Please note that this web page may contain outdated information. Please confirm any information by contacting the Local 802 Health Benefits Office.
Summary Materials Modification (“SMM”)
October 2014 Plan Changes
May 2015 Buy-Up Extension
September 2016 Express Scripts – Management Programs
September 2016 Express Scripts – Anti-Obesity
March 2017 AETNA
AETNA TeleDoc SMM – May 2017
Privacy Notice (revised 9/17/2013)
Health Insurance Claim Form
Dependent Enrollment Form
NYS COBRA Continuation Assistance Program Application
Women’s Health and Cancer Rights Act of 1998
Newborns and Mothers Health Protection Act
Waiver of Benefit Coverage
Credit Card Authorization Form
Form W-9 HBF
LOCAL 802 MUSICIANS HEALTH FUND
322 West 48th Street, New York, NY 10036
Phone: (212) 245-4802, ext. 171, 172, 173 and 178
Fax (212) 245-2304, E-mail: email@example.com
Mail all claim forms to:
Local 802 Musicians Health Fund
P.O. Box 1001
Garden City, New York 11530
The Local 802 Musicians Health Fund was established in 1951 for musicians and their families and is administered by a joint board of employer and union trustees and a plan administrator. The union trustees are Local 802’s President, Recording and Financial Vice-Presidents and rank-and-file members of the union. The Fund was established to receive contributions on behalf of musicians from employers only. This means that the plan cannot be purchased by musicians individually, except as provided by law (COBRA).
Employers are required to make contributions to the Fund on your behalf if you work for an employer who is a signatory to a Local 802 AFM collective bargaining agreement (CBA) requiring such contributions. The CBA sets the contribution level for the work you perform for a participating Employer.
If a certain amount of employer contributions are made on your behalf during a six-month Contribution Period, you will be eligible for health coverage from the Fund during the corresponding six-month Coverage Period. Since you may work for several employers in a single Contribution Period, the Fund looks at all of the employer contributions made on your behalf during that period in order to determine whether you are eligible for coverage.
In order to be eligible, you must have the following minimum contributions made on your behalf during a six-month Contribution Period (January 1- June 30th or July 1st to December 31st). You will be eligible for one of the Fund’s three benefit levels based on the amount of contributions that are received on your behalf in accordance with the following:
|MINIMUM CONTRIBUTION REQUIREMENTS|
|Plan B (Dental/Vision Only)||$500|
When you reach the minimum contribution level during a six-month Contribution Period, you and your eligible Dependents are eligible for coverage under one of the above options for the corresponding Coverage Period, subject to payment of the required premium (if applicable) as follows:
|For the Six-Month Contribution Period from:||The Six-Month Coverage Period will be:|
|January 1 - June 30||September 1 - February 28|
|July 1 - December 31||March 1 - August 31|
|CONTRIBUTION REQUIREMENTS AND SELF-PAY AMOUNTS|
|PLAN A+||PLAN A|
|Required 6-month Employer Contribution||$4,500||$2,000|
|Individual Participant Premium||$300 quarterly||$300 quarterly|
|Family Participant Premium||$1,200 quarterly||$1,200 quarterly|
|*Individual Empire Direct HMO Buy-up||$183/month||$348/month|
|*Family HMO Buy-up||$540/month||$770/month|
* Please note that the Empire Direct HMO Buy-up option will no longer be available to new participants effective 10/1/14. It will continue to exist as an option for those members enrolled prior to 10/1/14.
NEW ENROLLMENT RULES EFFECTIVE 10/1/2014
Effective 10/1/14, eligible individuals will no longer be automatically enrolled for coverage under the fund (unless the individual qualifies for Plan B coverage).
In August and February of each year, the Fund Office will notify Participants of any change in their eligibility based on their coverage in the prior 6-month Coverage Period. The new 6-Month Coverage Periods will be September – February and March – August (except that a 5-Month Coverage Period will apply for the first Coverage Period beginning on the effective date of the new program – October 1, 2014 – February 28, 2015).
If you and your spouse or eligible domestic partner are both active employees working for an employer contributing to the Fund on your behalf, but neither of you has earned sufficient employer contributions to establish eligibility, the earned employer contributions may be combined for the purpose of obtaining family coverage.
However, only one member can be considered the covered participant; the other person is considered a dependent. You have the option to designate who will be considered the covered participant. This decision does not have to be based on who has the greater amount of employer contributions.
Quarterly Participant Premiums
Participants are required to contribute toward the cost of their own individual or family coverage under both Plans A and A+)as detailed in the chart below:
Individuals who are eligible for Plan B are not required to pay a quarterly participant premium to be enrolled in the New Plan B dental and vision benefits. This includes individuals who have $500 -$1,999 in employer contributions during a 6 month eligibility period as well as those who qualify for Plan A+ or Plan A but choose not to pay their quarterly participant premium will drop down to Plan B.
|QUARTERLY PARTICIPANT PREMIUM|
|Plan A+ ($4,500 level of employer contributions)||$300 for Individual Coverage
$1,200 for Family Coverage
|Plan A ($2,000 level of employer contributions)||$300 for Individual Coverage
$1,200 for Family Coverage
|Plan B Dental/Vision ($500 minimum level of employer contributions)||Individuals eligible for Plan B are automatically enrolled in these benefits. Those covered under Plan A or Plan A+ may add this benefit for an additional premium.|
If you are required to make a quarterly premium payment , you will receive a quarterly invoice from the Fund. Once you receive your invoice, you must remit by the payment deadline.
Plan A and Plan A+ participants who do not pay the required quarterly premium for individual coverage will default to the new Plan B dental/vision coverage. Late premium payments will be returned to you.
DOMESTIC PARTNER BENEFITS PROGRAM
Domestic Partner Application
The Plan offers coverage for participants’ Domestic Partners. For purposes of the Plan, a Domestic Partner is defined as two individuals who:
- are at least 18 years of age or older;
- are of the same or opposite sex;
- are not married to, or legally separated from, another individual, and are not in a domestic partner relationship with any other individual;
- are not related by blood to a degree of closeness that would prohibit marriage in their state of residence;
- have lived together in the same residence for at least six months prior to the application for benefits and presently intend to live together indefinitely; and are financially interdependent, which must be demonstrated by the types of evidence described in the Fund’s Policy regarding Domestic Partner Benefits.
For purpose of the Fund’s Policy, the term Domestic Partner also includes two people of the same gender who are legally married in a state that recognizes such marriages, or are parties to a civil union in a state that recognizes such unions. The parties must submit to the Fund a copy of their marriage certificate or civil union certificate (and need not provide the Fund with evidence of financial interdependence).
Enrollment of Domestic Partners
A participant may enroll a Domestic Partner and his/her eligible dependent children for coverage under the Fund by submitting to the Fund Office a completed and signed Affidavit of Domestic Partnership (which must be notarized) along with the required proof (e.g., marriage certificate, civil union certificate, proof of financial interdependence, birth certificate for child, etc), and a completed enrollment form obtained from the Fund Office. Enrollment of a Domestic Partner (and child) must occur at one of the following times:
(i) when the participant first becomes enrolled in the Fund for him/herself,
(ii) during the Fund’s annual enrollment period,
(iii) within 30 days of marriage or entering into a civil union,
(iv) within 30 days of the birth or adoption of a child of the Domestic Partner (provided that the Domestic Partner is enrolled for coverage either before or at that time), or
(v) within 30 days of the individual’s loss of other coverage, provided that sufficient proof of loss is provided to the Fund Office.
Coverage will be effective in accordance with the Fund’s enrollment rules.
Important Note Regarding Penalties for Providing Incorrect or Incomplete Information: If the Fund (or its designee) determines that a Fund participant or Domestic Partner has committed fraud or made an intentional misrepresentation of a material fact (including, for example, in the Affidavit or enrollment forms; in a benefit claim or appeal; in response to any request for information by the Fund (or its designee); or by failing to timely notify the Fund of the termination of a Domestic Partnership (including a divorce or dissolution of a civil union) within 30 days of such termination, divorce or dissolution), coverage may be terminated retroactively on thirty (30) days written notice. Coverage may also be terminated retroactively and without notice (unless required by law) if the Fund (or its designee) determines that the Domestic Partner or child is ineligible for coverage under the Plan and such retroactive termination would not be considered a “rescission” under applicable federal law.
If coverage is terminated retroactively, the participant and Domestic Partner will be required to reimburse the Fund, its insurers and agents for any expenditures made by them for benefit claims, processing fees, administrative charges and all other costs (including interest and any attorneys’ fees incurred in order to collect such amounts) on behalf of a Domestic Partner and his or her child. In addition, the participant may be subject to further action (such as termination of coverage).
Domestic Partner Coverage and Important Tax Consequences
Domestic Partners (and their eligible children) are eligible for self-pay health coverage on the same basis as spousal (and dependent child) coverage is provided under the Fund.
However, the Internal Revenue Service (“IRS”) generally does not recognize domestic partners, civil union partners or same-sex spouses (or their children) as eligible dependents under the Internal Revenue Code’s provisions regarding employer-sponsored health plans. Therefore, unless the Domestic Partner (or child) is the participant’s “dependent” as defined in Section 105(b) of the Internal Revenue Code, the fair market value of the health coverage provided by the Fund to the Domestic Partner and his or her children will be included in the participant’s gross income, subject to Federal income tax withholding and employment taxes, and will be reported by the Fund on an IRS Form W-2. The value of the coverage may also be subject to State and City income tax depending on the applicable state and locality.
A participant who enrolls a Domestic Partner (and his or her child) for coverage under the Fund will receive an IRS Form W-2 reflecting the value of the coverage provided by the Fund (as determined in the Fund’s discretion, and as may be changed from time to time without prior notice). The Fund generally calculates the fair market value of Domestic Partner coverage using the applicable COBRA rate (not including the 2% administrative fee).
If a participant believes that his or her Domestic Partner or his/her child qualifies as the participant’s dependent under the Internal Revenue Code, the participant must submit a notarized certification to the Fund Office. In general, in order to qualify as the participant’s dependent for this purpose, the individual: (i) must be a member of the participant’s household during the entire taxable year, and (ii) must receive more than half of his or her support from the participant. Participants are strongly encouraged to consult with a tax advisor regarding all of the requirements for dependent status before completing such a certification.
Termination of Domestic Partner Coverage
Coverage extended to a Domestic Partner and his/her eligible children will end on the earliest to occur of the following:
- on the date that the participant’s coverage under the Fund ends for any reason (including the participant’s death);
- when the child loses eligibility under the terms of the Fund;
- when the participant fails to timely pay the required contributions for such coverage in accordance with the Fund’s rules;
- when the participant voluntarily dis-enrolls the Domestic Partner and child from coverage at any time, by providing written notice to the Fund Office; or
- when the partners no longer satisfy the requirements of a Domestic Partnership as described in the Fund’s Policy and the Declaration (or, in the case of a marriage or civil union, when the parties have divorced or dissolved their civil union), in which case coverage will end on the last day of the month in which the parties no longer satisfy the requirements for a Domestic Partnership, or on the date of the divorce or dissolution of their civil union. You must notify the Fund Office in writing within 30 days of the date that the parties no longer satisfy the requirements of a Domestic Partnership (or within 30 days of a divorce or dissolution of a civil union, in those cases). In cases of divorce or dissolution of a civil union, the participant must provide the Fund Office with a copy of divorce decree or dissolution certificate within 30 days of the divorce or dissolution.
Important Note: Upon termination of coverage, a Domestic Partner and his/her children will only be entitled to federal COBRA continuation coverage if the participant is eligible for and receiving COBRA coverage for him/herself. However, New York State continuation coverage may be available to a same-sex spouse (and his or her child) under certain circumstances upon a loss of the insured hospitalization coverage provided by the Fund.
A participant may not enroll a new Domestic Partner for coverage under the Fund within twelve (12) months of the termination of another Domestic Partner’s coverage, except in cases of a new marriage or civil union.
EMPIRE BLUECROSS BLUESHIELD
Effective 10/1/2014, the Local 802 Musicians Health Fund no longer accepts new enrollees into the Empire Blue Cross Direct HMO.
Please consult your Direct HMO card for your group number (D1, D2 or M1):
VISION (Fund-Administered benefit) Plans A+ & A
The Local 802 Fund Administered Vision benefit, described in the chart below, will continue to be included at no additional coast as part of Plan A+ and Plan A eligibility.
Effective 10/1/2014, there will also be a new vision benefit available as part of the new Plan B dental and vision plan described later in this summary.
How The Plan Works
The Fund provides Vision benefits through a variety of cooperating vision care providers. Once a year, you and your Dependent are eligible for a routine eye examination, one pair of eyeglasses, and one pair of frames (limited selection). For a list of vision providers, you can call or e-mail the Plan Office.
Vision benefits are paid according to the following schedule. You will not be reimbursed for any amount over those listed in the Schedule of Benefits below.
|VISION SCHEDULE OF BENEFITS|
|Service||Maximum Allowance Per Year|
|Routine Eye Examination (one per calendar year)||$15.00|
What’s Not Covered
Benefits are not payable for examinations, lenses and frames in excess of one of each (two lenses) per Calendar Year; sunglasses unless they are prescribed to work essentially at all times; tinted-lens glasses unless they are prescribed by an ophthalmologist for medical reasons; and routine annual examinations required by an employer in connection with the occupation of the covered individual.
PLAN B DENTAL AND VISION PLAN
If you qualify for Plan B benefits based on your employer contributions, the dental and vision benefits will be provided at no cost to you.
If you are covered under either Plan A+ or Plan A, the Plan B dental and vision benefits will be available on a “self-pay” basis, and you must pay the required premium. The premium for dental and vision benefits is payable for six months in advance at $247.00 for individual coverage and $692.00 for family coverage.
A description of the Plan’s new dental and vision benefits is included below:
|DENTAL AND VISION COVERAGE|
|Dental Coverage||Benefit Level|
|Annual Maximum Benefit||$1,500.00|
|Services through a Network Provider|
|Basic Restorative Services||80%|
|Major Restorative Services||50%|
|Services through a Non-Network Provider||Paid at Network Allowance|
|Orthodontia||50% to $1,500 Maximum|
WHAT’S COVERED AND WHAT’S NOT?
SEE ATTACHED SUMMARY PLAN DESCRIPTION, PAGES 38-47.
This is a covered benefit for both Plan A & Plan A+.
As required by law, the fund covers all expenses for well-child care, with no deductible or co-payment applied. Well-child care includes the full series of immunizations and tests, from infancy through adolescence, recommended by the American Academy of Pediatrics.
MUSICIANS EARPLUG BENEFIT
Plan A & Plan A+
The Fund provides earplugs through several preferred earplug providers. Participants who obtain earplugs through a preferred provider will be reimbursed up to a maximum of $105 for a set. This benefit is available once every two years. Contact the Fund Office for additional information regarding the preferred providers.
Plan A & A+ ONLY
Be sure to use your Prescription Drug Card to get prescriptions filled at a local participating pharmacy for a 30-day supply or less. You may use the Mail Order service for chronic medications (30 days or longer, up to a 90-day supply).
|PRESCRIPTION DRUG CO-PAYMENT|
|Retail Generic||$20 Co-payment|
|Retail Formulary||$35 Co-payment|
|Retail Non-Formulary||*40% coinsurance; $50 minimum/$75 maximum|
|Mail Order Generic||$40 Co-payment|
|Mail Order Formulary||$70 Co-payment|
|Mail Order Non-Formulary||*40% coinsurance; $100 minimum/$150 maximum|
*Your cost is the greater of the Co-payment or the percentage of the total cost.
How The Plan Works
Prescription Drug benefits are available to Plan A+ and Plan A participants and their eligible dependents through Express Scripts. Prescription Drug coverage is not available to Plan B participants. Effective 10/1/2014, there is no longer an annual maximum cap on prescription drug benefits for either Plan A or Plan A+.
How to Obtain Your Prescription Drugs
Express Scripts has established a Network of pharmacies through which you may fill prescriptions. If you use one of Express Scripts participating pharmacies, your out-of-pocket costs may be lower than if you use a non-participating pharmacy.
The Express Scripts Network consists of over 60,000 pharmacies nationally, including chain drugstores like CVS, Rite Aid and Walgreens. You may contact Express Scripts Member Services at (866) 544-2926 to find a pharmacy in your area that participates with Express Scripts. You can also locate a participating pharmacy on Express Scripts web site at www.express-scripts.com.
For service, simply present your identification card and a valid prescription at any pharmacy for service. While a pharmacy can usually check eligibility online without an ID card, if you purchase a prescription at a participating pharmacy without your ID card, you might need to pay for the prescription and submit the prescription drug receipt to Express Scripts for reimbursement. The participating pharmacy will dispense a prescription in a quantity not to exceed a 30-day supply and collect the applicable Co-payment (as described on the next page).
If you purchase a prescription at a non-participating pharmacy, you will have to submit a claim form along with the prescription drug receipt to Express Scripts for reimbursement. You must submit the receipt(s) no later than 12 months from date of purchase in order to receive reimbursement. Please note that any difference between the cost of the prescription and the amount allowed by the Plan will be your responsibility (in addition to the applicable Co-payments). It is always to your advantage to use a Participating Pharmacy.
See the “Claims Information and Appeals” Section of this booklet for information on how to file a prescription drug claim.
Prescription Drug benefits are available for Plan A+ and Plan A participants. Plan B participants are not eligible for prescription drug coverage.
The prescription drug benefit is structured as a three-tiered program with Co-payments, as follows:
Mandatory Generic Drug Program
If you are a Plan A participant, you must ask your provider to authorize a generic substitution for a brand-name prescription, if an approved generic is available and it is acceptable for you to use. If your doctor agrees, get a new prescription for the generic medication and take it to your local retail pharmacy or send to Express Scripts by Mail. You will pay an amount in addition to the Co-payment listed above when you purchase a brand-name medication that has a generic equivalent. The additional amount will be the difference between the approved cost of the brand-name and the generic medication. Note: The difference will be charged even if your provider indicates “Dispense as Written” or “No Substitution” on the prescription.
Save Money – For You and the Plan By Using Generics
Some interesting facts about generic drugs:
- Generics contain the same active ingredients and must meet the same standards as their brand-name counterparts.
- Generics must also be equivalent in strength and usage and produce the same effect as the original brand-name drug.
- Generics usually cost 30-60% less.
- Half of all prescription drugs are now available as generics.
Plan A Specific Exclusions
The following drugs are not covered and are excluded from Plan A coverage:
- All Proton Pump Inhibitors (PPIs), including Aciphex, Prevacid, Protonix, Omeprazole, and Nexium
- Non/Low Sedating Antihistamines (NSAs), including Allegra, Zyrtec, and Clarinex.
In addition, some PPIs and NSAs are excluded because they are now available as over-the-counter drugs – e.g., Prilosec OTC, and OTC NSAs such as Loratadine, Claritin 24-Hour Allergy, and Tavist ND among others.
Want to Know if a Drug is Covered?
See the following link to the updated 2016 Preferred Drug List Exclusions or simply access the Express Scripts Health website at www.express-scripts.com for a list of preferred drugs on the formulary or to find out which medications may have been excluded. You can also call Member Services at (866) 544-2926.
Mail Order Prescriptions
If you are prescribed chronic medication or use “maintenance” prescription drugs, you have the option of participating in the Express Scripts By Mail prescription Mail Order program where you can obtain up to a 90-day supply of prescription drugs, rather than a 30-day supply at your local retail pharmacy. To participate in the program, ask your doctor to indicate the number of refills needed for the “maintenance” drug prescription. You can then mail your prescription, with an applicable Co-payment, as well as the patient profile/registration form available from the Plan Office to Express Scripts By Mail. Remember: If you are in Plan A, you must use the Mandatory Generic Program if a generic equivalent is available and acceptable for you to use.
In order to receive refills, simply complete the prescription order form provided with your order and mail it to Express Scripts By Mail.
Your medication will be delivered to you at no additional cost. Please allow 7-11 days turnaround time for delivery. It is recommended you have an adequate supply of medication to cover the delivery period. In an emergency situation, your prescription can be sent overnight for an additional fee. If your doctor faxes the prescription, please allow 5-8 days for delivery.
If you need assistance or have questions about Express Scripts By Mail, call Member Services at (866) 544-2926 or access their website at www.express-scripts.com.
Limitations Under the Mail Order Program
The following limitations would apply for mail order prescriptions:
- No prescription may exceed a three (3) month supply.
- There will be an additional charge for injectables, other than injectable insulin for the treatment of a diabetic condition, which are not covered under the Medical benefits.
- Prescription drugs administered in a Physician’s office and prescription drugs compounded for IV infusion are not covered.
- Maintenance prescription drugs that are limited to two retail fills must be submitted to the mail order service.
Covered prescriptions include:
- Prescriptions which require compounding.
- Prescriptions for legend drugs (drugs which cannot be dispensed by a pharmacy without a prescription)
- Insulin (daily dosage includes needles and syringes), diabetic drugs, and birth control pills.
What’s Not Covered
Please contact Express Scripts for the most up-to-date information on which drugs are not covered by the Plan. This list is reviewed from time to time, in light of new drugs approved by the FDA and other considerations, and the list is revised from time to time based on criteria established by Express Scripts.
SICK PAY BENEFIT
Sick Pay Claim Form
The Sick Pay benefit applies to participants who do work that is covered by the Local 802 AFM & Broadway League agreement. The benefit will be paid when you provide the Fund Office with a completed claim form and have accrued eligibility.
Eligibility for Sick Pay Benefits
You are eligible to begin accruing Sick Pay benefits on the date you become covered under an employment agreement with the Broadway League [on your first performance played].
Accrual of Sick Pay Benefits
The Sick Pay year runs from Labor Day to Labor Day. You accrue benefits for all employment covered under an agreement with the Broadway League as a regular orchestra employee or substitute. There is no minimum number of shows performed to begin to be eligible to accrue sick time. You will accrue one (1) sick day for every fifty-two (52) Broadway performances played. For purposes of this benefit, absences for [paid] vacation are counted as performances played.
Your Sick Pay Benefits
Sick Pay Benefits are paid directly by the Fund. However, you are not eligible for a paid sick day until you have performed at least 52 performances. You may claim sick pay benefits if you are ill and miss a performance for which you are engaged.
Sick days may be accrued retroactively. In other words, if you take a sick day before you have played 52 performances, you may be reimbursed for that previous sick day as of the date that you have played 52 performances.
The Plan allows for a maximum of eight paid sick days per year. If you do not use your accrued sick days by Labor Day, you will forfeit any unused days. However, in the case of a prolonged, continuous illness that lasts for longer than seven (7) consecutive days, you may claim any unused sick days from the preceding year. To claims these benefits, you must provide the Fund Office with a physician’s certification attesting to your continued illness.
Make sure you notify your employer of your illness when you give notice of your absence and your substitute.
Amount of Sick Pay Benefit
The amount of the benefit payable for each sick day is equal to the gross wages (subject Medicare and Social Security taxes) you lost due to the absence caused by your illness.
How to Claim Sick Pay Benefits
In order to claim benefits, you must complete the “Application for Benefits from the Sick Pay Fund of Local 802 American Federation of Musicians” form (PDF attached). You must have your employer complete the form and certify that you were absent on the date claimed. You must submit the completed claim form to the Fund Office within 30 days of your illness in order to receive benefits. If your claim form is not received by the Fund Office within 30 days, you will not receive benefits for the day(s) you were out sick. Mail or bring your completed claim form to the Fund Office, 322 West 48th Street, New York, NY 10036.
If you are claiming benefits due to an extended illness (over 7 days) and wish to use the prior year’s unused benefits, you must attach a physician’s certification to the benefit claim form.
If you are claiming benefits before you have worked the necessary number of days to have accrued a sick pay day, submit your claim as soon as you return to work, and within 30 days from the date you take the sick day. You will receive payment of benefits as soon as you have worked the necessary number of days to be eligible for this benefit.
The Loss of Time benefit applies to Plan A+ (with hospitalization), Plan A+ and Plan A participants. The benefit will be paid when you provide proof that while covered under this benefit, you became Totally and Continuously Disabled as a result of:
- a non-occupational accidental Injury; or
- an Illness, not due to Occupational Disease.
The Fund will pay $75 per week for up to a maximum of 13 weeks. For any Period of Disability that is less than one week in duration, the benefits will be paid at one-seventh of the weekly amount multiplied by the number of days.
Benefits will be paid for the period stated on the claim form. If disability continues beyond that period, a second form must be filed.
Contact Fund Office for Loss of Time claim form.