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1199SEIUNATIONAL BENEFIT FUNDOVERVIEWOF YOUR BENEFITS1199SEIU FONDO NACIONAL DE BENEFICIOSDESCRIPCIÓN GENERAL DE SUS BENEFICIOSEN ESPANOL P. 12
The coverage described in this Overview is for both full-time and part-time membersof the 1199SEIU National Benefit Fund who have a Wage Class I or a Wage Class IIlevel of benefits.Prescription Benefits are provided through Express Scripts, the Fund’s Pharmacy BenefitManager. Dental Benefits are provided through EmblemHealth (PPO plan) or Aetna (DMOplan). These benefits are described in more detail in the Summary Plan Description(SPD) and in information provided to you by Express Scripts, EmblemHealth and Aetna.If you receive services from a provider who is not in the Fund’s network, you will beresponsible for any additional costs the provider may charge you.Members who have a Wage Class III level of benefits receive a different package ofbenefits. Please consult your Summary Plan Description (SPD) or contact the BenefitFund’s Member Services Department at (646) 473-9200 for information on your benefits.BENEFIT COVERAGEHOSPITAL CAREWAGE CLASS IWAGE CLASS IIFamilyFamilyInpatient Hospital Care This benefit is for the hospital’s charge for the useof its facility only. Coverage for services renderedby doctors, labs, radiologists or other services thatare billed separately by these providers may becovered, as described in Section II.H of the SPD Up to 365 days per year Semi-private room and board Acute care for Medically Necessary services Inpatient admissions Up to 30 days per year for inpatient physicalrehabilitation in an acute care facilityYou must call 1199SEIU CareReviewat (800) 227-9360 before going to thehospital or within two business days ofan Emergency admission. Benefits are not provided for care in a sub-acutenursing home or skilled nursing facilityOutpatient Hospital Care Ambulatory care Observation care and servicesHOSPICE CARE Coverage for a combined total of up to 210 daysper lifetime in a Medicare-certified hospice programin a hospice center, hospital, skilled nursing facilityor at homeFamilyFamilyYou must call 1199SEIU CareReview at(800) 227-9360 for Prior Authorizationof inpatient hospice care.PLEASE NOTE: MEMBERS WHO HAVE A WAGE CLASS III LEVEL OF BENEFITS RECEIVE A DIFFERENT PACKAGEOF BENEFITS. PLEASE CONSULT YOUR SUMMARY PLAN DESCRIPTION (SPD) OR CONTACT THE BENEFIT FUND’SMEMBER SERVICES DEPARTMENT AT (646) 473-9200 FOR INFORMATION ON YOUR BENEFITS.2
BENEFIT COVERAGEEMERGENCY DEPARTMENT VISITSWAGE CLASS IWAGE CLASS IIFamilyFamily This benefit is for the hospital’s charge for the useof its facility only. Coverage for services renderedby doctors, labs, radiologists or other services thatare billed separately by these providers may becovered, as described in Section II.H of the SPD Use of the Emergency Department must be for alegitimate medical Emergency within 72 hours ofan accident, injury, or the onset of a sudden andserious illnessCall the Benefit Fund at (646) 473-9200for more information. Observation care and services Benefit Fund pays negotiated rate at ParticipatingHospital or reasonable charge at Non-participatingHospitalPROGRAM FOR BEHAVIORAL HEALTHFamilyFamilyMental Health Outpatient care Intensive Outpatient Programs (IOP) Inpatient care Partial Hospitalization Programs (PHP)Alcohol/Substance Abuse Inpatient detoxification and rehabilitationYou must call 1199SEIU CareReviewat (800) 227-9360 to Pre-certifyinpatient care.You must call the Benefit Fund at(646) 473-6868 to Pre-certify PHP andIOP services. Outpatient care Intensive Outpatient Programs (IOP)SURGERY Inpatient or outpatient (ambulatory) surgery Benefits based on the Fund’s allowance for thesurgical procedure Participating Surgeons bill the Benefit Fund directlyand accept the Fund’s payment as payment in fullFamilyFamilyYou must call 1199SEIU CareReviewat (800) 227-9360 before havingnon-Emergency surgery.Call the Benefit Fund at (646) 473-9200to make sure your surgeon is aParticipating Provider.PLEASE NOTE: MEMBERS WHO HAVE A WAGE CLASS III LEVEL OF BENEFITS RECEIVE A DIFFERENT PACKAGEOF BENEFITS. PLEASE CONSULT YOUR SUMMARY PLAN DESCRIPTION (SPD) OR CONTACT THE BENEFIT FUND’SMEMBER SERVICES DEPARTMENT AT (646) 473-9200 FOR INFORMATION ON YOUR BENEFITS.3
BENEFIT COVERAGEANESTHESIA Benefits based on the Fund’s Scheduleof AllowancesMATERNITY CARE An allowance which includes all prenatal andpostnatal visits and delivery charges Hospital Benefit for the mother and newborn, if themother is you or your spouse Disability Benefit for you, if you are the mother Lactation consulting by a certified provider Breast pumpMEDICAL SERVICESWAGE CLASS IWAGE CLASS IIFamilyFamilyCall the Benefit Fund at (646) 473-9200to make sure your anesthesiologist is aParticipating Provider.FamilyFamilyCall the Wellness Department at(646) 473-8962 to register for thePrenatal Program.Call the Benefit Fund at(646) 473-9200 for information aboutbreast pump options.FamilyFamily Treatment in a doctor’s office, clinic, hospital,Emergency Department or your home Well-child care for dependent children Immunizations Acupuncture: up to 25 visits per year, whenperformed by a licensed medical physician orlicensed acupuncturist Allergy: up to 20 visits per year, includingup to two testing visits Chiropractic: up to 12 visits per year Dermatology: up to 20 visits per yearCall the Benefit Fund at (646) 473-9200for more information. Physical/Occupational/Speech therapy: up to25 visits per discipline per year Podiatry: up to 15 visits per year for routine foot care X-rays and laboratory tests Durable medical equipment and appliances Hospice care Ambulance services Participating Providers bill the Benefit Fund directlyand accept the Fund’s payment as payment in fullPLEASE NOTE: MEMBERS WHO HAVE A WAGE CLASS III LEVEL OF BENEFITS RECEIVE A DIFFERENT PACKAGEOF BENEFITS. PLEASE CONSULT YOUR SUMMARY PLAN DESCRIPTION (SPD) OR CONTACT THE BENEFIT FUND’SMEMBER SERVICES DEPARTMENT AT (646) 473-9200 FOR INFORMATION ON YOUR BENEFITS.4
BENEFIT COVERAGEWAGE CLASS IWAGE CLASS IITELELHEALTH VISITSFamilyFamily Through telehealth, you can have an office visitby phone or video with your own ParticipatingProvider or with the Benefit Fund’s telehealthprovider, who can diagnose, recommend treatmentand prescribe medication for many of your medicalor mental health needs If your doctor is unavailable, use the Benefit Fund’stelehealth provider for on-demand non-Emergencyvisits by phone or video (available 24 hours a day,7 days a week), with doctors and pediatricianslicensed in your stateCall the Benefit Fund at (646) 473-9200for information on how to access theFund’s telehealth provider. If you prefer to access a licensed mental healthprofessional through the Benefit Fund’s telehealthprovider, you can schedule a phone or videoappointment (available 7 days a week), and choosefrom a variety of board-certified counselors,therapists, psychologists and psychiatrists. Youmust be age 18 or older to use this benefit.SERVICES REQUIRING PRIOR AUTHORIZATION Home health care Long-term acute care hospital services Hospital transfer ambulance services Durable medical equipment and appliances Medical supplies Cellular and gene therapy Specific medications, including specialty drugs MRI, MRA, PET and CAT scans, and certainnuclear cardiology tests Molecular, genomic and other diagnosticlaboratory tests Radiation therapy and medical oncology services Hospice care Ambulatory surgery or inpatient admissions Certain mental health and alcohol/substanceabuse services Certain infusion drugs administered on anoutpatient basisFamilyFamilyYou must call the Prior AuthorizationDepartment at (646) 473-9200 forPrior Authorization of services, exceptEmergency ambulance and the serviceslisted below.You must call eviCore healthcare at(888) 910-1199 for Prior Authorizationof radiological tests, molecular andgenomic testing, radiation therapy andmedical oncology services.Call One Call Care Management at(800) 398-8999 for a referral to apreferred radiology facility.You must call 1199SEIU CareReview at(800) 227-9360 for Prior Authorizationof inpatient hospice care, ambulatorysurgery or inpatient admissions.You must call CareContinuum at(877) 273-2122 for Prior Authorizationof certain infusion drugs administeredon an outpatient basis.PLEASE NOTE: MEMBERS WHO HAVE A WAGE CLASS III LEVEL OF BENEFITS RECEIVE A DIFFERENT PACKAGEOF BENEFITS. PLEASE CONSULT YOUR SUMMARY PLAN DESCRIPTION (SPD) OR CONTACT THE BENEFIT FUND’SMEMBER SERVICES DEPARTMENT AT (646) 473-9200 FOR INFORMATION ON YOUR BENEFITS.5
BENEFIT COVERAGEVISION CAREWAGE CLASS IWAGE CLASS IIFamilyFamily One eye exam every two years One pair of eyeglasses every two years; In lieuof eyeglasses, one order of contact lenses everytwo years No out-of-pocket costs when using a ParticipatingProvider for lenses and frames included in theBenefit Fund’s vision programHEARING AIDS Once every three years Co-payments may apply when usingParticipating ProvidersDENTAL BENEFITSCall the Benefit Fund at (646) 473-9200for a referral to a Participating Provider.FamilyFamilyCall the Benefit Fund at (646) 473-9200for a referral to a Participating Provider.FamilyNot Covered Coverage through a Plan Network for basic andpreventive services, major restorative care andorthodontia treatment Annual benefit limits or network restrictionsmay apply Network Dentists bill the Benefit Fund’s PlanNetwork Administrator directly and accept theNetwork Administrator’s Schedule of Allowancesas payment in full for Covered ServicesCall the Benefit Fund at (646) 473-9200for a referral to a Participating Provider. For certain upgrades and materials,co-payments may applyPLEASE NOTE: MEMBERS WHO HAVE A WAGE CLASS III LEVEL OF BENEFITS RECEIVE A DIFFERENT PACKAGEOF BENEFITS. PLEASE CONSULT YOUR SUMMARY PLAN DESCRIPTION (SPD) OR CONTACT THE BENEFIT FUND’SMEMBER SERVICES DEPARTMENT AT (646) 473-9200 FOR INFORMATION ON YOUR BENEFITS.6
BENEFIT COVERAGEPRESCRIPTION DRUGSWAGE CLASS IWAGE CLASS IIFamilyNot Covered Coverage of FDA-approved prescriptionmedications for FDA-approved indications, exceptPlan exclusions No co-payments when you use Preferred Drugswhere available Use Participating Pharmacies Use The 1199SEIU 90-Day Rx Solution(Mandatory Maintenance Drug Access Program)for chronic conditionsCall Express Scripts at (800) 818-6720for more information. Comply with the Benefit Fund’s prescriptiondrug programs, including Prior Authorizationwhere required Please refer to “What Is Not Covered” inSection II.L of the SPDLIFE INSURANCE Wage Class I: During your first year of service,amount is 1,250. After your first year, benefit isbased on your Wage Class and annual base payup to a maximum amount of 50,000. Wage Class II: During your first year of service,amount is 1,250. After your first year, maximumamount is 2,500.DISABILITY This benefit is a partial salary replacement.Coverage is only for accidents, injuries or illnessesthat are not work-related. Amount is based on your Average WeeklyEarnings or on statutory minimums Maximum weekly benefit is 385 Maximum duration of 26 weeks leavewithin a 52-week period Your Benefit Fund coverage for all other benefitsmay continue while you are receiving Benefit FundDisability BenefitsMember OnlyMember OnlyCall the Benefit Fund at (646) 473-9200for more information.Member OnlyMember OnlyYou must submit a Disability Claim Formto the Benefit Fund within 30 days ofyour accident, injury or the start of yourillness. To get this form, or to make sureyou are eligible for benefits before youstop working, call the Fund’s MemberServices Department at (646) 473-9200or visit www.1199SEIUBenefits.org.PLEASE NOTE: MEMBERS WHO HAVE A WAGE CLASS III LEVEL OF BENEFITS RECEIVE A DIFFERENT PACKAGEOF BENEFITS. PLEASE CONSULT YOUR SUMMARY PLAN DESCRIPTION (SPD) OR CONTACT THE BENEFIT FUND’SMEMBER SERVICES DEPARTMENT AT (646) 473-9200 FOR INFORMATION ON YOUR BENEFITS.7
BENEFIT COVERAGEWAGE CLASS IWAGE CLASS IIPAID FAMILY LEAVEMember OnlyMember Only This benefit is a partial salary replacement. YourBenefit Fund coverage for all other benefits maycontinue while you are receiving Benefit Fund PaidFamily Leave Benefits. Maximum weekly benefit is 67% of your averageweekly earnings or the New York State averageweekly wage, whichever is less How long you can receive benefits isbased on verified need, up to a maximum of 12weeks leave within a 52-week periodACCIDENTAL DEATH AND DISMEMBERMENT For accidental death or dismemberment Equal to, or half of, your life insurance amount,depending on the loss sufferedBURIAL If available, a free burial plot with permanent careor a 75 payment to your beneficiary Plots located in New York and New JerseyANNE SHORE SLEEP-AWAY CAMP PROGRAMBefore you stop working, call the BenefitFund’s Member Services Department at(646) 473-9200 to make sure you areeligible for benefits.You must submit a Paid Family LeaveBenefit Request Form to the Fundwithin 30 days of your qualifying event.To get this form, call (888) 447-9055,email 1199pfl@alicare.com or visitwww.1199SEIUBenefits.org.Member OnlyMember OnlyCall the Benefit Fund at (646) 473-9200for more information.Member andSpouseMember andSpouseCall the Benefit Fund at (646) 473-9200for more information.Children OnlyNot Covered For eligible children of Benefit Fund members(ages 9 to 15) Summer sleep-away camp program provided atno cost to you, except administrative fee FICA taxes and applicable withholdings paid forby the Benefit Fund (you will be responsible fortaxable earnings)JOSEPH TAUBER SCHOLARSHIP PROGRAM For eligible children of Benefit Fund members(age 22 or younger) Scholarships provided to attend accreditedschools after high schoolCall the Anne Shore Sleep-AwayCamp Program at (212) 564-2220for more information.Children OnlyNot CoveredCall the Joseph Tauber ScholarshipProgram at (646) 473-8999 formore information.PLEASE NOTE: MEMBERS WHO HAVE A WAGE CLASS III LEVEL OF BENEFITS RECEIVE A DIFFERENT PACKAGEOF BENEFITS. PLEASE CONSULT YOUR SUMMARY PLAN DESCRIPTION (SPD) OR CONTACT THE BENEFIT FUND’SMEMBER SERVICES DEPARTMENT AT (646) 473-9200 FOR INFORMATION ON YOUR BENEFITS.8
BENEFIT COVERAGESOCIAL SERVICESWAGE CLASS IWAGE CLASS IIFamilyFamilyMember Assistance Program (MAP) Help for personal and family problemsCall MAP at (646) 473-6900for more information.Citizenship Program Assistance in applying for UnitedStates citizenshipCall the Citizenship Program at(646) 473-8915 for more information.Earned Income Tax Credit (EITC)Assistance Program Tax preparation helpCall the EITC Assistance Program at(646) 473-9200 for more information.Financial Wellness and HomebuyerEducation Program Help with home ownership, managingcredit and financial wellnessCall the Financial Wellness andHomebuyer Education Program at(646) 473-9200 for more information.Monday Night Legal Clinic Access to attorneys for free legal consultationsregarding various personal legal mattersCall the Monday Night Legal Clinic at(646) 473-6488 for more information.Weekly Workers’ Compensation Legal Clinic Assistance to members suffering from a workrelated injury or illnessCall the Weekly Workers’Compensation Legal Clinic at(646) 473-6717 for more information.PLEASE NOTE: MEMBERS WHO HAVE A WAGE CLASS III LEVEL OF BENEFITS RECEIVE A DIFFERENT PACKAGEOF BENEFITS. PLEASE CONSULT YOUR SUMMARY PLAN DESCRIPTION (SPD) OR CONTACT THE BENEFIT FUND’SMEMBER SERVICES DEPARTMENT AT (646) 473-9200 FOR INFORMATION ON YOUR BENEFITS.9
LEGENDMemberYou, the memberSpouseYour spouse, if eligibleChildrenYour children, if eligibleFamilyYou, your spouse and your children, if eligibleSchedule ofAllowancesList of fees for each service allowed or paid by the PlanSPDSummary Plan DescriptionWage Class IFull-time or part-time members who earn 100% ofthe minimum full-time wageWage Class IIPart-time members who earn at least 60%, but lessthan 100%, of the minimum full-time wageIMPORTANT PHONE NUMBERSMember Services(646) 473-9200Outside NYC: (800) 575-7771Telehealth (Teladoc)(800) 835-23621199SEIU CareReview(800) 227-9360Prescriptions (Express Scripts)(800) 818-6720Member Assistance Program(646) 473-6900Prenatal Program(646) 473-8962Dental (EmblemHealth)(800) 624-2414Dental (Aetna)(877) 238-6200PLEASE NOTE: MEMBERS WHO HAVE A WAGE CLASS III LEVEL OF BENEFITS RECEIVE A DIFFERENT PACKAGEOF BENEFITS. PLEASE CONSULT YOUR SUMMARY PLAN DESCRIPTION (SPD) OR CONTACT THE BENEFIT FUND’SMEMBER SERVICES DEPARTMENT AT (646) 473-9200 FOR INFORMATION ON YOUR BENEFITS.10
DISCLAIMERThis document is NOT the official Summary Plan Description (SPD) ofthe 1199SEIU National Benefit Fund. Please consult the SPD for a fulldescription of your Fund benefits, including limitations and exclusions.In case of any conflict between this document and the SPD, the termsof the SPD shall govern. Members can request an SPD by calling theMember Services Department at (646) 473-9200. Outside New YorkCity, call (800) 575-7771.The 1199SEIU Benefit Funds comply with applicable federal civil rightslaws and do not discriminate on the basis of race, color, nationalorigin, age, disability or sex.The 1199SEIU National Benefit Fund considers itself a “grandfatheredhealth plan” under the Patient Protection and Affordable Care Act(the “Affordable Care Act”). A grandfathered health plan can preservecertain basic health coverage that was already in effect when thatlaw was enacted in 2010. Being a grandfathered health plan meansthat this plan may not include certain consumer protections of theAffordable Care Act that apply to other plans, for example, therequirement for an external review process for claims appeals.However, grandfathered health plans must comply with certain otherconsumer protections in the Affordable Care Act, for example, theelimination of lifetime limits on benefits. The Wage Class III plan is nota grandfathered health plan. Questions regarding which protectionsapply and which protections do not apply to a grandfathered healthplan can be directed to the Plan Administrator at (646) 473-9200. Youmay also contact the Employee Benefits Security Administration, U.S.Department of Labor at (866) 444-3272 or n/ask-ebsa. This website has a tablesummarizing which protections do and do not apply to grandfatheredhealth plans.PLEASE NOTE: MEMBERS WHO HAVE A WAGE CLASS III LEVEL OF BENEFITS RECEIVE A DIFFERENT PACKAGEOF BENEFITS. PLEASE CONSULT YOUR SUMMARY PLAN DESCRIPTION (SPD) OR CONTACT THE BENEFIT FUND’SMEMBER SERVICES DEPARTMENT AT (646) 473-9200 FOR INFORMATION ON YOUR BENEFITS.11
La cobertura descrita en este Resumen es para afiliados de tiempo completo y detiempo parcial del Fondo Nacional de Beneficios de 1199SEIU que tienen un nivel debeneficios de clase de salario I o clase de salario II.Los beneficios de medicamentos recetados se proporcionan a través de Express Scripts,el administrador de beneficios de farmacia del Fondo. Los beneficios dentales seproporcionan a través de EmblemHealth (plan PPO) o Aetna (plan DMO). Estos beneficiosse describen con más detalle en la Descripción Abreviada del Plan (SPD, por sus siglas eninglés) y en la información que le proporcionan Express Scripts, EmblemHealth y Aetna.Si usted recibe servicios de un proveedor que no está en la red del Fondo, seráresponsable de los costos adicionales que le pueda cobrar el proveedor.Los afiliados que tienen un nivel de beneficios de clase de salario III reciben un paquetede beneficios diferente. Para obtener información sobre sus beneficios, consulte suSPD o comuníquese con el Centro de servicios para afiliados del Fondo de Beneficiosllamando al (646) 473-9200.COBERTURA DE LOS BENEFICIOSCLASE DESALARIO ICLASE DESALARIO IIATENCIÓN HOSPITALARIAFamiliaresFamiliaresAtención hospitalaria para pacientes internados Este beneficio es para el costo hospitalario porel uso del centro únicamente. Los serviciosbrindados por médicos, laboratorios, radiólogosu otros servicios que estos proveedores facturanpor separado pueden estar cubiertos, según sedescribe en la Sección II.H de la SPD. Hasta 365 días por año. Habitación semiprivada y comidas. Cuidados agudos para servicios médicamentenecesarios. Admisiones para hospitalización. Hasta 30 días por año para rehabilitación físicapara pacientes hospitalizados en un centro decuidados agudos.Debe llamar a 1199SEIU CareReview al(800) 227-9360 antes de ir al hospital odentro de los dos días hábiles posterioresa una admisión de emergencia. No se proporcionan beneficios para la atenciónen una residencia de ancianos ni en un centrode atención de enfermería especializada paracasos subagudos.Atención hospitalaria para pacientes externos Atención ambulatoria. Atención y servicios de observación.TENGA EN CUENTA LO SIGUIENTE: LOS MIEMBROS QUE TIENEN UN NIVEL DE BENEFICIOS DE CLASE DESALARIO III RECIBEN UN PAQUETE DE BENEFICIOS DIFERENTE. PARA OBTENER INFORMACIÓN SOBRESUS BENEFICIOS, CONSULTE LA DESCRIPCIÓN ABREVIADA DEL PLAN (SPD) O COMUNÍQUESE CON ELDEPARTAMENTO DE SERVICIOS PARA LOS MIEMBROS DEL FONDO DE BENEFICIOS AL (646) 473-9200.12
COBERTURA DE LOS BENEFICIOSCLASE DESALARIO ICLASE DESALARIO IIATENCIÓN EN HOSPICIOSFamiliaresFamiliares Cobertura para un total combinado de hasta 210días de por vida en un programa de hospicios concertificación de Medicare en un hospicio, hospital,centro de enfermería especializada o en el hogar.CONSULTAS A LOS DEPARTAMENTOSDE EMERGENCIASDebe llamar a 1199SEIU CareReviewal (800) 227-9360 para obtener laautorización previa para la atención en unhospicio como paciente hospitalizado.FamiliaresFamiliares Este beneficio es para el costo hospitalario porel uso del centro únicamente. Los serviciosbrindados por médicos, laboratorios, radiólogosu otros servicios que estos proveedores facturanpor separado pueden estar cubiertos, según sedescribe en la Sección II.H de la SPD. Debe utilizar el departamento de emergencias encaso de una emergencia médica legítima dentro deun periodo de 72 horas después de un accidente,una lesión o la aparición de una enfermedad gravey repentina.Llame al Fondo de Beneficiosal (646) 473-9200 para obtenermás información. Atención y servicios de observación. El Fondo de Beneficios paga la tarifa acordada enun hospital participante o una tarifa razonable enun hospital no participante.PROGRAMA PARA SALUD CONDUCTUALFamiliaresFamiliaresSalud mental Atención ambulatoria. Programas intensivos para pacientes externos(IOP, por sus siglas en inglés). Atención para pacientes hospitalizados. Programas de hospitalización parcial (PHP, por sussiglas en inglés).Abuso de alcohol y de sustancias Desintoxicación y rehabilitación para pacienteshospitalizados.Debe llamar a 1199SEIU CareReviewal (800) 227-9360 para precertificar laatención para pacientes hospitalizados.Debe llamar al Fondo de Beneficios al(646) 473-6868 para precertificarservicios de PHP e IOP. Atención ambulatoria. Programas intensivos para pacientes externos(IOP, por sus siglas en inglés).TENGA EN CUENTA LO SIGUIENTE: LOS MIEMBROS QUE TIENEN UN NIVEL DE BENEFICIOS DE CLASE DESALARIO III RECIBEN UN PAQUETE DE BENEFICIOS DIFERENTE. PARA OBTENER INFORMACIÓN SOBRESUS BENEFICIOS, CONSULTE LA DESCRIPCIÓN ABREVIADA DEL PLAN (SPD) O COMUNÍQUESE CON ELDEPARTAMENTO DE SERVICIOS PARA LOS MIEMBROS DEL FONDO DE BENEFICIOS AL (646) 473-9200.13
COBERTURA DE LOS BENEFICIOSCLASE DESALARIO ICLASE DESALARIO IICIRUGÍAFamiliaresFamiliares Cirugía con hospitalización o ambulatoria. Beneficios basados en las asignaciones del Fondopara procedimientos quirúrgicos. Los cirujanos participantes facturarán directamenteal Fondo de Beneficios y aceptarán el pago porparte de este como el pago completo.ANESTESIA Beneficios basados en el programa deasignaciones del Fondo.ATENCIÓN POR MATERNIDAD Asignación que incluye todas las consultas pre- yposnatales, y los costos del parto. Beneficio hospitalario para la madre y el reciénnacido, si la madre es usted o su cónyuge. Beneficios por discapacidad para usted, si ustedes la madre. Consulta de lactancia con un proveedor certificado.Debe llamar a 1199SEIU CareReviewal (800) 227-9360, antes de someterse auna cirugía que no sea de emergencia.Llame al Fondo de Beneficios al(646) 473-9200 para asegurarse de que sucirujano sea un proveedor participante.FamiliaresFamiliaresLlame al Fondo de Beneficios al(646) 473-9200 para asegurarse deque su anestesiólogo sea un proveedorparticipante.FamiliaresFamiliaresLlame al Departamento de Bienestar al(646) 473-8962 para inscribirse en elPrograma Prenatal.Llame al Fondo de Beneficios al(646) 473-9200 para obtener informaciónsobre las opciones de sacaleches. Sacaleche.TENGA EN CUENTA LO SIGUIENTE: LOS MIEMBROS QUE TIENEN UN NIVEL DE BENEFICIOS DE CLASE DESALARIO III RECIBEN UN PAQUETE DE BENEFICIOS DIFERENTE. PARA OBTENER INFORMACIÓN SOBRESUS BENEFICIOS, CONSULTE LA DESCRIPCIÓN ABREVIADA DEL PLAN (SPD) O COMUNÍQUESE CON ELDEPARTAMENTO DE SERVICIOS PARA LOS MIEMBROS DEL FONDO DE BENEFICIOS AL (646) 473-9200.14
COBERTURA DE LOS BENEFICIOSCLASE DESALARIO ICLASE DESALARIO IISERVICIOS MÉDICOSFamiliaresFamiliares Tratamiento en el consultorio de su médico,la clínica, el hospital, el departamento deemergencias o su hogar. Atención pediátrica para hijos dependientes. Vacunas. Acupuntura: hasta 25 sesiones por año, si las realizaun médico autorizado o un acupunturista autorizado. Alergia: hasta 20 consultas por año, incluidashasta dos consultas para pruebas. Quiropráctica: hasta 12 consultas por año. Dermatología: hasta 20 consultas por año. Fisioterapia/terapia ocupacional/terapia del habla:hasta 25 consultas por disciplina por año.Llame al Fondo de Beneficiosal (646) 473-9200 para obtenermás información. Podiatría: hasta 15 consultas por año para elcuidado de rutina de los pies. Radiografías y exámenes de laboratorio. Equipo médico duradero y aparatos. Atención en hospicios. Servicios de ambulancia. Los proveedores participantes facturarándirectamente al Fondo de Beneficios y aceptarán elpago por parte de este como el pago completo.TENGA EN CUENTA LO SIGUIENTE: LOS MIEMBROS QUE TIENEN UN NIVEL DE BENEFICIOS DE CLASE DESALARIO III RECIBEN UN PAQUETE DE BENEFICIOS DIFERENTE. PARA OBTENER INFORMACIÓN SOBRESUS BENEFICIOS, CONSULTE LA DESCRIPCIÓN ABREVIADA DEL PLAN (SPD) O COMUNÍQUESE CON ELDEPARTAMENTO DE SERVICIOS PARA LOS MIEMBROS DEL FONDO DE BENEFICIOS AL (646) 473-9200.15
COBERTURA DE LOS BENEFICIOSCLASE DESALARIO ICLASE DESALARIO IICONSULTAS POR TELESALUDFamiliaresFamiliares Por medio de telesalud, puede realizar una consultapor teléfono o video con su proveedor participanteo con el proveedor de telesalud del Fondo deBeneficios, que puede diagnosticar, recomendar untratamiento y recetar medicamentos para muchasde sus necesidades médicas o de salud mental. Si su médico no está disponible, puede recurrir alproveedor de telesalud del Fondo de Beneficiospara realizar consultas que no sean de emergenciapor teléfono o video previa solicitud (disponiblelas 24 horas del día, los 7 días de la semana), conmédicos y pediatras autorizados en su estado.Llame al Fondo de Beneficios al(646) 473-9200 para obtenerinformación sobre cómo acceder alproveedor de telesalud del Fondo. Si prefiere acceder a un profesional de la saludmental autorizado por medio del proveedorde telesalud del Fondo de Beneficios, puedeprogramar una cita por teléfono o video (disponiblelos 7 días de la semana) y elegir entre una variedadde asesores, terapeutas, psicólogos y psiquiatrascertificados por la Junta. Debe ser mayor de 18años para utilizar este beneficio.TENGA EN CUENTA LO SIGUIENTE: LOS MIEMBROS QUE TIENEN UN NIVEL DE BENEFICIOS DE CLASE DESALARIO III RECIBEN UN PAQUETE DE BENEFICIOS DIFERENTE. PARA OBTENER INFORMACIÓN SOBRESUS BENEFICIOS, CONSULTE LA DESCRIPCIÓN ABREVIADA DEL PLAN (SPD) O COMUNÍQUESE CON ELDEPARTAMENTO DE SERVICIOS PARA LOS MIEMBROS DEL FONDO DE BENEFICIOS AL (646) 473-9200.16
COBERTURA DE LOS BENEFICIOSSERVICIOS QUE REQUIERENAUTORIZACIÓN PREVIA Atención médica en el hogar. Servicios hospitalarios de cuidados agudos alargo plazo. Servicios de ambulancia para traslados a hospitales. Equipo médico duradero y aparatos. Suministros médicos. Terapia celular y génica. Medicamentos específicos, incluidos losmedicamentos especializados. Exámenes de resonancia magnética (MRI, porsus siglas en inglés), angiografía por resonanciamagnética (MRA, por sus siglas en inglés),tomografía por emisión de positrones (PET,por sus siglas en inglés), tomografía axialcomputarizada (CAT, por sus siglas en inglés) yciertas pruebas de cardiología nuclear. Pruebas moleculares, genómicas y otras pruebasde laboratorio de diagnóstico. Servicios de radioterapia y oncología médica. Atención en hospicios. Admisiones para hospitalización o cirugíaambulatoria. Ciertos servicios de salud mental y por abuso dealcohol o sustancias.CLASE DESALARIO ICLASE DESALARIO IIFamiliaresFamiliaresDebe llamar al Departamento deAutorización Previa al (646) 473-9200para obtener la aprobación previa deservicios, a excepción de los serviciosde ambulancia de emergencia y de losindicados a continuación.Debe llamar a eviCore Healthcareal (888) 910-1199 para obtener laaprobación previa de exámenesradiológicos, pruebas moleculares ygenómicas, servicios de radioterapia yoncología médica.Llame a One Call Care Management al(800) 398-8999 para obtener un referidoa un centro de radiología preferido.Debe llamar a 1199SEIU CareReviewal (800) 227-9360 para obtener laautorización previa para la atenciónen un hospicio como pacientehospitalizado y para las admisiones parahospitalización o cirugía ambulatoria.Debe llamar a CareContinuum al(877) 273-2122 para obtener laautorización previa para ciertosmedicamentos de infusiónadministrados como paciente externo. Ciertos medicamentos de infusión administrad
Manager. Dental Benefits are provided through EmblemHealth (PPO plan) or Aetna (DMO plan). These benefits are described in more detail in the Summary Plan Description (SPD) and in information provided to you by Express Scripts, EmblemHealth and Aetna. If you receive services from a provider who is not in the Fund's network, you will be
