan $10 copay $0/admit; no charge

□ PPO Non-Needles □ Medical Opt-Out/Waiver**

□ HMO Gold Access+ Plan $40 copay $100/admit; plus 20% $3,500 copay max Cal-yr Network: Access+

□ HMO Gold Plan $40 copay $100/admit; plus 20% $3,500 copay max Cal-yr

□ PPO Needles

□ HMO Gold Trio Plan $20 copay $100/admit; plus 20% $3,500 copay max Cal-yr Network: Trio

Mailing Address: P.O. Box 571 San Bernardino, CA 92402-0571


INITIAL HERE

SECTION 4: ELECT MEDICAL AND DENTAL COVERAGE (Continued)

DELTA DENTAL OPT-OUT/WAIVER

□ Delta DHMO* □ Delta PPO □ Dental Opt-Out/Waiver**

*Delta DHMO enrollees will continue with your current Delta-assigned Dentist if applicable, see Section 5. Alternately, a dentist located near your home will be assigned to you. Contact Delta Dental to change Dentists.

**Employees selecting to Opt-Out/Waiver of Medical and/or Dental Coverage are required to submit a completed & signed “Opt-Out/Waiver” Form; the Opt-Out/Waiver Form must be submitted, with all required documents as listed on

the Form, to the Trust Administrative Office for Review and Approval/Deny Decision.

SECTION 5: EMPLOYEE ENROLLMENT – CHANGE DUE TO QUALIFYING LIFE EVENT Paperwork must be received within 60 days of the qualifying life event. Elections made within 30 days will be processed retroactively.

Last Name, First Name, Middle Initial Marital Status

□ Single □ Married □ Domestic Partner

BLUE SHIELD HMO ENROLLEES ONLY

Med. Group Name Physician Name Physician PCP ID# Existing Patient?

□ Yes □ No

DELTA DHMO ENROLLEES ONLY

Dentist Name Facility # Existing Patient?

□ Yes □ No

SECTION 6: DEPENDENT ENROLLMENT List all dependents to be covered; dependent verification documentation is required for all dependents. Provide the Social Security Number of each dependent you enroll. Federal regulations require health plans to report the names and Social Security Numbers of every covered individual to the IRS.

SPOUSE / DOMESTIC PARTNER:

Enroll in all products selected by Employee: □ Yes □ No (if no, describe coverage selection)

Relationship

□ Spouse □ D.Ptnr

Last Name, First Name, Middle Initial □ Male

□ Female

Date of Birth




□ Yes □ No



□ Yes □ No

CHILD(REN) / STEPCHILD(REN):


Relationship

□ Child □ Stepchild


□ Female

Date of Birth




□ Yes □ No



□ Yes □ No


INITIAL HERE

SECTION 6: DEPENDENT ENROLLMENT (Continued)

CHILD(REN) / STEPCHILD(REN):


Relationship



□ Female

Date of Birth




□ Yes □ No



□ Yes □ No


Relationship



□ Female

Date of Birth




□ Yes □ No



□ Yes □ No


Relationship



□ Female

Date of Birth




□ Yes □ No



□ Yes □ No


Relationship



□ Female

Date of Birth




□ Yes □ No



□ Yes □ No


Relationship



□ Female

Date of Birth




□ Yes □ No



□ Yes □ No

If you have more dependents to enroll, print out additional copy(ies) of page 3 and attach to your form.


INITIAL HERE

SECTION 7: NEEDLES PLAN ENROLLMENT - COUNTY OF SAN BERNARDINO, NEEDLES SUBSIDY ELIGIBLE

I understand that Needles Plan Enrollment Eligibility and the County of San Bernardino "Needles Subsidy" are entirely contingent on my work-assignment to Needles, Trona, or Baker as my work location. I understand that it is my responsibility to notify both the Trust Administrator and the County Human Resources Department - Employee Benefits and Services Division (HR-EBSD) should my assigned work-location change to an area other than Needles, Trona, or Baker. I further understand that should it be discovered that the Needles Subsidy has been paid to me in error, the Employer (County of San Bernardino) may collect, through payroll deduction, any amount of subsidy for which I received and was not eligible.

SECTION 8: ARBITRATION AGREEMENT

I understand that (except for Small Claims Court cases, claims subject to a Medicare appeals procedure or the ERISA claims procedure regulation, and any other claims that cannot be subject to binding arbitration under governing law) any dispute between myself, my heirs, relatives, or other associated parties on the one hand and the Health Plan and Dental Plan selected above, any contracted health care providers, administrators, or other associated parties on the other hand, for alleged violation of any duty arising out of or related to membership in the Plan, including any claim for medical or hospital malpractice (a claim that medical services were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered), for premises liability, or relating to the coverage for, or delivery of, services or items, irrespective of legal theory, must be decided by binding arbitration under California law and not by lawsuit or resort to court process, except as applicable law provides for judicial review of arbitration proceedings. I agree to give up our right to a jury trial and accept the use of binding arbitration. I understand that the full arbitration provision is contained in the Evidence of Coverage.

Your signature indicates that you have completed all requested information as accurately as possible and understand all agreements implied including your agreement to submit disputes to binding arbitration. I have read and made the appropriate corrections and changes to the information on file with the Teamsters Local 1932 Health and Welfare Trust Administrative Office.

Employee Signature Date

/ /

INSTRUCTIONS SCREEN

1. The website is secure – The first time you log

on, you must register for an Account.

2. You will register by calling Customer Service

at 909-494-2916 or toll-free, 1-866-484-1337,

to set up your account; they will help you

enroll, or assist you with registering so that

you can enroll yourself at a later time.

3. Once you have activated your account, you

can enroll through the Teamsters Local 1932

Health & Welfare Trust online enrollment

module at https://Teamsters1932.zenith-

american.com; or Customer Service can

help walk you through enrollment.

YOUR ACCOUNT IS ACTIVATED YOU ARE READY TO ENROLL

1. Once you have activated your account, and

you choose to self-enroll; visit

https://Teamsters1932.zenith-american.com;

2. Key in your user name and password and

click on the button, Log into Your Account.

3. The first time (only) you log into your

account; you will see the Terms of Use

language.

a. To continue with the enrollment process, check the box to agree with the terms and use, and click continue.

Important note: The online session will

expire after 30 minutes of inactivity. Any

changes you have made will be lost if you

have not completed the enrollment

process.





4. Click on the Enroll Now button, or Enrollment

Form. You will be directed to the Online

Enrollment page.

5. Review the Participant Information page for

accuracy. This is the information you

provided to Customer Service. If any portion

is inaccurate, please contact the Customer

Service department to update, once your

enrollment has been completed.

b. Click continue.

6. On the Dependent screen, if you have

dependents to add to your Plan, click the

Add New button located at the bottom of the

page.

a. Enter your dependents information, as requested in the fields displayed.

i. If the dependent you are adding has a different address than you, scroll down using the gray bar on the right side of the text box and key in their address.

b. Click the Save button

c. The new dependent will now display on your dependent screen. Click the Enroll button.

d. You can continue to add dependents. Once completed, click Continue.


7. Medical Plan Selection – When selecting the

Medical Plan option of your choice, you

must select Before Tax (BTX) or After Tax

(ATX). When selecting Before Tax or After Tax

for your medical plan, the same choice must

be made for your dental plan.

a. Blue Shield HMO Gold Trio ($20 co-payment) – New Option

b. Blue Shield HMO Platinum POS ($10 co-payment)

c. Blue Shield HMO Gold Access+ ($40 co-payment)

d. Blue Shield PPO (Non-Needles)

e. Blue Shield PPO Needles

f. Kaiser Gold Choice

g. Kaiser Platinum Plus

8. Select the medical plan option that best suits

you and your family’s needs and click the

button, Choose This Plan.

a. Once selecting your plan, you will need to click on the box next to each family member to be enrolled under your plan.

b. If you are selecting a Blue Shield HMO or POS Plan, you will need to enter the Primary Care Provider (PCP) Identification Number, or click on the option for Blue Shield to pick a PCP for you and/or your dependents.

c. If you request Blue Shield to select a PCP for you, one will be chosen in your geographical area.

d. Scroll to the bottom of the page and click Continue.


9. If you want to Waive/Opt Out of medical

coverage, scroll to the bottom of the page

and click on the Waive/Opt Out button.

a. You will be required to provide the Fund’s Administrative office proof of other coverage at the time the waive or opt-out is elected

b. You can submit the documentation via one of the below methods:

Email:

[email protected];

Mail:

Teamsters Local 1932 Health and Welfare Trust, P.O. Box 571, San Bernardino, CA, 92402-0571.

Fax: (909) 789-1311

10. Select the Dental coverage that best suits

you or your family’s needs.

a. Once you’ve selected your Plan, click on each family member you are enrolling in your Dental Plan.

b. Click Continue.




11. Vision Plan

a. Employee only coverage is paid for by the County. Click Continue.

12. Review your enrollment information.

a. Review the Plan selections for you and each of your family members.

b. Review your bi-weekly benefits cost, based upon your Plan selections.

c. If there are no changes, click the Authorize box at the bottom of the screen verifying you have reviewed all information.

d. An Authorization box will display; scroll down using the gray bar on the right side of the text box. Click the Accept button.

e. Click the Submit button.

f. You will receive a message noting that your enrollment is complete. The message will include a reference number.

13. There is a dashboard on the left side of the

screen that will appear each time you log

into your account.


14. You can upload supporting documents, such

as marriage certificates or birth certificates

when adding new dependents, and have

them attached to your electronic file.

a. There are Customer Service Representatives to assist you in completing your enrollment form, and answer any questions you may have. Contact us at 909-494-2916 or (866) 484-1337 Monday through Friday from 8:00 a.m. – 5:00 p.m. PDT.

b. Other benefits are available to you through your employer. Make sure you also review your other benefit enrollment opportunities on the Employee Benefits section of the County’s portal.

BLUE SHIELD

HMO PLATINUM POS PLAN

($10-$30 COPAY)

BLUE SHIELD

HMO GOLD ACCESS+

PLAN

($40 COPAY)

BLUE SHIELD

HMO GOLD TRIO PLAN

($20 COPAY)

BLUE SHIELD

PPO NON-NEEDLES PLAN

KAISER

HMO PLATINUM PLAN

($10 COPAY)

KAISER

HMO GOLD PLAN

($40 COPAY)

LEVEL I - HMO LEVEL II - PPO ACCESS+HMO TRIO HMO PARTICIPATING PROVIDER NON-PARTICIPATING

PROVIDER KAISER KAISER

Plan Network Blue Shield Access+ HMO Network

Blue Shield PPO Network

Blue Shield Access+

HMO Network

Blue Shield

Trio HMO Network

Shield PPO Network

(includes Blue Card Program

access) Out-of-Network

Kaiser physicians and

facilities only

Kaiser physicians and facilities

only

Calendar year (CY)Deductible combined PPO/OON

None None None None $250 per individual

$500 per family

$250 per individual

$500 per family None None

Hospital or Ambulatory Surgical Center deductible

None Not covered None None None None None None

Lifetime benefits

maximum None None None None None None None None

Out-of-Pocket annual maximum

$1,500 per individual $3,000 per family

$8,00 per individual

$16,000 per family




$2,250 per individual $4,500per family


$3,500 per individual

$7,000 per family

Preexisting condition Fully covered Fully covered Fully covered Fully covered Fully covered Fully covered Fully covered Fully covered

Office/

Outpatient Care

Office Visits – Primary

Care Physician (PCP) $10 copay $30 copay $40 copay $20 copay

$10 copay

(deductible does not apply)

You pay 30% after CY

deductible $10 copay $40 copay

Office Visits – Specialist

(self-referral within

assigned PCP’s

medical group)

N/A N/A $50 copay $20 copay N/A N/A N/A N/A

Office Visits -Specialist $10 copay $30 copay $40 copay

(referred by PCP)

$20 copay

(referred by PCP)

$10 copay


You pay 30% after

CY deductible $10 copay $50 copay

Tele-Medicine

Covered through Teladoc 24/7 – No

charge

Covered through

Teladoc 24/7 – No

charge

Covered

through Teladoc 24/7

– No

charge

Covered through

Teladoc 24/7 - No

charge

Covered through Teladoc

24/7 – No charge Not covered No charge No charge

Preventive Services No charge $30 copay No charge No charge No charge

(CY deductible waived)


deductible No charge No charge

Hearing screenings No charge $30 copay No charge No charge No charge




Immunizations No charge $30 copay No charge No charge No charge




Tubal ligation No charge Not covered No charge No charge No charge


You pay 30% after CY deductible

No charge No charge

Vasectomy $10 copay/surgery Not covered $10 copay/surgery $20 copay/surgery You pay 20% after CY

deductible

You pay 30% after

CY deductible $10 copay $250 copay

Well baby/Well child

care No charge $30 copay No charge No charge

No charge


You pay 30% after

CY deductible No charge No charge

Well woman exam

(annual) No charge $30 copay No charge No charge

No charge


You pay 30% after


Emergency Medical

Care

Ambulance

No charge

(for emergency or

authorized transport)

No charge

(for emergency or


No charge (for

emergency or


No charge(for

emergency or authorized

transport)


Deductible (for emergency or


You pay 20% after

CY deductible (for

emergency or

authorized

transport)

No charge when

medically necessary

$150 copay when medically

necessary

Emergency room

(if admitted to the

Hospital, see

Hospitalization Services

for cost share)

$50 copay/visit (does not apply if admitted)

$50 copay/visit

(does not apply if

admitted)

$50 copay/visit (does

not apply if admitted)

$50 copay/visit (does not

apply if admitted)

$50 copay/visit plus 20% after CY deductible; copay does not apply if admitted

Physician: 20% after CY deductible

$50 copay/visit plus 20% after CY deductible; copay does not apply if admitted

Physician: 20% after CY deductible

$50 copay (does not

apply if admitted)

$150 copay (does not apply if

admitted)

Urgent care $10 copay $10 copay $40 copay $20 copay $10 copay (deductible does

not apply) 30% after CY


Diagnostic Services

Laboratory and Pathology Tests

No charge No charge

Outpatient

department of

Hospital – No charge

Other – You pay 40%

Outpatient department

of Hospital – No charge



deductible

You pay 30% after

CY deductible No charge $10 copay.

Diagnostic Tests and X-

Ray No charge

Covered only when performed in physician’s office

Not covered for CT, MRI, MUGA, PET, and SPECT

Outpatient

department of

Hospital – No charge


Outpatient department

of Hospital – No charge



deductible

You pay 30% after

CY deductible No charge

$10 copay MRI, most CT and PET: $100 copay

Diabetes Care

Covered Diabetic drugs and testing supplies

See “Prescription

Drugs”

See “Prescription

Drugs”

See “Prescription

Drugs” See “Prescription Drugs” See “Prescription Drugs”

See “Prescription Drugs”



Diabetes Self-Management Training & Education

No charge $30 copay Office Visit: $40

copay Office Visit: $20 copay

$10 copay (deductible does

not apply)

You pay 30% after


Devices, Equipment, and Non-Testing Supplies

No charge Not covered You pay 40% You pay 40% You pay 20% after CY

deductible

You pay 30% after

CY deductible

See Durable Medical

Equipment

See Durable Medical

Equipment

Maternity Care

Prenatal and Postnatal office visits

No charge You pay 20%

coinsurance No charge No charge

$10 copay after CY

deductible

You pay 30% after


Delivery (Professional

Services) No charge Not covered No charge No charge


deductible

You pay 30% after


Newborn Care

Newborn covered 30 days; must enroll through the Teamsters 1932 Health Trust

Covered under

HMO, Level I Benefit

No charge. Newborn covered 30 days; must enroll through the Teamsters 1932 Health Trust within 60 days of birth

No charge. Newborn covered 30 days; must enroll through the Teamsters 1932 Health Trust within 60 days of birth

Newborn covered 30 days; must enroll through the Teamsters 1932 Trust within 60 days of birth

Newborn covered 30 days; must enroll through the Teamsters 1932 Trust within 60 days of birth

Newborn covered 30 days; must enroll through the County within 60 days of birth

Newborn covered 30 days; must enroll through the County within 60 days

within 60 days of birth

of birth

Hospital Services

Hospital care (Hospital and Physician charges)

No charge Not covered

Hospital:

$100/admission plus

20% Physician: No charge

Hospital: $100/admission

plus 20%

Physician: No charge


deductible

You pay 30% after

CY deductible No charge $500copay per day

Surgical Services

Hospital – In-Patient Surgical Services

No charge (Facility and Physician)

Not covered

Facility: $100

admission plus 20%


Facility: $100 admission

plus 20%


Facility: You pay 20% after CY

deductible

Physician: You pay 20% after

CY deductible

Facility: You pay 30%

after CY deductible

Physician: You pay

30% after CY

deductible


Facility: $500 copay per day


Outpatient / Ambulatory Surgery Center


Not covered





Facility: You pay 20% after CY

deductible

Physician: You pay 20% after

CY deductible


after CY deductible

Physician: You pay

30% after CY

deductible

Facility: $10 copay per procedure


Facility: $250 copay per

procedure


Alternatives to Hospital Care

Home health services

No charge up to 100 visits per calendar year

Not covered

No charge up to 100

visits per calendar

year

No charge up to 100 visits per calendar year


deductible up to 100 visits per

calendar year

Not covered

No charge up to 100 visits per accumulation period

No charge up to 100 visits per accumulation period

Hospice

No charge; includes routine home care, 24-hour continuous home care, short-term IP care for pain/ symptom management

Not covered

No charge; includes routine home care, 24- hour continuous home care, short-term IP care for pain/symptom management

No charge; includes routine home care, 24- hour continuous home care, short-term IP care for pain/symptom management

No charge (deductible does

not apply)

24-hr continuous home

care/Short-term inpatient care

for pain and symptom mgmt.:


deductible

Not covered No charge No charge

Skilled nursing facilities

(SNF) No charge Not covered

No charge up to 100

days per Benefit

Period

No charge up to 100 days per Benefit Period


deductible up 100 days per

Benefit period - combined

PPO/Non-PPO maximum

You pay 20% after CY deductible up 100 days per Benefit period - combined PPO/Non-PPO maximum

Hospital based SNF:


deductible

No charge up to 100 days per benefit period

No charge up to 100 days per benefit period

Mental Health Care

and Substance Abuse

Treatment

MHSA

Participating Provider

MHSA

Non-Participating

Provider

MHSA


MHSA


MHSA


MHSA

Non-Participating

Provider

Outpatient services $10 copay $10 copay

$40 copay

All other services are

no charge

$20 copay

All other services are no

charge

Outpatient: $10 copay (deductible does not apply)

All other services: You pay 20% after CY deductible


deductible

$10 copay per

individual

$5 copay per group

$40 copay individual;

$20 copay group

Substance abuse: $5 copay

group

Inpatient services No charge Not covered


Hospital services and

residential care:

$100/ admission plus


Hospital services and

residential care: $100/

admission plus 20%


deductible


deductible No charge $500 copay per day

20%

Prescription Drugs

Prescription drugs (per

fill)

Includes Diabetic drugs and testing supplies

Retail Pharmacy (30-

day supply):

Tier 1- $5 copay

Tier 2 - $10 copay

Tier 3 - $25 copay

Tier 4 - $10 copay

(excluding specialty

drugs)

Specialty Pharmacy:

Tier 4 - $10 copay

(Specialty Drugs 30-

day supply)

Mail order

(90-day supply):

Tier 1- $10 copay

Tier 2 - $20 copay

Tier 3 - $50 copay

Tier 4 - $20 copay


drugs)

Not covered Retail Pharmacy (30-

day supply):

Tier 1- $5 copay

Tier 2 - $10 copay

Tier 3 - $25 copay

Tier 4 – 20% up to

$200/Rx (excluding

specialty drugs)

Specialty Pharmacy:

Tier 4 – 20% up to

$200/Rx (Specialty

Drugs 30- day supply)

Mail order

(90-day supply):

Tier 1- $10 copay

Tier 2 - $20 copay

Tier 3 - $50 copay

Tier 4 – 20% up to $400/Rx (excluding specialty drugs)

Retail Pharmacy (30-day

supply):

Tier 1- $5 copay

Tier 2 - $10 copay

Tier 3 - $25 copay

Tier 4 – 20% up to $200/Rx


drugs)

Specialty Pharmacy:

Tier 4 – 20% up to $200/Rx

(Specialty Drugs 30- day

supply)

Mail order

(90-day supply):

Tier 1- $10 copay

Tier 2 - $20 copay

Tier 3 - $50 copay

Tier 4 – 20% up to $400/Rx (excluding specialty drugs)

PARTICIPATING PHARMACY

Retail Pharmacy (30-day supply):

Tier 1- $15 copay

Tier 2 - $30 copay

Tier 3 - $30 copay

Tier 4 - $15 copay (excluding specialty drugs)

Specialty Pharmacy:

Tier 4 - $15 copay (Specialty Drugs 30- day supply)

Mail order

(90-day supply):

Tier 1- $30 copay

Tier 2 - $60 copay

Tier 3 - $60 copay Tier 4 - $30 copay (excluding specialty drugs)

NON-

PARTICIPATING

PHARMACY

Retail Pharmacy (30-day supply):

(Member pays 25% of billed amount plus copay)

Tier 1- $15 copay

Tier 2 - $30 copay

Tier 3 - $30 copay

Tier 4 - $15 copay (excluding specialty drugs)

Specialty Pharmacy:

Not covered

Mail order:

Not covered

Pharmacy (up to a 100-day supply):

Generic – $10 copay

Brand – $15 copay

Most specialty items - $15 copay (up to a 30-day supply)

Mail order (up to a

100-day supply):

Generic – $10 copay

Brand – $15 copay

Pharmacy (up to a 30-day supply): Generic – $15 copay Brand – $35 copay Most specialty items: 30%, not to exceed $200 (up to a 30-day supply)

Mail order (up to 100-day supply): Generic – $30 copay Brand – $70 copay

Pharmacy (retail and

mail order) copays

do not apply toward

the out-of- pocket

maximum.

Pharmacy (retail and mail

order) copays do not apply

toward the out-of- pocket

maximum

Pharmacy (retail and mail order) copays do not apply toward the out-of- pocket maximum

Other Services

Allergy testing

$10 copay

Allergy Serum: No

charge

$30 copay

Allergy Serum: No

charge

$40 copay

Allergy Serum: You

pay 40% copay

$20 copay

Allergy Serum: You pay

40% copay

You pay 20% (deductible does not apply)

Allergy Serum: 20% after CY deductible


deductible

Allergy serum: $10

copay Allergy serum: $5 copay

Chiropractic care Not covered Discount

program available

Not covered

Discount program

available

Not covered

Discount program

available

Not covered

Discount program

available

20% after CY deductible up

to 30 visits per calendar year

combined PPO/Non-PPO

maximum

30% after CY

deductible up to 30

visits per calendar

year combined

PPO/Non-PPO

maximum

Not covered

Not covered

Durable medical

equipment (DME)

Breast Pump

Orthotic

Equipment/devices

Prosthetic Equipment

No charge Not covered

DME: You pay 40%

No charge

No charge

No charge

DME: You pay 40%

No charge

No charge

No charge


deductible

Breast Pump: No charge


deductible

Breast Pump: Not

covered

No charge You pay 50%

Physical and Occupational Therapy

Office Location: $10

copay

Outpatient Dept. of a

Hospital: No charge

Office Location: $30 copay (up to 12 visits per calendar year

Outpatient Dept. of

$40 copay $20 copay You pay 20% (deductible

does not apply)



a Hospital: Not

covered

Speech Therapy

Office Location: $10

copay

Outpatient Dept. of a

Hospital: No charge

Office Location: $30 copay

Outpatient Dept. of a Hospital: Not covered

$40 copay $20 copay You pay 20% (deductible

does not apply)



Vision (exam only)

$10 copay

(one exam in a

consecutive 12-

month period

provided through

contracted VPA)

$0 up to $60/year

plus 100% of

additional charges

(one exam in a

consecutive 12-

month period

provided through

contracted VPA)

(Not covered) (Not covered)

You pay 20% self-referred

exam per 12 consecutive

months, no age limit (Vision

plan administrator’s providers

only)

You pay 20% self-

referred exam per 12

consecutive months,

no age limit (Vision

plan administrator’s

providers only)

No charge No charge

Travel

Network

(For urgent care

services)

Inside of US: Blue Card Program Outside of US: Blue Shield Global Core Program

Refer to your EOC


Refer to your EOC


Refer to your EOC


Refer to your EOC


Refer to your EOC


Refer to your EOC

Kaiser facilities in the US.

Claim forms required for Out of Area Urgent and ER care

Kaiser facilities in the US.

Claim forms required for Out of Area Urgent and ER care

Immunizations for purposes of Foreign Travel

$10 copay/injection $30 copay/injection $10 copay/injection $10 copay/injection You pay 20% after CY

deductible



Additional Travel

Information

provider.bcbs.com

bcbsglobalcore.com

provider.bcbs.com

bcbsglobalcore.com

provider.bcbs.com

bcbsglobalcore.com

provider.bcbs.com

bcbsglobalcore.com

provider.bcbs.com

bcbsglobalcore.com

provider.bcbs.com

bcbsglobalcore.com

kp.org (search for

“Travel Health”)

kp.org (search for “Travel

Health”)

Note! This is a Brief Comparison. Please refer to the Healthplan's Evidence of Coverage or Summary of Benefits for a detailed description of coverage, limitations and exclusions.

http://www.kp.org/

http://www.kp.org/

PlanCoverage

Type

Medical

Premium

Subsidy (MPS)

County Plan

2020-21

Bi-Weekly

Rates*

County Plan

Employee

Out-of-Pocket

Teamsters Plan

2020-21

Bi-Weekly

Rates*

Teamsters Plan

Employee

Out-of-Pocket

BLUE SHIELD OF CALIFORNIA

HMO Platinum Plan EE $240.72 $274.09 $33.37 $269.72 $29.00

$10 copay EE+1 $452.80 $546.19 $93.39 $541.80 $89.00

$0/admit; no charge EE+2 $640.14 $772.03 $131.89 $768.14 $128.00

HMO Gold Access+ Plan EE $240.72 $238.13 $0.00 $240.72 $0.00

$40 copay EE+1 $452.80 $474.28 $21.48 $474.28 $21.48

$100/admit; plus 20% EE+2 $640.14 $670.28 $30.14 $670.28 $30.14

HMO Gold Trio Plan EE $240.72 $240.72 $0.00

$20 copay EE+1 $452.80 $472.75 $19.95

$100/admit; plus 20% EE+2 $640.14 $664.88 $24.74

PPO Non-Needles Plan EE $240.72 $509.02 $268.30 $509.02 $268.30

$10 OV - $250 Ded. EE+1 $452.80 $1,035.30 $582.50 $1,035.30 $582.50

80/70% Co-ins. EE+2 $640.14 $1,605.82 $965.68 $1,605.82 $965.68

PPO Needles Plan^ EE $545.48 $574.48 $33.37 $574.48 $29.00

$10 OV - $0/$250 Ded. EE+1 $1,079.08 $1,168.08 $93.39 $1,168.08 $89.00

100/70% Co-ins. EE+2 $1,680.86 $1,808.86 $131.89 $1,808.86 $128.00

KAISER PERMANENTE - SOUTHERN CALIFORNIA

HMO Platinum Plan EE $240.72 $313.40 $72.68 $313.40 $72.68

$10 copay EE+1 $452.80 $624.78 $171.98 $624.78 $171.98

$0/admit; no charge EE+2 $640.14 $883.21 $243.07 $883.21 $243.07

HMO Gold Plan EE $240.72 $272.16 $31.44 $272.16 $31.44

$40 copay EE+1 $452.80 $542.31 $89.51 $542.31 $89.51

$100/admit; plus 20% EE+2 $640.14 $766.53 $126.39 $766.53 $126.39*Note: Includes Teamsters and County, Medical Plan management fee of $2.01

^Note: Includes Department Subsidy

Coverage

TypeDPS

County Plan

Bi-Weekly*

County Plan

Out-of-Pocket

Teamsters Plan

Bi-Weekly*

Teamsters Plan

Out-of-Pocket

DeltaCare USA - DHMO EE $9.46 $9.88 $0.42 $9.88 $0.42

Plan: CAD90 EE+1 $9.46 $15.94 $6.48 $15.94 $6.48

EE+2 $9.46 $20.77 $11.31 $20.77 $11.31

Delta Dental - PPO EE $9.46 $25.09 $15.63 $25.09 $15.63

$0 Ded, $1,700 Annual Max. EE+1 $9.46 $46.80 $37.34 $46.80 $37.34

Ortho: 50% up to $1,700 Lifetime EE+2 $9.46 $80.11 $70.65 $80.11 $70.65

*Note: Includes Teamsters and County, Dental Plan management fee of $1.44

●●●●● 2020 - NEW PLAN ●●●●●

Teamsters Local 1932 Health & Welfare TrustMedical and Dental Plans - County Plan and Teamsters 1932 Plan: Employee Cost Comparison

2020-21 Plan Year

Date Prepared: 06/04/2020

Teamsters 1932 Exclusive Plan

teamsters local 1932 health & welfare trust enrollment ... · initial here section 4: elect...

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