Health Benefits Provided

Each benefit’s waiting period starts when Covered Employment begins, as long as you are enrolled. If enrollment occurs after a benefit’s waiting period, eligibility for that benefit will begin on the date of enrollment.

Benefit
Health Center for Care
& Related Pharmacy
Immediate
Coverage
Covered in full with no charge provided a Health Center is used.
Prescriptions available for the Urgent Care visit only with a co-pay.
(See below.)
Health Center & Pharmacy
30 Days
Provided by the Health Center
$5 co-pay for generic drugs on formulary.
$15 co-pay for brand-name drugs on formulary
        but not available generically.
90-day supplies of certain generic drugs are $12.00 or less.   90-day
        formulations and dosages may vary and are at the discretion
        of the pharmacy.
Drugs not on formulary may be provided at actual cost to the Fund.
Use of an outside pharmacy is not reimbursed.
All Other Health
Center Services
30 Days
Covered in full with no charge provided a Health Center is used.
Hospitalization
60 Days
1.) With participating hospitals, 100% for covered services. First 120 days
(semi-private room) covered in full. Next 180 days covered at 50% of
semi-private room rates. 2.) With non-participating hospitals, first 120
days (semi-private room) covered at $30 a day for room and 80% of
allowed charges. Next 180 days covered at $15 a day for room and
40% of allowed charges.
Emergency Room
(see terms above)
60 Days
You must go within 72 hours of injury or 12 hours of onset of illness.
Ambulance services are only covered for acute conditions by
referral from the Health Center.
Dental Care
30 Days
Dental services provided through Health Centers & related providers.
Optical Care
60 Days
Eye Care available through the Queens, Brooklyn, and Harlem Health Centers
& 14 Penn Plaza. Prescription eye wear available from a store of your choosing,
reimbursements offered according to plan details and eligibility.
Members Health
Assistance Program
(MHAP)
30 Days
Confidential consultative and crisis prevention assistance for emotional,
alcohol- and drug-related problems.
Substance Abuse
Treatment
60 Days
Must receive referral from MHAP office. 7 days of active treatment per
calendar year for detoxification. 30 days of in-patient rehabilitation services
with a maximum of 2 admissions per lifetime.
Inpatient Psychiatric
Treatment
(non-substance abuse
related)
60 Days
30 days of inpatient care per calendar year for approved conditions.
You must call Empire BlueCross BlueShield using the number
on the back of your card before admission.
Life Insurance
6 months
For member only, $10,000
Accidental Death
& Dismemberment
6 months
For member only, up to $10,000
Disability
4 Weeks
For member only, 50% of your gross weekly salary (max of $300)
for up to 26 weeks. Health coverage also continued during a
period of paid disability.

For more information, read the Health Summary Plan Description – Health SPD July 2014