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North Fund Tri-State Plan - Frequently Asked Questions (FAQs)
ELIGIBILITY FOR BENEFITS
1. What benefits do I have?
The North Fund Tri-state Plan provides a comprehensive health benefits, including hospital, medical, behavioral health and substance abuse, prescription drug, dental, vision, long-term disability, life insurance (including Accidental Death & Dismemberment coverage) and a death benefit for plan participants who are receiving a pension (“pensioners”). For more details about your benefits, please review your Summary Plan Description (SPD).
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2. How can I get a new or another insurance ID card?
If you need a new ID card for any of your health benefits, or you need an additional ID card for a dependent, please call Member Services at 800-551-3225, Monday–Friday, 8:30 a.m. –8 p.m., and Saturday, 9 a.m.–5 p.m.
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3. How do I know if a health service is covered?
You should review your Summary Plan Description (SPD) for detailed coverage information about all of your benefits. If you have questions, please contact Member Services at 800-551-3225.
MEDICAL & HOSPITAL
Your Plan provides coverage for you to see both in-network and out-of-network doctors.
IMPORTANT: Using out-of-network doctors can be very expensive for you and is not recommended.
You pay only your regular, minimal copays when you see an in-network doctor. Through the Anthem BlueCross & BlueShield Direct Point-of-Service (“POS”) network, your Plan gives you access to thousands of in-network doctors in the “NYC metropolitan area”, which includes New York, New Jersey and Connecticut. You can find in-network doctors by visiting findadoctor.32bjfunds.org or by calling Member Services at 800-551-3225.
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The Plan pays 100% for office visits with 5 Star Center doctors, including primary care physicians (PCPs) and specialists. For other in-network doctors who are not part of a 5 Star Center, you have a $40 copay for office visits, and the Plan pays 100% of the remaining cost for the office visit.
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5 Star Centers are private doctors’ offices where members have $0 copays for most health services. 5 Star Centers’ team-based approach to healthcare has proved to deliver comprehensive, high-quality services with positive results for our members, which is why the Health Fund covers your copays for office visits, lab work, urgent care and X-rays at a 5 Star Center. To be designated a 5 Star Center, a practice must meet high standards established by the National Committee for Quality Assurance (NCQA). In addition, most 5 Star Centers provide services we know are important to our members, such as extended appointment hours, multilingual staff and much more.
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You can search for a 5 Star Center by clicking here or by calling a 5 Star Center Rep at 877-299-1636.
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When you are outside of the POS network coverage area, you are covered only for medically necessary care. If you are traveling in another country and have a medical emergency, go to the nearest hospital. The BlueCross BlueShield Global Core service center can answer your questions about out-of-area coverage. You can call them toll free at 800-810-2583 or collect at 804-673-1177, 24 hours a day, seven days a week.
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You pay a $100 copay per visit for your first two Emergency Room (ER) visits, and then the Plan pays 100% of the remaining costs. After the second ER visit, your copay increases to $200 per visit.
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Your inpatient copay is usually $100 at a preferred hospital or $1,000 at a non-preferred hospital. IMPORTANT: For certain healthcare services, the Health Fund has created special, low-cost programs that have specific guidelines and restrictions, including the Lantern Network for Bariatric, Joint Replacement, and Spine Surgeries and the 32BJ Maternity Program . Please call Member Services at 800-551-3225 if you have questions or need help.
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If you only see doctors that are in-network and only use facilities that are in-network, the chart below lists all of the copays you might have to pay. When you stay in-network, you do not have a deductible or coinsurance payments to worry about.
*You have no copay for outpatient maternity services. You are limited to one copay per calendar year for outpatient radiation therapy and chemotherapy. You are limited to one copay per episode of treatment for intensive outpatient mental health or substance abuse services.
| Hospital & Facility Visits | IN-network Hospital or Facility | OUT-of-network Hospital or Facility |
| Hospital emergency room | You pay a $100 copay per visit for first two visits, and the Plan pays 100% of the remaining costs. After the second visit, you pay a $200 copay per visit, and the Plan pays 100% of the remaining costs. | |
| Hi-tech radiology (CAT, MRI, PET, MRA and nuclear studies) | You pay a $100 copay at a Preferred Hospital or an Independent Facility (a facility not affiliated with a hospital), and the Plan pays 100% of the remaining cost. You pay a $250 copay at a Non-preferred Hospitals, and the Plan pays 100% of the remaining costs. | You pay 50% after the deductible and any charges above the allowed amount. Plan pays 50% of the allowed amount. |
| Hospital inpatient | You pay a $100 copay per admission at a Preferred Hospital, and the Plan pays 100% of the remaining cost. You pay a $1,000 copay per admission at a Non-preferred hospital, and the Plan pays 100% of the remaining costs. | |
| Hospital out-patient department | You pay a $75 copay at a Preferred Hospital or an Independent Facility (a facility not affiliated with a hospital), and the Plan pays 100% of the remaining costs. You pay a $250 copay at a Non-preferred Hospital, and the Plan pays 100% of the remaining costs. | |
BEHAVIORAL HEALTH OR SUBSTANCE ABUSE
12. How can I find an in-network mental health or substance abuse doctor or other licensed professional?
To find in-network doctors please go to findadoctor.32bjfunds.org or call Member Service at 800-551-3225.
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13. What do I pay when I see an in-network mental health or substance abuse doctor?
| Benefit | In-Network |
| Inpatient behavioral health or substance abuse | You pay a $100 copay per admission at a Preferred Hospital, and the Plan pays 100% of the remaining costs. You pay a $1,000 copay per admission at a Non-preferred Hospital, and the Plan pays 100% of the remaining costs. |
| Physician/behavioral health professional office visits | You pay a $20 copay for each visit, and the Plan pays 100% of the remaining costs. |
| Outpatient hospital facility | You pay a $75 copay at a Preferred Hospital, and the Plan pays 100% of the remaining costs. You pay a $250 copay at a Non-preferred hospital, and the Plan pays 100% of the remaining costs. |
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14. What if I or my family needs mental health or substance abuse assistance?
Call WebTPA at 877-487-4300.
PRESCRIPTION DRUG BENEFIT
The Plan has a “formulary”, which is a list of covered generic and brand name drugs. To find out if a specific prescription medication is covered, please call OptumRx at 844-569-4148, the same phone number that is on the back of your OptumRx ID card.
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| 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 copay | $20 copay |
| Brand Drugs | $30 copay | $60 copay |
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For prescription medications that you will take for a limited period only (60 days or less), you can use any participating pharmacy. OptumRx participating pharmacies include many of the large chain drugstores, like Rite Aid, Duane Reade or Walgreens, as well as many local independent retail pharmacies.
For prescription medications that you will need to take for the long term (more than 60 days), you must get a 90-day supply through either a CVS retail pharmacy or the OptumRx mail service. You must fill all Specialty Prescription Drugs through the OptumRx Specialty Pharmacy
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For maintenance drugs that you take over a long period, the 90-day supply saves you money because your copay is equivalent to two 30-day copays for a 90-day supply of medicine. Ask your doctor to write you a prescription for 90 days with whatever number of refills he/she feels is appropriate. You must get these prescriptions at a CVS retail pharmacy or through the OptumRx mail service.
DENTAL BENEFIT
The Dental Plan covers a wide range of dental services, including:
- Preventive and diagnostic services – like routine oral exams, cleanings, X-rays, topical fluoride applications and sealants
- Basic therapeutic and restorative services – like fillings and extractions
- Major services – like fixed bridge work, crowns,dentures and gum surgery, and
- Orthodontic services, including diagnostic procedures and appliances to realign teeth
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Your Dental Plan has a large network of participating dentists in and outside of the New York City metropolitan area, administered by Delta Dental. The Delta Dental network that covers you depends on where you live. If you live in New York State, you are covered by the Delta Dental NY Select network. If you live outside New York State, you are covered by the Delta Dental PPO network. When you use a participating dentist, you get the most out of your benefit. . You can find a participating dentist near you by searching or by contacting Delta Dental at 800-589-4627.
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 the same amount that they would pay a participating dentist for the same services minus your coinsurance amount. You are responsible for any remaining costs (“balance billing”) from the non-participating dentist.
Please check your SPD or call Member Services at 800-551-3225 for more information.
VISION BENEFIT
All in-network vision coverage is provided through Davis Vision, which has thousands of participating vision professionals throughout the United States. Please contact Davis Vision at 800-999-5431 or visit findadoctor.32bjfunds.org to find an in-network professional near you.
There is an out-of-network vision benefit for Plan participants and their dependents who are over age 19. You will have to pay all of the charges upfront and then request reimbursement for the allowed amount. Question 22 explains how much you will pay for an eye exam and glasses at Davis Vision.
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If you use a Davis Vision participating professional, you can get an exam and choose the frames and lenses for your glasses from the Plan’s wide selection at Davis Vision–with no out-of-pocket cost to you. However, if you want frames and/or lenses that are outside of the Plan’s selection, you will need to pay the difference in cost.
If you use a non-participating vision professional, you can get reimbursed up to $30 for eye exams, $60 for lenses and $60 for frames. You are responsible for paying all of the charges upfront and then requesting reimbursement directly from Davis Vision for up to the allowed amounts.
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Yes, but the maximum allowed amount for contacts is $120.
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You can use your vision benefit one time in any 24-month period, starting with the date you first have a vision care expense (typically an eye exam). Plan participants and their dependents who are age 19 and under are eligible to use their vision benefit once every 12 months.
LIFE INSURANCE BENEFIT
25. What is my life insurance benefit, and how does my beneficiary claim this benefit?
You have a $15,000 life insurance benefit with MetLife. Your beneficiary should call Member Services at 800-551-3225 to file a claim.