Overview
The BOLR Full-Time Plan offers you and your eligible dependents medical, dental, and vision benefits. You also have access to Life and Accidental Death and Dismemberment (AD&D) insurance, in addition to disability income protection.
There is an additional premium to pay should you choose to enroll your children in your health plan.
Medical Benefits
Below is a summary of your coverage for common healthcare services. For a more detailed list, check your Enrollment Guide or your Summary Plan Description.
| BENEFIT | IN-NETWORK /REFERRED | OUT-OF-NETWORK/ SELF-REFERRED |
|---|---|---|
| Deductible (Annual) Individual Family | $0 $0 | $250 $500 |
| Annual Out-of-Pocket Maximum Individual Family Lifetime maximum | $6,750 $13,500 None | $6,750 $13,500 None |
| Hospital Inpatient1 | 100% | 70% of allowed amount, after deductible Up to 70 days per calendar year |
| Inpatient Physician Services | 100% | 70% of allowed amount, after deductible |
| Knee and Hip Replacement1,2 Blue Distinction Center + All other facilities | 100% 70% | Not Covered Not Covered |
| Emergency Room | For visits 1 & 2: 100% after $100 copay For visits 3 or more: 100% after $200 copay Waived if admitted | For visits 1 & 2: 100% after $100 copay For visits 3 or more: 100% after $200 copay Waived if admitted |
| Urgent Care | 100% after $40 copay | 70% of allowed amount, after deductible |
| Skilled Nursing Facility1 Up to 60 days per year | 100% | Not Covered |
| Doctor’s Office PCMH PCP | 100% after $10 copay | 70% of allowed amount, after deductible |
| Doctor’s Office Non-PCMH PCP and Specialists | 100% after $20 copay | 70% of allowed amount, after deductible |
| Preventive Care for Adults and Children3 | 100% | 70% of allowed amount, no deductible |
| Routine GYN Exam/Pap Smear One per year | 100% | 70% of allowed amount, no deductible |
| Mammogram | 100% | 70% of allowed amount, after deductible |
| Pediatric Immunizations | 100% | 70% of allowed amount, after deductible |
| Surgery Pre-certification may be required for some outpatient surgeries | 100% | 70% of allowed amount, after deductible |
| Lab/Pathology Outpatient4 | 100% | 70% of allowed amount, after deductible |
| Outpatient Diagnostic X-ray/ Radiology1,4,5 | 100% | 70% of allowed amount, after deductible |
| Home Health Care1 Up to 200 visits per calendar year | 100% | 70% of allowed amount, after deductible |
| Physical/Occupational Therapy4,5 Speech Therapy Up to 30 visits per modality, per calendar year | 100% after $20 copay | Not Covered |
| Cardiac or Pulmonary Rehabilitation Up to 36 visits per modality, per calendar year | 100% after $20 copay | 70% of allowed amount, after deductible |
| Durable Medical Equipment1 Select items require precertification | 100% | Not Covered |
| Ambulance Emergency Transport Non-Emergency Transport1 | 100% 100% | 100% of allowed amount, no deductible 70% of allowed amount, after deductible |
| Maternity First OB visit Hospital | 100% 100% | 70% of allowed amount, after deductible 70% of allowed amount, after deductible |
| Chiropractic (Spinal Manipulation)5 Up to 10 visits per calendar year | 100% after $20 copay | 70% of allowed amount, after deductible |
| Dialysis/Radiation1/Chemotherapy | 100% | 70% of allowed amount, after deductible |
| Nutrition Counseling 6 visits per year | 100% | 70% of allowed amount, after deductible |
| Nutritional Formulas & Medical Solid Food Products1 Precertification may be required | 100% | 70% of allowed amount, after deductible |
| Outpatient Private Duty Nursing1 Up to 360 hours per calendar year | 90% | 70% of allowed amount, after deductible |
| Hospice Care1 Up to 210 days per lifetime | 100% | Not Covered |
| Behavioral Health and Substance Use Program Services Provided by MHC, Inc. Call (800) 255-3081 | ||
| Inpatient6,7 | 100% | 70% of allowed amount, after deductible |
| Non-Office Outpatient Visits6 | 100% | 70% of allowed amount, after deductible |
| Outpatient6 | 100% after $20 copayment | 70% of allowed amount, after deductible |
1 Precertification required for these services. Please contact the member services department of Keystone HPE (Independence Blue Cross) for more information on those services requiring pre-certification.
2 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 or AmeriHealth designated facility is covered at 70%. There is no coverage for knee/hip replacements done out-of-network.
3 Must go to your chosen Primary Care Physician (PCP).
4 Must go to the PCP-designated site for care to be considered in-network.
5 Referral from Primary Care Physician (PCP) required.
6 In-network services administered by MHC, Inc. not Keystone or AmeriHealth. Contact MHC for a listing of network providers. Call MHC at 800-255-3081 or visit MHC online at www.mhconsultants.com.
7 Precertification required for these services. Contact MHC for more information about pre-certification of services related to Behavioral Health/Substance Use Treatment.
Prescription Drug Benefits
When you enroll in medical coverage, 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 BOLR BMCA Full-Time Plan offers complete vision care for routine eye exams, glasses, or contact lenses through the National Vision Administrator (NVA) participating provider network of ophthalmologists, optometrists, and opticians. If you don’t use participating NVA providers, you’ll be reimbursed for a portion of the cost of eye exams, glasses, or contact lenses.
| Vision Benefit Summary | ||
| Service | NVA Provider | Non-NVA Provider |
| Eye exam | 1 free exam every 24 months (12 months for children under age 19) | $30 allowance for one exam every 24 months (12 months for children under age 19) |
| Lenses and frames | $120 allowance every 24 months (12 months for children under age 19) | $60 allowance for lenses and $60 allowance for frames every 24 months (12 months for children under age 19) |
| Contact lenses | $120 allowance every 24 months (12 months for children under age 19) | $60 allowance every 24 months (12 months for children under age 19) |
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-$3,000 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. The specific amount of dismemberment coverage is determined by your loss.
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.
Disability Benefits
If you are a full-time employee and your employer makes an additional contribution to the Fund for disability benefits, you are eligible for disability benefits. Disability benefits provide you and your family with a supplemental weekly payment if you become disabled and cannot work due to a non-work-related illness or injury.
The specific time allowance for disability is determined by the diagnosis and established disability guidelines. However, no disability can exceed the maximum benefit of 26 weeks. For disability benefits to be considered, you must complete a disability claim form, and you must provide documentation from a legally qualified doctor certifying that you are disabled and unable to perform your normal work duties. Please note: MHC providers can also certify disability.
If you’re eligible, you’ll receive a weekly benefit equal to a percentage of your regular pay, up to a weekly maximum, while you are disabled and remain under the direct regular care of a legally qualified doctor or your care is being managed by an MHC Mental Health/Substance Use provider.
Your disability claim begins on the fourth working day after you visit your doctor as a result of your disability. Disability benefits will not be paid for any period in which you missed work before you visited your doctor.
Disability forms must be submitted on time. If you are out of work on a continuing disability that exceeds a month, you must submit continuation forms (“blue forms”) on a regular basis–usually once a month. See the form for more information about timing and deadlines. Contact the Fund Office to get a form.
For more information about disability benefits, see your Summary Plan Description, or call the Fund Office at 215-568-3262 or 800-338-9025 outside the local calling area.
* If your employer is required to make an additional contribution for disability benefits.
Please note: Some employers may still be under the flat rate benefit allowance, based on their contract requirements. If you are eligible under the flat rate weekly benefit for full-time employees who work 40 or more hours a week, the rate will be $210 per week. For full-time employees who work between 30 and 39 hours per week, the rate will be $175 per week.
