The Plan provides quality medical benefits for you and your covered spouse or domestic partner. Your Plan partners with Blue Shield of California with the goal of controlling your out-of-pocket costs while expanding the network of contracted providers available.
Once eligible, you can schedule appointments with Blue Shield of California network providers for you and your covered spouse or domestic partner.
TIP: Remember to present your Blue Shield of California identification card to your medical provider before receiving benefits. Verify that the providers and facilities participate in the PPO network.
Search Blue Shield’s extensive provider network at www.blueshieldca.com/networkppo or by using the Blue Shield of California mobile app.
REMINDER: Some physicians and anesthesiologists working in a PPO hospital or emergency room may not be part of your Plan’s network.
After you meet your calendar year medical deductible (explained above), most covered services are paid based on the Blue Shield of California PPO network rate or allowable charge, whichever applies.
The Blue Shield of California PPO network rate is the amount a participating provider agrees to accept as payment for specific services. The participating provider cannot charge above the PPO network rate. In most cases, the Plan pays 80% of the PPO network rate. In some cases, the Plan pays an allowable charge instead of the PPO Network Rate. See the Summary Plan Description (SPD) or contact the Fund Office for more information.
Choose PPO network providers (doctors, hospitals, labs) that participate in the Blue Shield of California PPO network. If you use out-of-network providers, your out-of-pocket costs may be higher. Search for PPO providers at www.blueshieldca.com/networkppo or by using the Blue Shield of California mobile app.
REMINDER: Call 9-1-1 if you experience a life-threatening emergency. Or go to an emergency room immediately.
If it’s not an emergency, look for the nearest PPO network urgent care center. Your out-of-pocket costs will be more affordable.
Click here for Frequently Asked Questions about medical coverage.
The Pensioners & Surviving Spouses Health Fund determines, administers and pays prescription drug benefits. The Plan partners with Blue Shield of California to provide network access and help you take advantage of discounts on most prescription medications.
The deductible is the amount you owe each calendar year for covered prescription drugs before the Plan begins to pay. Your Plan has a separate $50 deductible per covered person for prescription drugs.
Once the $50 calendar year deductible is met, the Plan reimburses 100% of covered charges for each covered person up to a maximum benefit of $1,200 per person each calendar year.
EXAMPLE
You paid $6,550 for covered prescription drugs in 2020. The first $50 you paid was applied to your prescription deductible. The next $1,200 you paid was reimbursed at $1,200 ($1,200 x 100%). The remaining $5,300 you paid was higher than the prescription drug maximum benefit and was not reimbursed. In total, you received $1,200 in prescription drug reimbursements.
See your Summary Plan Description for details about prescription drugs, restrictions and exclusions. If you are not sure whether an item is covered, call the Fund Office at (800) 595-7473. Or if outside California, call (213) 385-6161.
REMINDERS:
Ask About Generic Drugs - They cost less yet provide the same clinical benefits as brand-name versions. Choosing generic drugs may make your out-of-pocket costs even lower.
Compare drug prices from different pharmacies. You can also save money by requesting a 90-day supply, especially through mail-order options.
How to Submit Prescription Drug Claims - You must submit prescription drug claims to the Fund Office for reimbursement by sending a properly completed Prescription Drug Claim Form along with a receipt or printout from a licensed pharmacy that includes all the following information:
Refer to the Summary Plan Description or contact the Fund Office for more information.
Services, prescriptions, medications, and supplies purchased outside of the United States and its territories are excluded, unless the services, medications, or supplies were the result of an accident or life-threatening emergency medical condition that occurred outside of the United States and its territories or the participant submits proof of residency in the country where the services were rendered.
Click here for Frequently Asked Questions about prescription drug coverage.
