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IBC Basic Plan - Frequently Asked Questions (FAQs)

   ELIGIBILITY FOR BENEFITS

 

What benefits do I have?

The IBC Basic plan provides a comprehensive program of health benefits including hospital, medical, mental health and substance abuse, prescription drug, dental, vision, long-term disability, life insurance (including Accidental Death & Dismemberment).

 

How can I get a new or another insurance ID card?

If you have not received an ID card for any of your benefits or need an additional ID card for a dependent please call Member Services at 800-551-3225.

 

How do I know if a health service is covered?

You should review your Summary Plan Description (SPD) for detailed coverage of all your benefits. If you have additional questions contact Member Services at 800-551-3225.

 

Are my dependent(s) eligible?

Yes, if your collective bargaining or participation agreement provides for family coverage. In general, your covered dependent(s) include your spouse and your children until they reach 26 years of age (refer to your (SPD) for more information).

 

What do I have to do to cover my dependent?

  • Fill out and return the appropriate form.
  • Provide documentation that proves that individual you want to enroll is your dependent. For example, you must provide a marriage certificate to cover your spouse or a birth certificate for a dependent child.

Call Member Services at 800-551-3225 for more information.

Click here to access the Dependent Enrollment form

 

What happens if I have a change in my life (like marriage, birth of a child or divorce)?

You must:

  • Notify the Fund within thirty (30) days of the date of the event or marriage or birth.
  • Fill out and return the appropriate form.
  • Provide documentation proving the relationship.

If you notify the Fund within thirty (30) days, your dependent will be covered from the date of the event (birth, adoption, marriage). If you do not notify the Funds within thirty (30) days of the event, your spouse/child will only be covered prospectively from the date you notify the Fund.

 

Do I need to enroll to be covered for benefits?

No, you are automatically enrolled in benefits but you will need to enroll your eligible dependents.


   MEDICAL & HOSPITAL

 

Which doctors can I see?

You have coverage for doctors both in-network and out-of-network. Using out-of-network doctors can be very expensive for you and is not recommended. You have access to a large network of in-network doctors with minimal co-pay costs to you through the Independence Blue Cross’s (IBC) Keystone Direct Point-of-Service ("POS") network*. To find in-network doctors please go to https://provdir.ibx.com/ or call Member Services at 800-551-3225.

*If you live outside the IBC service area which includes the Philadelphia metropolitan area and parts of New Jersey and Delaware, you have the IBC Personal Choice PPO network and you can find a full listing of providers at https://provdir.ibx.com/.

 

Do I need to select a Primary Care Physician (PCP)?

Yes. Each covered individual must select a PCP from the IBC POS network and advise IBC. Call IBC Customer Service at 800-275-2583 to select your PCP. This selection will be printed on your IBC identification card. Your PCP must make referrals for you for 5 services- X-Rays, physical therapy, occupational therapy, podiatry and laboratory services.

 

Do I need a referral from my Primary Care Physician (PCP) for other specialist visits?

No, you do not need a referral and can see all other participating specialists directly. Just make sure they are a participating IBC Keystone POS specialist to be covered with only a co-payment.

 

What does it cost me to see a doctor?

When you see an in-network doctor you may have a co-pay. The following chart clearly describes your co-pay based on the doctor or provider you choose.

  IBC Participating POS Providers
Doctor Office Visits $25 co-payment/visit
 

If you see an out-of-network doctor, you will pay more. You will pay the $1000 annual deductible, 50% of the allowed amount and all charges above the allowed amount. The allowed amount is usually significantly less than what an out-of-network doctor charges so the costs to you could be significant.

 

What is the 5 Star Wellness Program?

This program is exclusively designed for 32BJ members & their eligible dependents with Chronic Conditions. In order to be eligible for the program, you must be diagnosed with one of the following illnesses:

  • Asthma
  • Heart Disease
  • Diabetes
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Peripheral Artery Disease (PAD)
  • Stroke
  • Hypertension (High Blood Pressure)

To participate in the program, all your care for your Chronic Condition must be coordinated by your primary care doctor at the 5 Star Center. Once enrolled, you will pay $0 for all doctors’ visits* at your 5 Star Center and receive a discount on all of your prescription drug co-payments through CVS Caremark - $5 for a 30-day supply and $10 for a 90-day supply for each medication. A typical member enrolled in the 5 Star Wellness Program saves an average of $250 per year in medical and prescription drug costs.

 

If I am away from home, am I covered when I see a doctor?

Yes, just make sure you see a doctor that is a participating provider in a local BlueCross BlueShield network to get the highest level of coverage.

 

What happens if I need care while I am traveling abroad?

If you require care while traveling abroad, call the number located on the back of your card to help you find a provider. You are only covered for emergencies when traveling outside the country. You will need to submit a claim for reimbursement when you return to the U.S.

 

What do I pay when I use the Emergency Room?

When you use the Emergency Room you will pay a $100 co-pay for your first visit and a $100 co-pay for a second visit during a calendar year. After your second visit in a calendar year, you will pay a $200 co-pay per visit.

 

What do I pay if am admitted to the hospital for an overnight or longer stay?

If you are admitted to an in-network hospital you will pay a $100 co-pay for the hospital admission. There is no additional cost to you for in-network services, but if you are seen by out-of-network doctors (including surgeons and anesthesiologists) you may receive additional bills for those doctors. We advise you to only use in-network doctors while at the hospital whenever possible. Please call Member Services at 800-551-3225 if you receive bills for out-of-network providers at an in-network hospital.

 

Besides in-network doctor office visit co-pays, what other co-pays will I have when receiving care from an in-network provider?

If you only see doctors that are in-network and use facilities that are in-network the following chart details all co-pays that you may have to pay. If you stay in-network you do not have a deductible or co-insurance payments to worry about.

Hospital & Facility Visits  
Hospital emergency room $100 per visit. After 2nd visit in a calendar year, $200.
Hi-tech radiology (CAT, MRI, PET, MRA and nuclear studies) $100 per scan
Hospital
inpatient
$100 per admission
Hospital
out-patient department
$75 per visit (except for maternity, chemotherapy, radiation therapy & intensive out-patient mental health and substance abuse services)*

*No co-payment for out-patient maternity services. Out-patient radiation therapy and chemotherapy limited to one co-payment per calendar year. Intensive out-patient mental health or substance abuse services limited to one co-payment per episode of treatment.

 

Is prior authorization required to receive services? Do I need to get permission before I can use some services?

Yes, prior authorization is required for the following services:

  • High-tech Imaging (CT/PET scans, MRIs/MRAs and Nuclear Medicine tests)
  • Other Imaging Services (bone density testing and echo stress tests)
  • Hospital and in-patient surgery
  • In-patient and intensive out-patient Mental/Behavioral Health
  • In-patient and intensive out-patient Substance Abuse Disorder
  • Rehabilitation Services
  • Radiation Therapy
  • Skilled Nursing Care
  • Hospice Service (in-patient only)
  • Durable Medical Equipment
  • Physical and Occupational Therapy
  • Air ambulance (non-emergency)
  • Ambulatory surgery (reconstructive and optical procedures)

When you use participating providers, the provider is required to obtain the prior authorization for you.


   MENTAL HEALTH OR SUBSTANCE ABUSE

 

How can I find a mental health or substance abuse provider that is in-network?

To find in-network doctors please go to https://provdir.ibx.com/ or call Independence Blue Cross at 800-275-2583.

 

What do I pay when I see an in-network mental health or substance abuse provider?

Benefit In-Network
In-patient mental health or substance abuse $100 co-pay per admission
Office visits $25 Co-pay
Outpatient hospital facility $75 co-pay per episode of intensive outpatient treatment while in the hospital

 

 

What if I or my family needs immediate mental health or substance abuse assistance?

Call IBC’s Magellan Behavioral Health 24/7 at 800-688-1911.


   PRESCRIPTION DRUG BENEFIT

 

What prescription drugs are covered?

The Plan has a formulary or list of covered generic and brand name drugs. Please call CVS/Caremark at 877-765-6294. This number is also on the back of your CVS/Caremark ID card.

 

What do I pay when I get a covered drug?

  Short-term Drugs at a Participating Pharmacy (up to a 30-day supply) Maintenance Drugs by Mail or at a CVS Pharmacy (up to a 90-day supply)
Generic Drugs $10 co-payment $20 co-payment
Brand Drugs $30 co-payment $60 co-payment

 

 

Do I have to use a CVS pharmacy?

For prescriptions you will only take for a limited period (60 days or less), you can use any participating pharmacy. This will include many of the large chain drug stores like Rite Aid, Duane Reade or Walgreens as well as many local independent retail pharmacies. For prescriptions that you will need long term, you must get a 90 day supply through either a CVS retail pharmacy or CVS/Caremark mail service. For all Specialty Prescription Drugs you must use a CVS pharmacy or CVS/Caremark Specialty Mail Pharmacy.

 

Why do I need to get a 90 day supply of my medications? How do I do this?

For maintenance drugs that you take over a long period, the 90 day supply saves you money. The co-pay is equivalent to two 30 day co-pays, but you get a 90 day supply. Your doctor should write you a prescription for 90 days with whatever number of refills he/she feels is appropriate. These prescriptions need to be filled at a CVS retail pharmacy or through CVS/Caremark mail service.


   DENTAL BENEFIT

 

What does my dental benefit cover?

The Dental Plan covers a wide range of dental services, including:

  • Preventive and diagnostic services, such as routine oral exams, cleanings, x-rays, topical fluoride applications and sealants,
  • Basic therapeutic and restorative services, such as fillings and extractions,
  • Major services, such as fixed bridge work, crowns,dentures and gum surgery, and
  • Orthodontic services, such as diagnostic procedures and appliances to realign teeth

Dental benefits are subject to frequency limits and there is an annual maximum of $500 per person for dental care. Refer to your SPD for detailed information.

 

Which dentists can I see and what will I pay when I see a dentist?

Your Dental Plan has a large network of participating dentists which is administered by the dental administrator, Delta Dental. When you use a participating dental provider (PDP) most services are covered in full. You can find a PDP near you by searching Delta Dental or by contacting Delta Dental’s Customer Service at 800-932-0783. You can also use a non-participating dentist but you will need to submit a claim to Delta Dental for reimbursement. Delta Dental will reimburse you directly up to what Delta Dental pays an participating dentist for those services. You are responsible for any balance billing from the non-participating dentist.

Consult your SPD or call Member Services at 800-551-3225 for more information.


   VISION BENEFIT

 

Where can I get a vision exam and glasses if I need them?

All in-network vision coverage is provided through Davis Vision which has thousands of participating providers throughout the United States. Contact Davis Vision at 800-999-5431 for assistance in locating a Davis Vision provider near you or to find an in-network Davis Vision provider please go to Davis Vision.

There is an out-of-network benefit for participants and dependents over age 19, but you will have to pay charges in full and request reimbursement for the allowed amount.

 

How much will I pay for an exam and glasses?

If you use a Davis Vision participating provider, you can get an exam and glasses with no out-of-pocket cost. Your choice of frames and lenses will be limited to the Plan’s wide selection at Davis Vision. If you want frames and/or lenses outside of the Plan’s selection you will need to pay the difference.

If you use a non-participating provider, you can get reimbursed up to $30 for eye exams, $60 for lenses and $60 for frames. You are responsible for paying the charges in full and requesting reimbursement directly from Davis Vision for up to the allowed amounts.

 

Can I choose to get contacts instead of glasses?

Yes, but the maximum allowance for contacts is $120.

 

How often can I use my vision benefit?

The vision benefit is payable once in any 24 month period, starting with the date you first incur a vision care expense (typically an eye exam). Participants and dependents under 19 are eligible once every 12 months.


   LIFE INSURANCE BENEFIT

 

What is my life insurance benefit and how does my beneficiary claim this benefit?

You have a $10,000 life insurance benefit with MetLife. You beneficiary should contact Member Services at 800-551-3225 when filing a claim.


   GENERAL QUESTIONS

 

Do I have to file claims?

  • No, if you use a 5 Star Center, or in-network participating provider, you do not have to file claims. The provider will do that for you.
  • If you do not use a participating provider, you have to file the claims yourself.
 

What if I have other health insurance?

If you, or your dependent(s), have other insurance, the Plan and your other plan will coordinate benefit payments. One plan will be Primary and the other Secondary. Generally, the Plan that covers you, or your dependent, through work is the Primary Plan; for example, if your spouse has coverage at work, that plan will be Primary for your spouse. The Primary Plan will pay first and the Secondary Plan may reimburse you for the remaining expenses up to the allowed amount. This process is known as Coordination of Benefits or COB (refer to your SPD for more information).

 

If I change 32BJ covered employers, what happens to my health coverage?

If you change covered employers and you have a break of 91 days or less in employment, your coverage will begin on your first day back to work. If there is more than a 91 day break in employment, your coverage will not begin until you complete 90 consecutive days of employment with your new covered employers (refer to your SPD for more information).

 

If I leave the industry, how long can I stay on the health coverage?

Your coverage will end on the last day of the second pay period in which no hours are reported. Prior to the expiration of your coverage, you will be offered under the Consolidated Omnibus Budget Reconciliation Act of 1986 (“COBRA”) the opportunity to purchase vision coverage for up to seventeen (17) months from your eligibility end date. COBRA coverage is very expensive because you pay the entire premium. Before you elect COBRA, you should go to www.Healthcare.gov to learn what options may be available to you in the Healthcare Marketplace.

 

What happens to my health coverage if I become disabled?

If you are eligible, the Fund will pay continued health coverage (Fund-paid Health Extension). This coverage counts toward the time you are eligible for COBRA. To be eligible, you must:

  • Have become disabled (either totally or totally and permanently) while working in covered employment.
  • Be unable to work.
  • Be receiving (or be approved to receive) one of the following benefits:
    • Short-term Disability ("STD").
    • Worker’s Compensation.

If you are covered by the Tri-State or Basic plan, your coverage may be extended for up to six (6) months.

 

What happens to my family’s coverage if I die?

If your family is enrolled/covered on the date of your death, their coverage will continue at no cost for thirty (30) days. Prior to the expiration of the thirty (30) days, your family will be offered the opportunity to continue coverage under COBRA for 35 more months by paying a monthly premium. COBRA coverage is very expensive because you pay the entire premium. Before you elect COBRA, you should go to www.Healthcare.gov to learn what options may be available to you in the Healthcare Marketplace.

 

Who do I call if I have questions?

Call Member Services at 800-551-3225 Monday through Friday between the hours of 8:30am to 5:00pm. Or visit the Welcome Center at 25 West 18th Street, New York, NY 10011, Monday through Friday between the hours of 8:30am - 6:00pm.