Self-Funded (PPO)

Under the medical plan certain hospitals, doctors, and laboratories have agreed to accept negotiated rates for services provided to participants and dependents insured under this Plan. To receive the maximum available benefits, use an Anthem Blue Cross Prudent Buyer Hospital or Doctor for your covered services.

Self-Funded Medical Plan Summary

You are required to pay a $300 individual deductible per calendar year before the plan begins paying benefits.  Once you have met your deductible, you will be required to pay a percentage for covered services.  The chart below outlines the Health & Welfare Fund’s benefit schedule for covered expenses.  Please note that all exclusions and limitations of benefit coverages have not been included and this summary is not to be construed as a substitute for the provisions of  the Summary Plan Description.  A new Summary Plan Description booklet for further information is being prepared and will be sent to all members as soon as it is complete.  Retiree participants who are eligible for Medicare Part B must enroll in Medicare Part B.

Deductible &
OUT OF POCKET

$300 per person per calendar year, limited to $600 per family, per calendar year.
$3,000 per person per calendar year, limited to $6,000 per family per calendar year.
Maximum Unlimited
Hospital Benefits
(Inpatient or Outpatient)
PPO – 90% of the contract rate.  $1,000 in-patient only hospital admission charge.
Non PPO – 70% of usual and customary charges.
PPO 90% of the negotiated rate for the first $30,000 per person of covered charges per calendar year; 100% thereafter.
After $30,000 of PPO covered expenses in excess of the Deductible, in a calendar year, reimbursement is made at 100% of the contract rate during the remainder of the calendar year.
Non‑PPO 70% of UCR for the first $50,000 per person of covered charges per calendar year; 100% thereafter.
After $50,000 of Non-Preferred Provider covered expenses in excess of the Deductible in a calendar year, reimbursement is made at 100% of the Usual and Customary Charges during the remainder of the calendar year.
Physician Office Visit – $30.00 co-pay for a preferred provider physician instead of a deductible.  Does not apply towards deductible.  This $30.00 co-pay does not apply to Retirees on Medicare
Non PPO – 70% of usual and customary charges.  No $30.00 co-pay.
Preventive Care Benefits for Children Maximum allowance per periodic physical examination per age interval is $250, which includes examination, laboratory and inoculations.  Limited to 19 periodic physical examinations at approximately each of the following intervals: Birth, 2, 4, 6, 9, 12, 15, 18 and 24 months, 3, 4, 5, 6, 8, 10, 12, 14, 16 and 18 years.
Physical Exam Benefits 100% of physician examination including X-ray and laboratory expenses (no deductible applied) up to a maximum reimbursement of $200 per employee and spouse as follows: Every 5 years up to age 35; every 2 years for ages 36 through 50; every year ages 51 or over.
Chiropractic Benefit PPO ‑ 90% of the negotiated rate.
Non‑PPO – 70% of usual and customary charges.
Supplemental Accident 100% of Usual and Customary Charges up to $500 per injury (no deductible applied); regular benefit schedule applies thereafter.
Physical and Other Therapies PPO – 90% of the negotiated rate.
Non-PPO – 70% of usual and customary charges.
Laboratory Routine Lab – $10.00 co-pay for a preferred provider lab.  This does not apply towards the deductible.  This $10.00 co-pay does not apply to retirees on Medicare.
Non-PPO – 70% of usual and customary charges
Prescription Drugs Caremark Prescription Card – $15.00 generic and $30.00 for brand name on the Preferred Brand list for a 30-day supply.  All other Brands $50.00.  There is now a $100.00 calendar year deductible for all Brand named prescriptions.
Major Medical – 80% of usual and customary charges after deductible.
Caremark Mail Order Plan  – The same as the Caremark Prescription Card Plan except for a 90-day supply of maintenance medications.
Medicare Retirees are NO longer eligible for Prescription drug coverage
Skilled Nursing Facility 90% of charges incurred at a PPO skilled Nursing Facility and 70% at a non-PPO Skilled Nursing Facility.  Confinement therein must start within 14 days of a Hospital stay.  It must also be for continued treatment of the condition causing the hospital stay or any subsequent condition or complication related to the condition that caused the hospital stay or that arose as a result of the hospital stay.
Substance Abuse Inpatient – $1,000 Hospital Admission Charge.   For PPO providers 90% of contract rate.  For Non-PPO providers 70% of UCR.  Outpatient benefits are paid at 50% of Usual and Customary Charge.  The maximum payable for outpatient benefits is $500.  Hospitalization for acute alcohol or acute drug detoxification is limited to a maximum of 2 times per person lifetime.
Beat It! Plan – First time use is paid at 100% of inpatient or outpatient services approved by Beat It!  Second time use- 80% of inpatient or outpatient services approved by Beat It!  No benefits are provided after the second time use.
Benefits paid under the Beat It! plan and the Self-Funded plan have a combined lifetime maximum of $25,000.
The above is only a summary of the coverages provided by the Bay Area Roofers Self Funded Medical Plan. All exclusions and limitations of benefit coverages have not been included. The contents of this summary are not to be construed or accepted as a substitute for the provisions of the Summary Plan Description.

 

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