Active Plan Information
Click on the links below to learn more about the Plumbers and Steamfitters Local 21 Welfare Fund benefits available to active participants.
Summary Plan Description and Summary of Material Modifications
Active Plan Welfare Fund Summary Plan as of January 1, 2020
Active Plan Welfare Fund Summary of Material Modification (COVID and Hospice Care) - June 2020
Active & Retiree Plan Welfare Fund Summary of Material Modification (Retiree Opt-Out HRA and Apprentice Hours) - May 2021
Active & Retiree Plan Welfare Fund Summary of Material Modification (No Surprises Act, HRA Eligible Expenses) - July 2022
Active Plan Welfare Fund Summary of Material Modification (COVID) - April 2023
Active & Retiree Plan Welfare Fund Summary of Material Modification (Retiree Medical, Prescription Drug) - May 2024
Active & Retiree Plan Welfare Fund Summary of Material Modification (HRA Card) - July 2024
Active & Pre-Medicare Retiree Welfare Fund Summary of Material Modification (Changes to Medical Benefits) - October 2024
HRA Excerpt from SPD
Uniform Summary of Benefits and Coverage
2025 Active Plan SBC
2024-2025 Active Plan SBC
2023-2024 Active Plan SBC
2022-2023 Active Plan SBC
2021-2022 Active Plan SBC
2020-2021 Active Plan SBC
Below is some additional information the Fund would like to specifically point out about using certain benefits. This information is supplemental to your Summary Plan Description.
Prescription Drug Formulary Management Information
Formulary
There are often several types of medications that can be used to treat the same condition. Only drugs listed on the formulary as covered are covered. As part of the formulary, various clinical and utilization management programs are used to ensure the effective, safe and cost-conscious prescriptions are chosen. These programs are described in more detail below.
OptumRx frequently updates this formulary based on available therapies, costs, efficacy and alternatives. You will be notified by OptumRx of any change in the formulary and if it has any effect on medication you are taking. For more information about the formulary, please contact OptumRx directly at (866) 863-1408. You may also click here for the most recent formulary effective July 1, 2024.
Prior Authorization and Drug Quantity Management
Certain medications require prior authorization (PA) because of their potential side effects, potentially harmful interactions with other prescription medications or to confirm they are being prescribed in accordance with Food & Drug Administration (FDA) approved indications. This process is designed to help ensure your health and safety. If a PA is needed, OptumRx will work directly with your physician to obtain the necessary information prior to fulfillment.
Drug quantity management is a program designed to limit the amount per prescription that can be dispensed at one time by number and/or pill dosage. This not only eliminates potential waste, but ensures you are taking the correct amount that is considered safe and effective, according to guidelines from the U.S Food & Drug Administration (FDA).
The list of medications that require prior authorization or are limited in dosage and/or quantity are determined by OptumRx and will change from time to time. Since OptumRx will modify this list from time to time, you should contact OptumRx to determine whether a particular medication is being managed. You can also click here and here for the list of drugs managed by these programs effective July 1, 2024.
If you go to a participating pharmacy, medications affected by these programs will also be identified automatically by OptumRx. If you receive a prescription for one of the medications, you should consult with your physician or pharmacist to have them reach out to OptumRx at (866) 863-1408. If you fill a prescription without the required authorization or approval, your medication will not be covered.
Step Therapy
In a Step Therapy program, covered drugs are organized in a series of “steps”. Step therapy is generally geared towards patients who regularly take prescriptions to treat chronic conditions or who are prescribed a high-cost medication where preferred therapeutically equivalent alternatives are available.
In essence, step therapy requires you to try the preferred alternatives prior to the more expensive prescription drug, unless your physician presents an acceptable medical reason for the more expensive drug or you have already tried the preferred drug and it was not effective. There are usually two "steps:” the step one preferred therapy and the step two non-preferred therapy. Click
here for the list of drugs subject to this program effective July 1, 2024.
If you have tried a step one medication and it doesn’t work for you and your physician has documentation that you previously tried and failed a first-step medication, the physician, pharmacist or you can contact the OptumRx clinical team at (866) 863-1408 and request a review of the medication.
Exceptions Process
In certain circumstances, there are exceptions to these formulary and management rules. Continued use of drugs that are not covered because they are non-formulary, or are subject to the aforementioned management programs must be approved through OptumRx’s exception process. The requests are evaluated on the basis of medical necessity, the individual’s health and safety and the existence of other viable alternatives. If you or your physician would like to request an exception, you should contact OptumRx at (866) 863-1408. Please note that the exception process must be initiated by your physician.
Telemedicine
The Welfare Fund offers LiveHealth Online telemedicine services in partnership with Anthem BlueCross BlueShield. Telemedicine is a telephone and online based physician consultation service available 24 hours a day, 365 days a year. It is a convenient and affordable option that allows you to talk to a doctor who can diagnose, recommend treatment and prescribe medication, when appropriate, or many common medical issues. LiveHealth online does not replace your primary care physician. Rather, it is designed to improve your family’s access to quality acute medical care at times when your physician’s office is closed or does not have an available appointment time that works with your schedule. At the same time, telemedicine has been shown to help minimize costs for members and benefit plans by preventing unnecessary emergency room and urgent care visits. Effective January 1, 2020, telemedicine consultations via LiveHealth Online are free of charge – you pay nothing.
Click
here for information about how to register for and use LiveHealth Online.
Click here for a flyer that explains how you can save time and money by utilizing LiveHealth Online when compared to an emergency room or urgent care visit.
Vision Providers
In order to use your vision benefits, please call Michelle Kendel at 914-737-7220 ext. 121 to request a vision voucher. Provided below are listings of participating vision providers.
Recently, Raymond Opticians has offered to provide services and products over and above your normal benefits. Click here for their flyer and call Michelle at the Fund Office for more details!
If you visit a non-participating provider, you must submit a detailed bill and receipt along with an Out-of-Network Manual Vision Claims Form. See the Summary Plan Description for more information on how to use a non-participating vision provider.
