Overview
The 36Phlex Plan is a health and welfare benefits plan that gives you the freedom to choose from a menu of benefits options. The various coverage options ensure that you can create a benefits package that meets your specific needs.
The 36Phlex Plan uses a point system called PhlexPoints. You have 100 PhlexPoints to spend on benefits options.
- If the benefits you choose cost less than 100 PhlexPoints, you may use your remaining PhlexPoints to enroll in a Healthcare Reimbursement Account and/or a Dependent Care Reimbursement Account.
- If the benefits you choose cost more than 100 PhlexPoints, you aren’t eligible to enroll in the reimbursement accounts and you will have to contribute to the cost of your coverage.
Medical Benefits
You may enroll in medical coverage for yourself, or for you and your eligible dependents. There are two medical plans for you to choose from:
- High Option Plan: This is a Direct Point of Service (DPOS) plan. You must choose a primary care physician (PCP), and the plan pays a lower level of benefits if you receive certain medical services from a specialist without a referral from your PCP.
- Basic Plan: This is a Health Maintenance Organization (HMO) plan. You must choose a primary care physician (PCP), and your PCP must coordinate your medical treatment. The plan pays 100% for most in-network services, but there is no out-of-network coverage under the Basic Plan.
If you have other medical coverage through another employer or your spouse, you may opt out of the Fund’s medical plan and spend your PhlexPoints on other benefits. You’ll need to complete a Proof of Other Coverage Form on an annual basis if you wish to opt out.
High Option Plan Medical Benefit Summary
This chart gives you a quick look at the Medical Plan. Please refer to your Summary Plan Description for complete information about the High Option Plan’s benefits.
| BENEFIT | IN-NETWORK/REFERRED | OUT-OF-NETWORK/SELF-REFERRED |
|---|---|---|
| Patient-Centered Medical office Visits | 100%, after $10 copay | 70% after deductible |
| Doctor’s office Visits (Non-PCMH Primary and Specialist services) | 100%, after $20 copay (at non-PCMH provider) | 70% after deductible |
| Routine GYN Ex am/Pap Smear 1 per calendar year | 100% | 70%, no deductible |
| Mammogram | 100% | 70% after deductible |
| Pediatric Immunizations | 100% | 70% after deductible |
| Physical, Occupational or Speech Therapy* up to 30 visits per | 100%, after $20 copay | Not covered |
| Cardiac or Pulmonary Rehabilitation up to 36 visits per calendar year | 100%, after $20 copay | 70% after deductible |
| Chiropractic (Spinal Manipulation) up to 10 visits per calendar year | 100%, after $20 copay | 70% after deductible |
| Hospital Inpatient* | 100% | 70% after deductible up to 70 days per calendar year |
| Knee and Hip Replacement* ** Blue Distinction Center + All other facilities | 100% 70% | Not Covered Not Covered |
| Urgent Care | $40 copay | 70% after deductible |
| Emergency Room ER Visit 1 & 2 ER Visit 3 plus | $100 copay (waived if admitted) $200 copay (waived if admitted) | $100 copay, no deductible (waived if admitted) $200 copay, no deductible (waived if admitted) |
| Outpatient Lab /Pathology | 100% | 70% after deductible |
| Dialysis/Radiation/ Chemotherapy | Chemotherapy | 70% after deductible |
| Home Healthcare* up to 200 visits per calendar year | 100% | 70% after deductible |
| Hospice Care* up to 210 days per lifetime | 100% | Not covered |
| Skilled Nursing Facility* up to 60 days per calendar year | 100% | Not covered |
| Outpatient Surgery(precertification may be required for some outpatient surgeries) | 100% | 70% after deductible |
| Outpatient X-ray/Radiology | 100% | 70% after deductible |
| Durable Medical Equipment* | 100% | Not covered |
| Ambulance Emergency transport Non-emergency transport* | 100% 100% | 100%, no deductible 70% after deductible |
| Outpatient Private Duty Nursing*up to 360 hours per calendar year | 90% | 70% after deductible |
| Annual Deductible | N/A | $250/person $500/family |
| Annual Out-of-Pocket Maximum*** | $5,400/person; $10,800/family | $5,400/person; $10,800/family |
| Behavioral Health/Substance Abuse Program (coverage for psychiatric care and substance abuse) NOTE: Program is not part of the medical plan. Call MH Consultants Inc. at (800) 255-3081. | ||
| Inpatient | 100% | 70% after deductible up to 70 days per calendar year |
| Intensive Outpatient/Partial Hospital**** | 100% | 70% after deductible |
| Outpatient | 100%, after $20 copayment | 70% after deductible |
| *Precertification required for these services. This is not a complete list of services. Please contact Blue Cross Member Services for more information about which services require precertification. Note: Only non-emergency or elective hospital admissions require precerti fication. **Treatment received at a Blue Distinction Center + facility for knee and hip replacement is covered at 100%; treatment received at a Blue Distinction Center or any other participating Keystone facility is covered at 70%. There is no coverage for treatment received out-of-network. ***Annual Out-of-Pocket Maximum includes expenses to meet your annual deductible, as well as money you spend in copayments and coinsurance during the year. There is a separate Out-of-Pocket Maximum for prescription drugs (see page 12). ****Intensive Outpatient/Partial Hospitalization benefits are considered part of your inpatient Behavioral Health/Substance Abuse benefit. Two intensive outpatient sessions or two partial hospitalizations count as one inpatient day, with the same benefit limits and coinsurance. | ||
Basic Plan Medical Benefit Summary
This chart gives you a quick look at the Basic Medical Plan. The Basic Plan has in-network coverage only. There is no coverage for going out-of-network. Please refer to your Summary Plan Description for complete information about the Basic Plan’s benefits.
BENEFIT | IN-NETWORK |
Patient-Centered Medical Home Office Visits | 100%, after $15 copay |
Doctor’s Office Visits | PCMH Provider: 100%, after $15 copay Non-PCMH PCP: 100%, after $30 copay; Specialist: 100% after $40 copay |
Routine GYN Exam/Pap Smear 1 per calendar year; no referral needed | 100% |
Mammogram Screening—no referral needed | 100% |
Pediatric Immunizations | 100% |
Physical and Occupational Therapy up to 30 visits combined per calendar year | 100%, after $40 copay |
Cardiac and Pulmonary Rehabilitation up to 36 visits per calendar year | 100%, after $40 copay |
Speech Therapy* up to 20 visits per calendar year | 100%, after $40 copay |
Chiropractic (Spinal Manipulation) up to 20 visits per calendar year | 100%, after $40 copay |
Hospital Inpatient* | 100%, after $100 per day copay; (Max copay: $500 per admission) |
Knee and Hip Replacement* ** Blue Distinction Center + All other facilities | 100% 70% |
Urgent Care | $50 copay |
Emergency Room ER Visit 1 & 2 ER Visit 3 plus | $100 copay (not waived if admitted) $200 copay (not waived if admitted) |
Outpatient Lab/Pathology | 100% |
Dialysis/Radiation/Chemotherapy | 100% |
Home Healthcare* | 100% |
Hospice Care* | 100% |
Skilled Nursing Facility* up 120 days per calendar year | 100%, after $50 per day copay; (Max copay: $250 per admission) |
Outpatient Surgery | 100%, after $50 copay |
Outpatient X-ray/Radiology | Routine/Diagnostic: 100%, after $40 copay MRI/MRA, CT/CTA Scan, PET Scan: 100% after $80 copay |
Durable Medical Equipment & Prosthetics* | 70% |
Ambulance (non-emergency ambulance services require precertification) | 100% |
Outpatient Private Duty Nursing* up to 360 hours per year | 90% |
Annual Out-of-Pocket Maximum*** | $5,400/person $10,800/family |
Behavioral Health/Substance Abuse Program (coverage for psychiatric care and substance abuse) NOTE: Program is not part of the medical plan. Call MH Consultants Inc. at (800) 255-3081. | |
Inpatient …………….100%, after $100 per day copay (Max copay: $500 per admission) No benefits are paid for out-of-network services; MHC must approve and manage all treatment or no benefits will be paid. | |
*Precertification required for these services. This is not a complete list of services. Please contact Blue Cross Member Services for more information about which services require precertification. Note: Only non-emergency or elective hospital admissions require precertification. **Treatment received at a Blue Distinction Center + facility for knee and hip replacement is covered at 100%; treatment received at a Blue Distinction Center or any other participating Keystone facility is covered at 70%. There is no coverage for treatment received out-of-network. ***Annual Out-of-Pocket Maximum includes money you spend in copayments and coinsurance during the year. There is a separate Out-of-Pocket Maximum for prescription drugs (see page 12). ****Intensive Outpatient/Partial Hospitalization benefits are considered part of your inpatient Behavioral Health/Substance Abuse benefit. Two intensive outpatient sessions or two partial hospitalizations count as one inpatient day, with the same benefit limits and copays. | |
Prescription Drug Benefits
When you enroll in medical coverage under one of the 36Phlex Plan options, you’re automatically enrolled in prescription drug coverage through CVS Caremark. You won’t be eligible for prescription drug coverage if you opt out of the Fund’s medical plan.
A 30-day supply of medication is available at any in-network pharmacy. For a 90-day supply of medication, go to any CVS Pharmacy location or use the CVS Caremark Mail Order Pharmacy.
Prescription Drug Benefit Summary | |||
If your prescription is for: | Retail: 30-day supply | Retail: 90-day supply | Home delivery: 90-day supply |
Generic drugs | $7 | $14 | $14 |
Formulary* drugs | $22 | $44 | $44 |
Non-formulary drugs | You pay 100% of the cost | ||
Annual Out-of-Pocket Maximum | |||
Single | $1,950 | ||
Family | $3,900 | ||
*A formulary is a list of preferred generic and brand-name drugs developed by physicians and pharmacists at CVS Caremark.
Vision Care Program
The 36Phlex Plan offers two options for vision coverage:
- The enhanced vision program offers care through the National Vision Administrator (NVA) network of optometrists and ophthalmologists. You’ll receive maximum benefits when you use NVA providers. If you don’t use NVA providers, you’ll be reimbursed for a portion of the cost of eye exams, glasses, and contact lenses.
- The discount vision program offers lower rates for eye exams, glasses, and contact lenses at NVA providers.
Vision Benefit Summary | ||
Service | Enhanced Plan | Discount Plan |
Eye exam | 1 free exam every 24 months (12 months for children under age 19) | Discounts vary |
Lenses and frames | $120 allowance every 24 months (12 months for children under age 19) | Discounts vary |
Contact lenses | $120 allowance every 24 months (12 months for children under age 19) | Discounts vary |
Dental Benefits
Our dental plan, provided through Delta Dental, covers a wide range of dental services, including diagnostic and preventive care. This chart gives you a quick look at the Dental Benefits. Please refer to your Summary Plan Description for complete information about the benefits.
Dental Benefit Summary | |
| Service | Coverage |
| Deductible | None |
| Annual Maximum Benefit | $1,000 per person, per year |
| Preventive and Diagnostic Care | 100% |
| Basic Restorative Care | 100% |
| Major Restorative Care | 50% |
| Endodontics and Periodontics | 80% |
| Orthodontia (children only) | 50% ($1,000 lifetime maximum) |
Life Insurance and Accidental Death & Dismemberment Insurance (Death Benefit—Participant Only)
Life insurance is designed to protect your family, or anyone who relies upon your income, in the event of your death. Accidental Death and Dismemberment (AD&D) insurance pays a benefit to you if you suffer an accidental loss of a limb or your eyesight, and pays a benefit to your beneficiaries if you die as a result of a covered accident. There are three coverage levels: $10,000, $25,000, and $50,000.
If you choose the $10,000 or $25,000 benefit option, there is no additional out-of-pocket cost to you when choosing the high option medical plan, dental plan, and enhanced vision plan.
Dependents are not eligible for life or AD&D coverage, but you may designate one or more dependents as your beneficiary. Contact the Fund Office if you need to update your Beneficiary Information Form.
Short-Term Disability Benefits
If you’re a full-time employee and your employer makes an additional contribution to the Fund for disability benefits, you’re eligible for disability benefits in the event that you’re disabled and unable to work. A legally qualified physician or MHC mental health/substance abuse provider must certify your temporary total disability.
You’ll receive 70% of your regular pay, up to a maximum of 26 weeks, subject to the Plan’s duration of disability guidelines. Benefits begin on the fourth working day after you visit your doctor certifying your temporary total disability. To submit a disability claim, contact the Fund Office.
Reimbursement Accounts
There are two separate accounts—a Healthcare Reimbursement Account and a Dependent Care Reimbursement Account. Depending on the benefit choices you make, you may be eligible to participate in one or both accounts.
The Healthcare Reimbursement Account allows you to use your PhlexPoints to pay for healthcare expenses not covered, such as deductibles or copayments. When you submit documentation to the Fund Office for reimbursement, you’re paid tax-free from your account. The IRS determines which healthcare expenses are eligible for reimbursement, which you can review here.
The Dependent Care Reimbursement Account allows you to use your PhlexPoints to cover expenses related to childcare for your dependents under age 13, or for your spouse, elderly parents, or your older child with a disability. Eligible expenses include day care, family care, in-home care, and before- and after-school programs.
IRS regulations permit you to use your reimbursement account(s) for eligible expenses through March 15 of the following year. Any unused funds remaining in your reimbursement account(s) after March 15 of the following year are forfeited.
