Health Care Benefits Provided by Your 2018-2022 Local ......RI Public Employees’ Health Services...

HealthCareBenefitsProvidedbyYour

2018-2022LocalUnion1033Contracts

•  ThispresentationisintendedtohighlightthehealthcarebenefitsprovidedtoLocalUnion1033membersthroughtheirUnionContract.

•  ThispresentationcannotreflectallofthespecificitythataPlanDescriptionProvides.Asalways,theSummaryPlandocumentationprevails.

•  OperativechangesarepresentedinBOLD.

RIPublicEmployees’HealthServicesFund

VISIONCARE•  Coordinatedwiththe1033HealthCarePlan-fulleyeexamduringeach12-

monthperiodwithadditionalexamsasrequiredduetomedicalconditions.•  Addedtothisbargainedforbenefitisyou1033HealthFundprovidedvision

hardware(glasses,frames,lensesandcontactlenses)benefit.TheFund’sImprovedVisionPlan(benefitsincreasedby50%)isthroughanewprovider,EyeMedVisionCare,L.L.C.(www.eyemed.com),asubsidiaryofLuxottica,withownershipinterestsinLensCrafters,PearlVision,TargetOptical,SearsOptical,JCPenneyOptical,SunglassHut,ILORI,contactsdirect.com,andglasses.comaswellaseyeglassframebrandsRay-Ban,D&G,Oakley,Prada,Coach,Vogue,Armani,ToryBurchandothers.

•  OurFund’srelationshipwithEyeMedsupportsLocalUnion1033memberswithavastlylargerNetworkofbenefitprovidersaswellasin-networkframesandlenses.ImprovedInNetworkbenefitsincludeupto$150.00towardframesandlens(every24monthperiod)anda20%discountforcostsabovethatallowance,a15%discountforLISAKorPRKprocedures.

RIPublicEmployees’HealthServicesFund PREPAIDPRESCRIPTIONPROGRAM

HIGHLIGHTSOFTHE1033ACTIVEMEMBERSHIPRXPROGRAM–providedthroughMAXORPlus(8006878629).CoveredPrescriptions:OnlymedicallynecessaryprescriptionmedicineswithapprovedFDAregistrationnumberswillbecovered.*Insuliniscoveredbutbloodglucosemonitors,teststrips,externalinsulininfusionpumps,devicesandinjectionaids,syringesarecoveredbytheBlueCrossHealthcarePlan,asdurablemedicalequipment,andnotbytheprescriptionplan.MembermustuseBlueCrossdesignatedDMESupplier.*AllselfadministeredinjectableRXs,(exceptEpi-Pens&Insulin,seeabove)aswellasbloodglucosemonitors&teststripsarecoveredat80%andFemaleContraceptivedevises&patches(ata$0copay),arecoveredbytheCaremark/CVSPlanandnotbytheMAXORprescriptionplan.TouseyourCVSbenefit,visitanyCVS,providebin#004336,groupRX7340,andyournameandDOB.•  OralContraceptiveRXsarefilledthroughMAXORat$0.copay

DMEsuppliers:USHOMEMED,LLC56PINEST,PROVIDENCE,RI 02903-2819NORTHEASTMEDICALEQUIPMENTINC,31WESTERNINDUSTRIALDRIVE,CRANSTON,RI 02921VANGUARDHOMEMEDICAL,155JEFFERSONBLVD,WARWICK,RI 02888-3878andmanyothers


•  Thebenefitdesignfortheactivemembershipincludesathree-tierprogram,whichcoincideswithapreferreddruglistwhichispublishedtwiceayear.Tier1isGenericRX,Tier2isBrandFormularyPreferredRXandTier3isNonFormularyNonPreferredRX.

•  GenericMedicationshallbedispensedwhenavailableandwhenthegenericistherapeuticallyequivalent.IftheMemberrequestsabrandwhenagenericdrugisavailable,thememberwillpaythegenericco-payplusthedifferencebetweenthebrandcostandgenericcost,eveniftheDoctorprescribesabrand.Thereareexceptionstothisruleforcertainbranddrugsthataretherapeuticallynarrowindexdrugs.ParticipantsareurgedtouseGenericMedicationandsavetheFundandtheadditionalcostsassociatedwithBrandNameMedication.


•  UseofthePlan:Membersdecidewhethertofillprescriptionsatthelocalretailpharmacy,orthroughmailorder.Co-paysanddispensedquantitiesdiffer.

–  LocalRetailPharmacy:Receiveuptoa30-daysupply;perprescriptionco-payshallbe:

–  GenericMedication-$5.00–  BrandName-Formulary(Preferred)Medication-$15.00–  BrandName–Nonformulary(Non-Preferred)Medication-$30.00

–  MailOrderPharmacy:Receiveuptoa90-daysupply;perprescriptionco-pay

shallbetwicetheamountofthe30-daysupply(fortriplethesupply!):–  GenericMedication-$10.00–  BrandName-Formulary(Preferred)Medication-$30.00–  BrandName–Nonformulary(Non-Preferred)Medication-$60.00

RIPublicEmployees’HealthServicesFundDENTALBENEFITS

•  CommencingJanuary1,2016,Local1033City&PSDMembersreceivedsignificantlyimprovedDentalBenefitsunderanewplannegotiatedandadministeredbytheirUnionHealthFund.Benefitswereimprovedagainin2017and2018andToday,the1033DeltaDentalPlanoffersthehighestlevelofcoverageintheState.

•  Network:DeltaDentalPremier,withover145,000DentistandDentalSpecialistin292,000locationsthroughouttheUSA.WhetherachildisawayatSchool,youaretravelingorathomeinRhodeIsland,InNetwork-DentalProfessionalsarereadilyavailable.UtilizinganInNetwork-providerwillalwaysresultinthegreatestandmostcompletebenefit.YoumayfindInNetwork-providersthroughouttheCountrybyvisitingdeltadental.com.

•  Deductible:Individual/Family$0.00

RIPublicEmployees’HealthServicesFundDENTALBENEFITS

•  YearlyMaximumbenefit:$2,000.00perfamilymember*withacarryoverbenefitLifetimeMaximum:Dentalunlimited-Orthodontics$2,000.00

•  Youandeverymemberofyourfamilywillreceive100%InNetwork-coverageforExams,Xrays,Cleaningstwiceayear,SealantsandSpaceMaintainers(adolescent),Fillings,RootCanalTherapy,ExtractionsandotherRoutineOralSurgery,PeriodontalMaintenance,Tissueregenerationandbonegraphs,RepairstoDentures,RecementingCrownsorBridges,Crownsovernaturalteeth,,Crownsoverimplants,Partialand,RootPlanning/Scaling,Bonesurgery,Gingivectomies,Softtissuegrafts,Crownlengthening;

•  80%InNetwork-coverageforImplants,Bridges,CompleteDenturesBuildups,Posts,Cores,and

•  50%InNetwork-coverageOrthodontics(toage26).*Effective7-1-18,withbenefitsretroactiveto1/1/16,our1033DentalBenefitPlanhasincludeaMaximumCarryOverbenefitandanInNetwork-CarryOverbonus.Thisenhancementallows1033membersandfamilymemberstoannuallycarryover$250,limitedtoacumulativeCarryOvermaximumbenefitof$2000.andanadditional$100.(total$350)ifallserviceswereprovidedbyanInNetwork-DentalOfficeandthemember/familymemberhadayearlydentalvisit.(seeplanforspecificinformation).

RIPublicEmployees’HealthServicesFundCity&PSDLocal1033-MedicalPlan

LocalUnion1033Members(andfamilymembers)employedbytheCity&PSDenjoyoneofthemostadvantageousMedicalHealthcarePlansavailablethroughouttheUSA.OurnegotiatedPlanisbaseduponBlueCrossofRI’sHealthmatePlanandhasbeencontinuouslyimproved.Your1033HeathFundinitiallydesignedthisPlanin1991.Duetooursuccessinprovidingtotallycomprehensivecoverageataffordablerates,ourPlanhasbeencopiedbyscoresofPublicEmployers.COVERAGELEVELS:InNetwork-Paymentofadesignatedandfixedcopaywithfullcoveragefromabroadnetworkofhospitals,PCP'S,andspecialistsacrosstheUnitedStates.MemberswillnotbebilledforchargesbeyondBlueCrossallowance.ThenetworkshallbeequivalenttotheBlueCrossNationalPPONetwork.Includesabroad-basedLocal,RegionalandNationalnetworkofhospitals,physiciansandotherhealthcareprofessionals,plusspecializednetworksforeyecare,lab&x-rayservices,DME,chiropractic,homecare,mentalhealth/substanceabuse.OutofNetwork-Membersmayalsochoosetoseeanyothernon-participatingproviderandstillreceivecoverageat80%oftheInNetwork.ThenetworkallowanceisbasedupontheU.S.BlueCrossPPORegionalallowancefortheRegioninwhichmedicalservicesarereceived.


•  Deductible–CurrentlythereisNOInNetworkdeductiblebutthereisanOutofNetworkannualdeductibleof$100perindividual-$300perfamily.

•  January1,2019-NewEmployeeswillhavea$750.perperson/$1500.maxperfamilydeductibleforIn&OutofNetworkservices(exceptingpreventativeandearlydetentioncare)

•  July1,2019-ALLEmployeeswillhavea$750.perperson/$1500.maxperfamilydeductibleforIn&OutofNetworkservices(exceptingpreventativeandearlydetentioncare)

BUTYOURFAMILIESCOVERAGEWILLBEENHANCED&YOUROUTOFPOCKETMEDICALEXSPENCESWILLBELOWER!OurCity&PSDLocalUnion1033MedicalPlanwillincludeaHealthcareReimbursementAccount(HRA)whichwilldirectlypaytoyourHealthcareProvidersalldeductibleexpenses….PreJanuary1,2019LocalUnion1033membersandtheirfamilymemberswillbearNOOUTOFPOCKETDEDUCTABLEEXSPENCES,whetherincurredINorOUTofNetworkthroughafundedHRAcoveringupto$750perindividualindeductiblecostsAndupto$1500inbenefitsfortheentireFamily.PostJanuary1,2019memberswillreceiveHRAbenefitsfundedat$300.foranindividualPlanand$600.foraFamilyPlan.TheUnionHealthFundwillprovideanadditional$100inFSAbenefitsduringthemembersinitialyearofUnionMembership.


•  MemberscontributionstotheCity&PSDLocal1033-MedicalPlan–July1,2019–  Employeeswithannualbasewageslessthan$43,501shallco-shareinthecostof

healthcareinsurancethroughpre-taxweeklypayrolldeductionbythepaymentof15%ofthenegotiatedworkingrate

–  Employeeswithannualbasewageslessthan$51,501.00butmorethan$43,501shallco-share…16.5%ofthenegotiatedworkingrate.

–  Employeeswithannualbasewagesof$51,501.00ormoreshallco-share…20%ofthenegotiatedworkingrate.

–  Theseratesshallbeindexedtoreflectthesalaryincreasesoverthelifeoftheagreement.ExampleUnionmembersreceive2%wageincrease,,,lessthan$44,371@15%;$44,501to$52,[email protected]%;$52,531andgreaterat20%

–  BUTbeginninginJuly,2019,1033Memberswillhaveanopportunitytoearna$300.annualIndividualPlanCreditora$600.annualFamilyPlanCreditbyparticipatinginourCity&PSDLocal1033WellnessBenefit;forexampleEnrollintheprogram,GetanAnnualExam,GetaDentalExamandCleaning,EnrollinTelmed,haveaVisionExam,attendthe1033HealthScreeningandreceivea$300.or$600(spousemustalsoparticipate)credittowardyourMedicalPlanCo-share.

Carrot&StickCity&PSD-Local1033WellnessBenefit

Purpose:EnhancetheQualityofLifeforeveryLocal1033MemberandtheirFamilyMembersby:IncentivizehealthybehaviorsthroughaCarrot&Stickapproach.EarnCoShareCreditsbyparticipatinginpreventativemedicine&goodhealthevents:Example:ClerkIVwithfamilycoveragepaysacoshareof$2652.,withWellnesscreditsof$600.coshareisreducedto$2052.OREffectiveJuly1,2019,anyemployeewhofailstoreceiveanAnnualPreventativeMedicineExamduringacontractyear(July1toJune30)shallhavehisorherco-shareobligationincreasedbyanadditionalonepercentagepoint(1%)(e.g.21%,17.5%or16%)forthefollowingcontractyearunlessexemptedbyboththeAdministratoroftheRIPublicEmployeesHealthServicesFundandtheCity’sDirectorofEmployeeBenefits.Example:ClerkIVwithfamilycoveragepaysacoshareof$2652,withWellnesscreditsof$600.coshareisreducedto$2052butbynotgettinganAnnualExam,cosharewillbe$2813.!!!$761.more


•  PRE-AUTHORIZATION:Authorizationisobtainedbyparticipating(InNetwork)providers.Membersareresponsibleonlywhenusingnon-participatingprovidersandforcertaindiagnostictesting,includingMRI.

•  ANNUALMAXIMUMEXPENSE:Benefitsincreasedtofullcoverageafteranannualmaximumexpenseof$1,000perindividual;$3,000perfamilyforallHealthCarePlanoutofpocketexpenses,separateInNetworkvsOutofNetwork.(deductibles&copaysformedicalservicescoveredbyyourPSDLocal1033HealthCarePlan).AndyourHRApays$750./$1500.(Priorto7-1-19$4000/$8000)Benefitsincreasedtofullcoverageaftermaximumexpenseof$1,300perindividual;$2,600perfamilyforallself-administeredinoculationoutofpocketexpenses.Benefitsincreasedtofullcoverageaftermaximumexpenseof$1,300perindividual;$2,600perfamilyforalloralRXoutofpocketexpenses.MOOP–Alldeductibles,copays,coinsuranceapplytotheMOOP!

RIPublicEmployees’HealthServicesFund CITY&PSDLocal1033-MedicalPlan

•  LIFETIMEMAXIMUMS:Unlimited.•  DEPENDENTCOVERAGE:Spouse,DomesticPartnerandchildren(Childrenthrough

theendofmonthinwhichthechildturnsage26).•  OUTPATIENTSERVICES:PREVENTIVE&EARLYDETECTIONCARE:IncludingWell-baby

visits,AdultAnnual,PediatricOfficevisits,Preventivecounseling/education,ImmunizationsadministeredbyaHealthcareProfessionalandPreventativeScreenings.InNetwork-coveredinfull.OutofNetwork-$15copay,thencoverageat80%oftheInNetworkallowanceaftermeetingtheannualdeductible.

OFFICEVISITS:InNetwork-$0.co-paymentatNetworkPCMH*,$15co-paymentatPrimaryCarePhysician,$30.co-paymentforSpecialist,exceptingPreventative&EarlyDetectionCareasdefinedabove.*PatientCenteredMedicalHomeProviders-seedirectory.OutofNetwork-$15copayatPrimaryCarePhysician,$30.co-paymentforSpecialist,thencoverageat80%oftheInNetworkallowanceaftermeetingtheannualdeductible.TeleMedicine–InNetworkONLY,$7.50copaymentthenCoveredinFull

RIPublicEmployees’HealthServicesFund City&PSDLocal1033-MedicalPlan

•  EYEEXAMS:InNetwork-$15co-paymentforoneroutineexamperyear,OutofNetwork-$15copay,thencoverageat80%oftheInNetwork-allowanceaftermeetingtheannualdeductible.•  OUTPATIENTSURGERY:InNetwork-Coveredinfull,aftermeetingannualdeductible.

(nolonger$100.copayment)OutofNetwork-Copaythencoverageat80%oftheInNetwork-allowance,aftermeetingannualdeductible.(nolonger$100.copayment)•  DIAGNOSTICLAB&X-RAY:InNetwork-Coveredinfullaftermeetingannualdeductible

(exceptingPreventative&EarlyDetectionCare),subjecttoPreauthorization,atInNetworklab,diagnosticandx-rayfacilities.

OutofNetwork-Planpays80%oftheInNetwork-allowanceafteranannualdeductible,(alsosubjecttoPreauthorization).•  CHIROPRACTICCARE(15peryeartotalvisits)InandOutofNetwork):InNetwork-Officevisits$30.co-payment;labtests&x-rayscoveredinfull.OutofNetwork-Officevisits$30.copaythencoverageat80%oftheInNetwork-allowanceafteranannualdeductible;labtests&x-raysPlanpays80%oftheInNetworkallowanceafteranannualdeductible.


•  INPATIENTSERVICES(includesMATERNITY):(NOLONGER$100.CoPayment)•  HOSPITALROOM&BOARDincludingSURGICAL-MEDICAL:InNetwork-Covered

infullforunlimiteddaysofcareinasemiprivateroomwithallnecessarymedicalservicesaftermeetingtheannualdeductible.

OutofNetwork-Coverageat80%oftheInNetworkallowanceforunlimiteddaysofcareinasemiprivateroomwithallnecessarymedicalservicesaftermeetingtheannualdeductible.•  ORGANTRANSPLANT:InNetwork-Coveredinfullforunlimiteddaysofcarefor

eligibleservicestotherecipientandthedonorassociatedwithkidney,liver,lung,heart,corneaandhomologousbonemarrowtransplants,aftermeetingtheannualdeductible.

OutofNetwork-Coverageat80%oftheInNetworkallowanceforeligibleservicestotherecipientandthedonor,aftermeetingtheannualdeductible.•  FreeStandingSurgiCenterInNetwork-Coveredinfullaftermeetingtheannual

deductible(NOLONGER$100.CoPayment)•  OutofNetwork-Coverageat80%oftheInNetworkallowanceaftermeeting

theannualdeductible,(NOLONGER$100.CoPayment)


•  EMERGENCYROOM:$125.co-paymentfortreatmentofaccidentorlifethreateningmedicalemergencywithin24hoursofonsetofsymptoms(co-paymentwaivedifadmittedtoHospitalwithin24hours,includingbeingheldforobservationfor8hourorlonger).

•  URGENTCENTER:“WalkIn”InNetwork-$45.CoPay.OutofNetwork-$45.CoPaythencoverageat80%oftheInNetworkallowanceaftertheannualdeductible.•  DIALYSISSERVICES:Inpatient,outpatient,andhome,InNetwork-coveredinfull

aftermeetingtheannualdeductible.OutofNetwork-coverageat80%oftheInNetworkallowanceaftermeetingtheannualdeductible.•  RADIATIONTHERAPY/CHEMOTHERAPYSERVICES:outpatient&physician’soffice,InNetwork-coveredinfull.OutofNetwork-coverageat80%oftheInNetworkallowanceaftermeetingtheannualdeductible.•  RESPIRATORYTHERAPY:outpatient&physician’soffice,InNetwork-coveredinfull.OutofNetwork-coverageat80%oftheInNetworkallowanceaftermeetingtheannualdeductible.


•  BEHAVIORALHEALTH,MENTALHEALTH&SUBSTANCEABUSEINPATIENT:InNetwork-Coveredinfullforanunlimiteddaysofcare,aftermeetingtheannualdeductible.OutofNetwork-Coverageat80%oftheInNetwork-allowanceaftermeetingtheannualdeductible.•  OUTPATIENT:InNetwork-Coveredinfullforanunlimiteddaysofcare.•  OutofNetwork-Coverageat80%oftheInNetwork-allowanceaftermeetingthe

annualdeductible.•  PHYSICAL,SPEECH&OCCUPATIONALTHERAPYOUTPATIENT:InNetwork-80%coverage.Coveredinfullifwithin30daysofhospitaladmission.OutofNetwork-80%oftheInNetworkallowanceaftermeetingtheannualdeductible.•  PRIVATEDUTYNURSING&HOMEHEALTHCARE:InNetwork-80%coverage.Coveredinfullifwithin30daysofhospitaladmission.OutofNetwork-80%oftheInNetwork-allowanceaftermeetingtheannualdeductible.•  AMBULANCE:-$50.Copayperoccurrence.DoesnotincludeAirAmbulance.


•  DURABLEMEDICALEQUIPMENT,MEDICAL&DIABETICSUPPLIES,ENTERNALFORMULA&FOOD,PROSTHETICDEVICES:

InNetwork-80%coverage.OutofNetwork-80%oftheInNetworkallowanceaftermeetingtheannualdeductible.•  SKILLEDNURSINGFACILITYCARE(skilledorsub-acutecare)InNetwork-$20.peradmissioncopaythenCoveredinFull.OutofNetwork-$20.peradmissioncopaythen80%oftheInNetworkallowanceaftermeetingtheannualdeductible.•  AUTISMSERVICES:Behavioralanalysis,PT,OT,STandAutismdiagnosis:InNetwork-coveredinfull.OutofNetwork-80%oftheInNetworkallowanceaftermeetingtheannualdeductible.*IntermittedHomecareservicesandHomeHospice,CardiacRehab,GenderAffirmationServices,Hearingexam,diagnostictestingandHearingaids,LeukocyteAntigentesting,InfusionTherapyAdministrationandInfertilityTreatmentarecoveredbyRILaw,greatestlevelofcoverageisalwaysreceivedInNetwork.

Health Care Benefits Provided by Your 2018-2022 Local ......RI Public Employees’ Health Services...

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