General SBF Overview

What is the SBF?

The Uniformed Firefighters Association Security Benefit Fund is the result of a collective bargaining agreement between the Uniformed Firefighters Association (UFA) and the City of New York. The contracts and agreements provide for contributions to be made by the City to the Security Benefit Fund (SBF), which is a supplemental health benefits fund for all members that is managed by the UFA. All benefits provided by the SBF are funded through employer contributions; no contribution is required on the part of the member. An annual contribution is pro-rated on a monthly basis and paid to the Fund on behalf of all eligible members. The financial records of the Fund are kept on a fiscal year basis (July 1st to June 30th). Benefits are subject to change if deemed fiscally necessary. This fund covers various supplemental health benefits for active & retired members, as described in this chapter.

Benefits Covered

As an active member of the Uniformed Firefighters Association (UFA), which is the labor union and official bargaining agent representing all its members, the UFA’s Security Benefits Fund covers your family/dependents for various supplemental health benefits, including dental, anesthesia (retirees not covered for SBF anesthesia), optical, hearing aid and prescription drugs. These benefits are funded by annual contributions by the City, which are mandatory pursuant to contracts negotiated with the City by your union, the UFA, whose Officers are elected every three years by the membership from among its members. (SBF only covers post January 1, 1971 retirees, post July 9, 1993 for retired wipers. SBF will also cover retired marine engineers and pilots at a date to be announced by the City in 2012.)

Benefits Not Covered

Keep in mind that SBF coverage is totally independent (and different) from your NYC Health Plan coverage (GHI, HIP, Blue Cross/Blue Shield, etc.). You must contact your individual NYC Health Plan carrier for info regarding your major medical coverage, though your Company Delegate may be able to point you in the right direction to get

you started. See Health Book (NYC Health Plans chapter) for more info on your major medical coverage.

Help Available

Your Delegate is usually most knowledgeable in UFA & SBF matters as they receive additional training and instruction from the UFA & SBF regarding the SBF. It is also most likely that your Delegate has helped other members of your company with the same issues that you may currently have. If your Delegate is unable to help with a particular situation, he or she will be able to get you in touch with the persons at the SBF or Board Officers of the UFA who can help you. Your Delegate is normally your first stop—or if you are uncertain or if your Delegate is not available, contact the UFA SBF directly. If you are not satisfied with help provided by the SBF, ask your Delegate for your Trustee’s help. But for matters you wish to keep private, you may call your Borough Trustee without contacting your Delegate.

Forms You Need

Your Company Delegate is responsible for keeping a supply of all various SBF forms available at all times for members of your company. Ask where they are kept. Forms should be available 24/7 to all company members. If you cannot find the form you need, contact the SBF office directly, or see the References Book: (Forms chapter) for blank master copies of forms to make copies from. Whenever you see the  symbol in this manual, you should find a copy of it in the Forms Chapter.

Changes to Plan

The Trustees of the Fund reserve the right to modify or discontinue the benefits of the Fund at any time. Notification of changes in the benefits or procedures will be sent to retiree addresses as listed in the Fund records, and to all firehouses of active members. Notices to active member residence address will be sent for major plan changes.

Address – Hours – Directions

Address & Office Hours

9am to 5pm weekdays (closed weekends/holidays). Located at 204 East 23rd Street, New York, NY 10010 (between 2nd & 3rd Aves). Please call 212-683-4723 prior to visiting to ensure the person you wish to see is available. See ‘Help!— Reaching Us’ section, below.

By Subway

N or R Train to 23rd St (& Broadway). Walk East 3 blocks, UFA is just past 3rd Avenue on your right. Or # 6 Train local to 23rd St. (& Lexington Ave.) The #4 & #5 Trains are Express and usually do not stop during business hours on 23rd Street. Walk East 1 block, UFA is just past 3rd Avenue on your right.

By Car

1. Midtown Tunnel: Head South on 2nd Avenue to 23rd Street. Turn right on 23rd St, UFA is just before 3rd Ave. on your left. Or head South on Lexington to 23rd Street. Turn left on 23rd St, UFA is just past 3rd Ave. on your right.
2. FDR Drive: Take 23rd Street Exit, take 23rd Street heading West 2 blocks. UFA is just before 3rd Ave on your left.
3. West Side Drive: From the North, exit left on 24th Street, make a quick right, then your first left onto 23rd St. From the South, exit on 11th Ave & turn right on 23rd St. Take 23rd Street 9 blocks East. UFA is just past 3rd Avenue on your right.

Parking

Street parking is extremely restricted. Traffic agents do not always extend firehouse vicinity courtesies to UFA Firefighter Parking Placards used while parking in the vicinity of the UFA. Paid parking is available in the close vicinity, but not on 23rd Street.

Help! — Reaching Us

Members and their families can call the SBF at 212-683-4723 or visit in person for assistance during office hours. When dialing the SBF switchboard, you may connect with a recording. If you have a touch-tone phone, just follow the instructions for SBF. *Note: If the person you leave the message for is out on leave time, you may not receive a return call for a few days, or longer. If you need service right away, call again and speak with an SBF staffer—if you don’t receive a call back shortly. For Prescription Drug, Dental and NYC Health/Medical Plan questions, members should first contact the Insurance Carriers directly (Healthplex/ Dentcare, CVS Caremark, GHI, HIP, Blue Cross/Blue Shield, etc.) The carriers can provide quick and comprehensive answers to your questions. If you do not feel the carrier has addressed your issue to your satisfaction, then contact the SBF staff, who will be happy to help you. See back cover pages of this chapter for Contacts section listing all SBF phone, fax, email and other contact info.

Keeping Your Insurance Info Current

*Family Status Change — Adding & Dropping Dependents Change of Beneficiary Checklist

The UFA, FDNY and certain insurance carriers do not share member and beneficiary info. It is advisable to review your beneficiaries each time any of the following occur: marriage, divorce, change of domestic partners, or new birth or adoption, loss of a family member, change of eligible dependents, add or remove a person as a life insurance or other beneficiary if you or your spouse die, or to add or remove a person from any health insurance policy.

Time Sensitive: These notifications are often time sensitive. You may lose benefits if you make a late notification. Be sure to notify each of your insurance providers ASAP to ensure that coverage will remain in full force for the beneficiaries you wish it to. Make sure you do the following, if applicable:

1. FDNY Pension Beneficiary: re your retirement pension contributions return and entitlements upon your death; to change a designated beneficiary, send a notarized ‘Designation of Beneficiary of Death Benefits’ to FDNY Pension Benefits Unit.
2. NYC Health & Medical Plans: Doctor/medical care & hospitalization; fill out and forward ERB Form (Employee Health Benefit Application) with copies of birth certificate and Social Security Card, to add dependent to your medical plan to the FDNY Bureau of Personnel Resources/Health Plan Unit. Must be submitted within 31 days of the event. You may also use the Employee Self Service. NOTE: If adding or deleting a spouse or child, the on-line updates will be held as “pending” until hard copies of the correct documentation are received.
3. FDNY Life Insurance Fund: is automatically updated when you notify the FDNY Bureau of Personnel Resources/Health Plan Unit
4. UFA Security Benefits Fund (SBF) Supplemental Health Benefits Coverage: Prescription drugs, dental, optical, anesthesia supplement, hearing aids; Copies, as appropriate, of marriage certificate, birth certificate, adoption decree, court guardianship papers, death certificate, divorce decree, certificate of domestic partnership, or affidavit of domestic partnership termination MUST accompany your notification to SBF Office for each respective matter. Submit these with a letter within 31 days of the event to SBF.
5. UFA Death Benefit: Which is separate from the UFA Group Life Insurance and is automatically updated when you notify the SBF as noted above.
6. UFA Group Life Insurance: Term coverage through the UFA; fill out  UFA Group Life Insurance Beneficiary form and send to UFA Group Life Insurance Office.
7. Surgical Assistance Fund: is automatically updated when you notify the SBF of change of beneficiary.
8. UFA Catastrophic Major Medical Insurance Plan: a UFA affiliated program; you must directly notify the Catastrophic Insurance Carrier through the contact info listed on your policy and by sending a letter regarding the change of covered person. Note: This company is especially strict when it comes to notification. If you do not let them know of additions within 30 days of a new birth, then that dependent will be added, BUT the 12 month restriction concerning pre-existing medical conditions only begins when that addition notification is made—and plan coverage will not be retroactive.
9. AFLAC Cancer Plan: a UFA affiliated program; you must directly notify AFLAC in writing through the contact info listed on your policy regarding the change of covered person.
10. AFLAC Personal Accident Expense Plan: a UFA affiliated program; you must directly notify AFLAC in writing through the contact info listed on your policy regarding the change of covered person.
11. Deferred Compensation/457: an NYC payroll deduction investment plan; to change the beneficiary, fill out and forward  Enrollment/Change Form to Deferred Compensation.
12. Compensation Accrual Fund (Annuity): your automatic annuity investment plan; notify the SBF in writing of change of beneficiary.
13. Fraternal Organizations or Societies Life Insurance: to change beneficiaries, notify the respective organization for instructions.

Change of Address Checklist

The UFA, FDNY and certain insurance carriers do not share member info. If you change your address or phone number, be sure to notify your each of your insurance providers. This will ensure that your coverage will remain in full force and that you will continue to receive any timely notifications, invoices and new info. You must notify the SBF Office in writing within 31 days if you move or change your mailing address, e-mail address or telephone number. Make sure you do the following, if applicable:

1. NYC Health & Medical Plans: Doctor/medical care & hospitalization; prepare and submit Change of Address Forms with the FDNY through your Officer.
2. FDNY Life Insurance Fund: is automatically updated when you notify the FDNY.
3. UFA Security Benefits Fund (SBF) Supplemental Health Benefits Coverage: Prescription drugs, dental, optical, anesthesia supplement, hearing aids; prepare an SBF Change of Address Form and submit to SBF.
4. UFA Death Benefit: is separate from the UFA Group Life Insurance, and is automatically updated when you notify the UFA SBF of change of address.
5. UFA Group Life Insurance: Term coverage through the UFA; contact the UFA Life Insurance Office.
6. Surgical Assistance Fund: is automatically updated when you notify the UFA SBF of change of address.
7. UFA Catastrophic Major Medical Insurance Plan: a UFA affiliated program; you must directly notify the Catastrophic Insurance Carrier through the contact info listed on your policy.
8. AFLAC Cancer Plan: a UFA affiliated program; you must directly notify AFLAC through the contact info listed on your policy.
9. AFLAC Personal Accident Expense Plan: a UFA affiliated program; you must directly notify AFLAC through the contact info listed on your policy.

Required Documentation

1. Change in Spouse or Dependents: Copies of marriage certificate, birth certificate, final adoption decree, court guardianship papers, death certificate, divorce decree, certificate of domestic partnership, or affidavit of domestic partnership termination MUST accompany your notification to SBF Office for each respective matter. A good rule of thumb is to notify both the SBF Office and the Fire Department if any change in personal status occurs.
2. Change of address, phone, e-mail: Send the UFA SBF Notice of Change of Address form, which must be signed by you.

New Parent / Spouse / Beneficiary Coverage

If you change dependents/spouses make sure you adjust all of your insurance coverage & beneficiaries accordingly with the proper carriers or managers. After 9-11-01, this was an unfortunate nightmare for too many of our families. The UFA, FDNY and certain insurance carriers do not share certain member and beneficiary info. It is highly advisable to review your beneficiaries each time any of the following occur: marriage, divorce, change of domestic partners, new birth or adoption, loss of a family member, change of eligible dependents, add or remove a person as a life insurance beneficiary or other beneficiary if you or your spouse die, or to add or remove a person from any health insurance policy. If you change your address or phone number, be sure to notify each of your insurance providers. This will insure that your coverage will remain in full force and that you will continue to receive any timely or important notifications, invoices and new info. Time Sensitive!!! You may lose benefits if you make a late notification. Be sure to notify each of your insurance providers ASAP to ensure that coverage will remain in full force for your current beneficiaries.

Retiring?

Members retiring are obliged to fill out the Retired Firefighter’s Security Benefit Fund Enrollment, Dental and Prescription Drug Cards. Failure to return the dental card by member will result in loss of dental coverage. Contact the SBF for these cards. If you are moving out of the DENTCARE service area, you should mark the box “UFA Family Dental Plan.” Note: If family status changes occur due to birth, divorce, or legal separation, notify the SBF immediately in writing.

Eligibility Criteria for Benefits

All categories listed below are covered for dental, anesthesia, optical, hearing aid and prescription drug benefits from the SBF, except where noted otherwise:

Firefighters, Fire Marshals, Marine Engineers, Pilots & Wipers

1. Active Firefighters, Fire Marshals, Marine Engineers, Pilots & Wipers who are on the Fire Department active payroll are eligible for the benefits of the Security Benefit Fund. Eligibility continues as long as they remain on the payroll of the Fire Department, and as long as the City continues to make contributions for them to the Security Benefit Fund. Benefit eligibility ceases on the day members are removed from the active City’s payroll. New and reinstated members become eligible on the date of their appointment or reinstatement.

Retired Members

1. Ordinary & Disability: SBF coverage continues for retired members (only for post January 1, 1971 retirees, post July 9, 1993 retired wipers. SBF will also cover retired marine engineers and pilots at a date to be announced by the City in 2012.) through the ‘UFA’s Retired Security Benefits Fund’, not the Active Security Benefits Fund. The City contributes the same amount of money each year, per member, into each fund. Co- mingling of the funds is not permitted. Though both funds cover dental, optical, hearing aids and prescription drugs, the limits differ. Retirees are not covered for SBF Anesthesia. Retirees are covered under the Surgical Assistance Fund (only if they were members of Surgical Assistance for at least 2 years prior to retirement date). Members must pay additional for this benefit while active. When planning your retirement, please ensure you refer to any Retired SBF listings and by contacting the SBF office or visiting the UFA website if you are uncertain about anything—before you retire!
2. Vested: Vested retirees may enroll in the Retired SBF if they make a contribution equal to that made by the City each year. If enrolled, the Vested Retiree and his/her eligible dependents would be covered for the following Retired SBF benefits: Prescription Drug ID Card coverage (w/o PICA), Family Dental Plan, Optical Benefits, Hearing Aid Benefit, Surgical Assistance Fund (though not surgical or maternity anesthesia) and Burial Allowance. Contact the SBF for more info.

Domestic Partners

Must be registered with City pursuant to Mayoral Executive Order #48 as follows:

1. Applying to the City: To qualify as a domestic partner relationship, you must apply through the Office of the City Clerk. They will send an application and Domestic Partner Affidavit. Fill out the ERB (Health Form Application), and send with the affidavit to the NYC Employee Health Benefits Office. If requirements are met, your request will be approved. This allows your partner to be covered under basic NYC Health Plans, but you must follow the following step to have SBF coverage approved.
2. Applying to the SBF: SBF mirrors the NYC requirements, subject to annual renewal of the Domestic Partner Coverage Program by the Trustees of the Fund. Once approved as a domestic partner with NYC, you must forward a copy of the Domestic Partner Affidavit Approval and a copy of the ERB Form (Health Form Application) to the SBF for your domestic partner to be added for SBF health & welfare benefits.

Dependent Coverage *

1. Spouse: Covered if not legally separated or divorced. If your spouse has employer coverage, see ‘Coordination of Benefits’ * which follows this section.
   1. Widows of Line-of-Duty Death Member: Coverage does not diminish or terminate, subject to normal limitations. Widows continue coverage with same benefits as if they were active members.
   2. Widows of Non-Line-Of-Duty Death Active Member: Are entitled to the following benefits for a three year period. Prescription Drug ID Card coverage (w/o PICA coverage), Dental Plan, Optical Plan, Hearing Aid, Anesthesia (In-hospital, covered in Health Plan). Plus, the SBF buys the following health coverage for the same period: Private Duty Nursing, Hospitalization for up to 365 days and Appliances (wheelchairs, nebulizers, etc). Pre January 1, 1971 retirees are not entitled to any SBF Benefits.
   3. Widows of Deceased Retired Members: Widows & dependents of members who pass away after retiring are covered for one year only, after the date of death.
2. Children under age 26 (whether married or unmarried): Under the Federal health care reform law, the Patient Protection and Affordable Care Act (PPACA), health plans that cover dependent children must continue to make dependent health coverage available until a dependent turns age 26, coverage will terminate (other than eligible disabled children) at the end of the month in which the “child” reaches age 26. In addition, he or she must meet the definition of “children” under the City’s Health Benefit Program, which follows:

Effective July 1, 2011 the term “children” means the following:

1. natural children;
2. children for whom a court has accepted a consent to adopt and for the support of whom an employee or retiree has entered into an agreement;
3. children required to be covered under a qualified medical child support order until the court order expires, at which time the child may continue to be eligible for coverage under (1) or (2) above;
4. children for whom a court of law has named the employee or retiree as legal guardian;
5. any other child who lives with an employee or retiree in a regular parent/child relationship and is the employee’s or retiree’s tax dependent. A child is the employee’s or retiree’s tax dependent if the employee or retiree claims the child on his/her income tax return as a dependent.
   1. Dependent Children – Disabled: Unmarried children age 26 and older who cannot support themselves because of a disability, including mental illness, developmental disability, mental retardation or physical handicap are eligible for coverage if the disability occurred before the age at which the dependent coverage would otherwise terminate. Employees or retirees must provide medical evidence of the disability. The proof of disability must be submitted to the health plan within 31 days of the date the dependent reaches age 26. Eligibility for such dependents only applies to current employees whose disabled dependent children reach the age limitation while covered by a City health plan. New employees with disabled dependent children already over the age limitation may not include such children as dependents on their City health plan coverage. In addition, employees may not add disabled dependent children to their health plan coverage, if the child is already over age 26.

Retirees must notify their basic NYC Health Plan carrier to ensure their handicapped dependents get coverage. Upon receipt of your NYC Health Plan carrier’s confirmation (you must send it to SBF), the Retired SBF coverage will continue in accordance with the above criteria.

* The Patient Protection & Affordable Care Act specifies that extension of dependent coverage for children under the age of 26 was implemented on July 1, 2011 by the City of NY Health Benefits Program.

Coordination of Benefits with Spouse Benefits

Overview – Saves You Money!

If you or your eligible dependents are entitled to any medical or dental benefits through any other source (excluding an individual insurance policy, such as AFLAC, Catastrophic, etc.), your combined plans can increase your coverage and lower your and your spouse’s combined costs. Though Coordination of Benefits can increase coverage to pay the maximum of any necessary, reasonable and customary health care costs, your coordinated/combined benefits will not exceed 100% of any necessary, reasonable and customary items of expense covered under this plan or any other such plan. Coordinated Benefits allow the secondary plan to pick up costs after the primary plan coverage reaches its limits. Prepare the SBF Coordination of Benefits form and submit to the SBF Office. It saves you money by combining both spouses’ plans to cover up to 100% of a charge, but in no event shall payments exceed 100% of a charge, as noted below:

1. Benefits under a plan that is primary are calculated as though other coverage did not exist.
2. Benefits under a plan that is secondary will be reduced so that the combined payment or benefit from all plans are not more than the actual charges for the covered service. The plan that is secondary will never pay more than its full benefits.
3. Example: If a UFA plan covered 70% of your dental, and your spouse’s plan covered only 50%, then 100% of reasonable and customary costs would be covered, but not more, when you Coordinate Benefits. Whereas separately, because it is not legal to make a separate claim under both plans, the maximum coverage you would receive is 70% of the dental costs. Members and their families can greatly reduce their annual medical expenses through Coordination of Benefits. Contact the SBF Office and the FDNY Health Benefits Unit (NYC Employee Health Plans Program for retirees) to register your spouse’s coverage and insure you both receive this coordinated benefit!

* Note: It is illegal to use both spouse’s plans for the same bill unless you Coordinate Benefits as noted above.

Spouse City Employee Coordination

Two NYC Firefighters living as spouses or registered domestic partners are entitled to Coordination of SBF benefits, but NYC employees are not entitled to Coordination of their two NYC Health Plans. See Health Book (NYC Health Plans chapter) for more info regarding this.

Rules of Coordination

The City program follows certain rules that have been established to determine which plan is primary; these rules apply whether or not you make a claim under both plans. The rules for determining primary and secondary benefits are as follows:

1. The plan covering you as an employee is primary before a plan covering you as a dependent.
2. When two plans cover the same child as a dependent, the child’s coverage will be as follows:
   1. The plan of the parent whose birthday falls earlier in the year provides primary coverage.
   2. If both parents have the same birthday, the plan that has been in effect the longest is primary.
   3. If the other plan has a gender rule (stating that the plan covering you as a dependent of a male employee is primary before a plan covering you as a dependent of a female employee), the rule of the other plan will determine which plan will cover the child. (See Section C for special rules concerning dependents of separated or divorced parents.)
3. If no other criteria apply, the plan covering you the longest is primary. However, the plan covering you as a laid-off or retired employee, or as a dependent of such a person, is secondary, and the plan covering you as an active employee, or as a dependent of such a person, is primary, as long as the other plan has a Coordination of Benefits provision similar to this one.

Dependents of Separated/Divorced Parents

If two or more plans cover a dependent child of divorced or separated parents, benefits are to be determined in the following order:

1. The plan of the parent who has custody of the child is primary.
2. If the parent with custody of a dependent child remarries, that parent’s plan is primary. The step-parent’s plan is secondary and the plan covering the parent without custody is tertiary (third).
3. If the specific decree of the court states one parent is responsible for the health care of the child, the benefits of that parent’s plan are determined first. You must provide the appropriate plan with a copy of the portion of the court order showing responsibility for health care expenses of the child.

Suspension/ Termination/Continuation of Benefits

Termination of Benefits

Your benefit coverage terminates when you are no longer a member. Spouse and dependent coverage terminates when your coverage terminates or when they are no longer eligible, whichever occurs first.

Continuation of Benefits (COBRA)

If you or a member of your family are terminated, and are not covered under the Retiree’s Program, you may continue your basic health coverage through COBRA, for a cost. You must enroll with your NYC health plan carrier within 60 days of termination. See Health Book (NYC Health Plans Chapter) for more info.

Suspension Coverage

SBF coverage will continue for 30 days after a member is suspended. This does not apply to NYC Health Plan Coverage.

Modifications to Fund

The Trustees of the UFA Security Benefit Fund reserve the right to modify or discontinue the benefits of the Fund at

any time. Notification of any changes in the benefits or procedures will be sent to your address as listed in the Fund records.

Appealing an SBF Claim Denial

If your claim for dental, drug, optical, surgical anesthesia, obstetrical anesthesia, or hearing aid benefits is denied and you would like to have the matter reviewed, send your written request to the UFA Security Benefit Fund. Upon request, the SBF Trustees will grant a hearing before a committee designated by the Board at which time you may or may not be represented by an attorney. See Health Book (NYC Health Plans Chapter) to appeal any NYC Health Plan coverage denials.

Optical / Vision Benefits

UFA No Out-of-Pocket Plan

You can quickly look up optical providers in your area that accept UFA SBF coverage via a link on the UFA website. Optical benefits provided by the SBF allow an eye examination and one pair of prescription eyeglasses for each member and each of their eligible dependents each calendar year (retirees every two calendar years), as follows (you have one year from purchase to submit a claim):

1. Covered: The benefits include a routine eye examination, glass or plastic single vision or bifocal prescription lenses and a standard frame. Contact lenses may be substituted for lenses and frame, subject to providers’ surcharges for fittings, follow-up examinations and/or materials. Surcharges, when applicable, are payable by the member. Make sure you inquire about surcharges in advance of any service.
2. Cataract Lenses (retirees only): The Retired SBF allows up to $75 towards purchase after NYC Health Plan & Medicare, etc., have paid their portions (if applicable). Send the paid bill and NYC Health Plan(s) Explanation of Benefits (EOB) to the SBF Office for direct reimbursement (you have one year from purchase to submit a claim).
3. Not Covered: sunglasses, shatter-proof lenses where requested, more expensive frames, tinting, case- hardened lenses, progressive lenses, high-indexed lenses and similar options, except as specified on the SBF optical provider listing.
4. Limits: Participating eyeglass service providers fees are paid by the SBF with no out-of-pocket to you for eye examinations and glasses (or contact lenses) up to a maximum limit of $60.00 per dependent each year, which is calculated as follows:
   1. Eye Exam – up to $15
   2. Lenses – up to $25
   3. Frames – up to $20
   4. Contact Lenses – up to $45

Direct Reimbursement Option

The reimbursement check will be made payable to the member from the SBF. A member who elects not to use provider(s) specified on the SBF optical provider listing must submit a short note in an envelope labeled “Optical Refund” to the SBF Office stating:

1. If member is active or retired, and
2. member’s name & last 4-digits of SS#, and
3. patient’s name (*Note if claim is for self, or for another family member.), and
4. original paid bill (if applicable)

NYC Flexible Health Spending Plan Vision Benefit

Members who are enrolled in this Program may use contributions to pay for prescription glasses and contacts. If you have unused $$ left in your Flexible Spending Account at the end of the year, rather than lose the money to the government (as per program rules), or spend your limited Union Health Care Funds, you could invest it in vision care items/surgery as follows:

1. extra prescription glasses, or prescription sunglasses for your car
2. to stockpile disposable contact lenses (including prescription color lenses) for the following year.
3. Surgery: lasik, cataract or other eye surgery

See Health Book , NYC Health Plans chapter, Tax-Free Health Care Flexible Spending Account section for additional general info about the Flexible Spending Program

Hearing Aid Benefit

Firefighters and their eligible dependents are covered for one (1) hearing aid once every five (5) years up to a maximum of $600, upon referral of physician or audiologist. To file a Claim: When you have purchased a hearing aid, send a copy of the paid bill and a copy of the audiologist’s report to the SBF office for reimbursement (you have one year from purchase to submit a claim). A check will be mailed directly to the member.

Prescription Drug Plans

*Line-of-Duty Injuries

Use your FDNY LODI Drug Card or your WTC Drug Card — Never use your SBF drug plan or card for any line- of-duty injury (LODI) drug prescriptions — ever! If you do this, the cost comes directly out of the limited money the City contributes annually into your SBF dental, optical, prescription drug, anesthesia, hearing aid, and other supplemental health benefits plan. It’s your money. Don’t waste it—the Dept is required to pay it!

Generic Drug F.A.Q.s

The generic version of a drug has the same chemical compound as its brand-name counterpart. The use of generic drugs offers a simple and safe alternative to help reduce prescription drug costs. (Source: CVS Caremark)

1. What is a generic medicine? A generic medicine is a Food and Drug Administration (FDA) approved copy of a brand name drug. The FDA reviews each generic medicine to ensure that it is the same as the brand name drug in safety, effectiveness, quality, and performance (how it works in the body). The generic version is available for the same use (high blood pressure, allergies, etc.) and in the same form (pill, liquid, cream, etc.) as its brand name equivalent. By law in the United States, a generic medicine cannot look exactly like the brand name medicine, but it must be equal to the brand name product in safety, effectiveness, quality and performance.
2. Are generic medicines as safe as brand name medicines? Yes. The Food and Drug Administration (“FDA”) rigorously reviews all drugs to make sure they are safe.
3. Why do generic medicines cost less? A pharmaceutical company may spend hundreds of millions of dollars to discover and develop new, original medicines. A new brand name medicine may receive patent protection for up to 20 years. During this time, no other company can sell the same medicine. The brand manufacturer has an opportunity to recover the investment in research, development, testing, and marketing the new medicine. A generic equivalent can only be introduced after the patent expires on the brand name medicine.

When the patent expires, other manufacturers can apply for permission to sell the same medicine as a generic. The generic medicine must be thoroughly tested and approved by the Food and Drug Administration (FDA) before it can be sold. Because the generic manufacturer doesn’t have the same investment in the research and development of the original medicine, the generic medicine can usually be sold at a much lower price. What’s more, when the patent expires, other drug companies can also sell generic versions of the medicine, if FDA- approved. This increased competition usually lowers prices.

1. Why doesn’t the generic look like the brand name medicine? By law, in the United States, a generic must look different from the brand name medicine. The generic may be a different color pill or may have a different symbol on the capsule. It’s important to remember that how the medicine looks has nothing to do with how it works.
2. Does every brand name medicine have a generic equivalent? No. About 35% of all brand name medicines have a generic equivalent.

SBF Prescriptions: Filling Prescriptions, Costs, Services

1. Costs & Limitations: Reimburses for all purchases of FDA approved prescription legend drugs (drugs which cannot be dispensed without a prescription) and prescriptions which require compounding (mixing/special preparation). If you have questions regarding your prescription drug coverage, call CVS Caremark (the number is on the back of your SBF Drug Card), or visit the CVS Caremark website. If you are still uncertain, call the SBF Office. Coverage is as follows:
   1. Annual Cap: It has an Annual Family Cap of $6,500. (☺ Retirees have a $5,000 cap, with an up- front annual family deductible of $125 that must be met before any drugs will be covered.)
   2. ID Card: Members must present the UFA SBF Prescription Drug ID Card for each prescription at participating pharmacies.

1. Co-Pays at Participating Pharmacies (Active members only):
   • $8.00 co-payment for brand names,
   • No charge for generic named drugs.
2. Pharmacies: Participating & Non- Participating
   1. Find Your Pharmacy: The CVS Caremark Network has over 55,000 chain and independent retail pharmacies. To see if your neighborhood pharmacy is included refer to the list in the CVS Caremark booklet that was mailed to you with your Drug Cards, call CVS Caremark or visit the CVS Caremark website.
   2. Participating Pharmacies (Retirees only): Once your $125 annual family deductible is met, you will pay 35% of the cost of the drug. However, in no case will the payment be less than $5 for generic or $20 for a brand name drug. Retirees can obtain up to a 30-day supply at a participating pharmacy.

1. Non-participating Pharmacy Reimbursement (Active members only): Active members may be reimbursed up to the average wholesale price plus a dispensing fee; minus the active co-payment. Obtain a Direct Reimbursement Card/Form from your Company Delegate, or from the SBF, and submit it to CVS Caremark.iv. Non-participating Pharmacy Reimbursement (Retirees only): Retirees using non-participating

pharmacies can obtain up to a 30-day supply and may be reimbursed up to the average wholesale price plus dispensing fee, minus the retiree co-pay. The $125 annual deductible must be met first before co-pays apply. Reimbursement forms can be obtained by calling CVS Caremark.

1. Mail Order (Long Term) Maintenance Drug Program: The mail service program is designed mainly for individuals on maintenance medications for the treatment of chronic, long-term conditions such as, but not limited to, diabetes (Non-Medicare: thru your City health plan provider. Medicare: thru CVS Caremark), arthritis, high blood pressure, heart conditions, etc. You may receive up to a 90-day supply at one time that is delivered directly to your home. CVS Caremark guarantees that all prescriptions will meet the highest pharmaceutical standards for safety, quality, and effectiveness. A record of your prescriptions is maintained by CVS Caremark to monitor for adverse reactions with other prescriptions you may receive from the mail service or retail network pharmacy. A pharmacist will contact your doctor or you before dispensing a medication if there is a concern for possible drug interactions or adverse reactions. Using Mail Service:
   • 90-Day Supply: For maintenance drugs, have prescription written for up to a 90-day supply with three (3) refills. By law, it can only be filled for quantity indicated by your doctor. ☺ 0 No

deductible will be required for retired FFs when filling prescriptions via mail service (deductible still applies to retail prescriptions).

1. Immediate Need: ask your doctor for two (2) separate prescriptions- one for a 30-day supply to be filled at a network retail pharmacy, and one to be filled by mail service. Make sure it includes dosage, doctor’s signature and your name/address/phone number.
2. Forms to Prepare: Complete the Confidential Patient Profile and Enrollment Form for you and your eligible family members and mail with your first prescription order (make sure to write your ID number on the back of each prescription you attach) and copayment to Express Pharmacy Services (submit form only for your first mail order prescription). Print ‘Uniformed Firefighters Association’ on the form. If you have additions or changes to your medical condition, please notify mail service in writing.
3. Delivery Time: If your medications are not delivered to your home within seven to ten working days, please call CVS Caremark customer service.
4. Refills via Mail: Check the label on your prescription(s) to make sure you have refills remaining. You can visit the CVS Caremark Mail Service website section or call CVS Caremark toll free. Be prepared to provide your member ID number, prescription number(s), and your credit card information.
5. Controlled substances: cannot be filled through mail-order.
   1. Not QCovered: Insulin on prescription, syringes and tapes in association with diabetes, and all injectables are not covered under the SBF plan. But they may be covered under your basic NYC Health Plans. Certain other injectables and drugs that are not covered under your NYC Health Plans, are covered under the PICA program if you are non-Medicare eligible, @ as noted in the PICA section, which follows this section.
6. Specialty Medical Condition Member Services: Patients with complex, chronic medical conditions need the necessary care management to monitor their condition. Specialty Pharmacy Services by CVS Caremark is a program that provides that attention; they work one-on-one with the patient, managing their treatment. Specialty Pharmacy Services by CVS Caremark provides a full complement of specialized drugs and services for patients with:
   • Hepatitis C, Multiple Sclerosis* , Cancer*, Rheumatoid Arthritis, Hemophilia, Organ Transplant, RSV, HIV/AIDS, Crohn’s Disease. (MS Injectibles* & Cancer Chemo Drugs* are covered by City PICA for non-Medicare. See @ PICA section, which follows this section.
     If you are taking medications for one of the above conditions, Specialty Pharmacy Services by CVS Caremark will dispense your medications and manage your condition. If you have questions, need an enrollment form, or would like to learn more about Specialty Pharmacy Services by CVS Caremark, call CVS Caremark Specialty Pharmacy Services or visit the Member Services section of the CVS Caremark website. The following lists several benefits of using the Specialty Pharmacy Services program:
7. Patient Support: All new patients are assigned to a Patient Care Coordinator. The Patient Care Coordinator manages all case management activities and schedules the appropriate follow-up with our Nurses, Clinical Pharmacists, and Social Workers. We practice proactive counseling and compliance management, and provide support 7 days a week, 24 hours a day.
8. Clinical Assessment and Management: Our innovative patient care management programs are specific to the patient’s condition. The programs are designed to teach patients about their illness and the medications used to treat them. We coordinate any necessary training with the right professionals.
9. Physician Support: We keep physicians up-to-date on correct dosage criteria and clinical information about the patient. We provide them with the patient’s progress via the appropriate documentation.
10. Convenient, Priority Delivery of Specialized Medications: We coordinate the delivery of medication directly to the patient’s home and/or physician’s office. With every shipment we include all necessary ancillary supplies, educational materials, and training material. All shipments are tracked online to ensure that the patient’s medication(s) arrive safely and in a timely manner. Please note, specialty drugs are only available through Specialty Pharmacy Services by CVS Caremark and will not be available through the standard CVS Caremark mail order program.
11. Drug Quick-Reference Cost Guide: The CVS Caremark booklet that is mailed to to each member’s home with your Drug Cards has a list you may to show to all physicians who may write prescriptions for you and/or your dependents to assist them in the selection of cost-effective drug products.

* PICA is an outdated acronym for Psychotropic, Injectables, Chemotherapy & Asthma. Changes to the City plan have moved Psychotropic & Asthma coverage from the PICA program to the UFA SBF plan for coverage. Keep in mind though, that the above plan is still referred to as PICA.

Help! – Getting Answers:

1. Customer Service Center: The CVS Caremark Customer Service Center is available 24 hours a day Monday through Friday, 9:00 a.m. to 8:00 p.m. EST on Saturday, and 9:00 a.m. to 6:00 p.m. EST on Sunday. The Customer Service Center can answer questions about your pharmacy benefit plan and allows you to:
   1. Speak with a pharmacist about a prescription;
   2. Obtain additional information about your benefits;
   3. Request additional ID cards; and,
   4. Determine if your local independent pharmacy is part of CVS Caremark network of retail pharmacies.
2. Help – Health & Medication questions: The CVS Caremark Healthline is a telephone information and education center members can call for answers to common health and medication related questions. You can call toll-free to be connected to pharmacists and technicians who have received specific training in various healthcare areas including: Healthy Women Information (info on such issues as breast cancer, birth control, migraines, bladder control, etc.), diabetes (how to test yourself for sugar levels, how often, and nutrition related issues), and other topics.

Part B Premium Reimbursement

1. Once the NYC Health Benefits Program is notified that you are covered by Medicare, deductions from your pension check will be adjusted, if applicable, and you will automatically receive the annual Medicare Part B premium reimbursement (See b, c & d below for reimbursement info). The NYC Health Benefits Program will notify your health plan that you are enrolled in Medicare so that your benefits can be adjusted. This may take several months. If your plan does not accept Medicare-Eligibles, you will receive special instructions concerning changing to another health plan. NOTE: If you are Medicare-Eligible and are enrolling in an HMO you must complete an additional application form, which is available directly from your Health Insurance Plan Carrier.
2. The City will reimburse retirees and their eligible dependents for a portion of the monthly premium for Medicare Part B.
3. Periodically, the Medicare Part B premium is increased by the Social Security Administration. At the time of each increase, legislation must be approved by the City Council authorizing the City to reimburse you at a new rate.
4. If you are receiving a Social Security check, the premium for Medicare Part B will be deducted from that check monthly. If you are not receiving a Social Security check, you will be billed on a quarterly basis by the Social Security Administration. You must be receiving a City pension check and be enrolled as the contract holder for City health benefits in order to receive reimbursement for Part B premiums. For most retirees, the refund is issued automatically by the NYC Health Benefits Program. Medicare Part B reimbursement checks are generally issued once a year in the summer following the year in which premiums are paid.

Medicare Part D—Prescription Drugs

• Medicare Part D Prescription Drug Coverage Information and updates were mailed to all retired members outlining their Prescription Drug Benefits along with a Summary of Benefits (with Charts) and Frequently Asked Questions. Please refer to this information. Updates regarding Medicare Part D benefits will continue to be mailed directly each retired member’s residence as new information becomes available. Please retain this important info for future reference as needed.

For more information about this notice or your current prescription drug coverage contact the Benefits Access Center, call your prescription drug provider, CVS Caremark, visit Medicare online, call your State Health Insurance Assistance Program, call Medicare, or call UFA Retired SBF.

PICA* Drug Program (Injectable & Chemo)

PICA covers medications in two specific drug categories— Injectables & Chemotherapy—for all non-Medicare members. Though PICA is not guaranteed to exist permanently, PICA is a prescription drug program made available through creative and challenging negotiations with the City by the Municipal Labor Committee in 2001, which the UFA is a member of. The PICA Prescription Drug Program is administered by National Prescription Administrators (NPA) a division of Express Scripts, who you can contact for more detailed literature regarding PICA coverage. Here is how the PICA program works:

1. Eligibility: PICA covers all NYC employees, non-Medicare retirees and their eligible dependents who are enrolled in any health plan offered by the City’s Health Benefits Program. You do not need to enroll separately. There is no payroll deduction for PICA. Medicare retired members must use UFA SBF coverage for Injectables & Chemotherapy—not PICA. However, non-Medicare dependents of Medicare members are still covered by PICA.
2. Retail Pharmacy: PICA cards are automatically mailed to each member’s residence. You may use the PICA Card, which is different than your UFA SBF Drug Card, for supplies of PICA drugs for up to 30 days.
3. PICA Mandatory Mail Order: all PICA drugs that are classified as maintenance medications MUST be filed through mail order after you have had two fills at retail. A maintenance drug is a medication that you will be utilizing on a regular basis over an extended period of time. If you are currently taking a maintenance PICA drug and have filled it twice at the retail pharmacy, you MUST send it to mail order. NPA offers a mail order program where you can receive a 90-day supply of PICA drugs. You will receive up to a 3 month supply of medication for only 2 retail co-payments, saving you money.
4. PICA Co-payments:
   1. Retail Pharmacy (up to a 30 day supply):
      • $10 Generic
      • $25 Preferred Brand (Formulary)
      • $45 Non-Preferred Brand (Non-Formulary)**
   2. Mail Order Pharmacy (up to a 90 day supply):
      • $20 Generic
      • $50 Preferred Brand (Formulary)
      • $90 Non-Preferred Brand (Non-Formulary)**

** If you choose a non-preferred brand drug that has a generic equivalent you will pay the difference in cost between the non-preferred brand drug and the generic drug PLUS the non-preferred brand co-payment.

1. $100 Annual Deductible: There is an annual deductible of $100 per person for Injectable & Chemotherapy medications. This deductible is independent of any other deductibles.
2. PICA and Other Drug Plans: In general, PICA drugs are not covered by your SBF Card. If your prescription is not covered by PICA, use your UFA SBF Pharmacy Drug Card—but only if the medicines are not covered by PICA. If you are not sure, you should present your NPA PICA drug card first. *Ask your pharmacist specifically if they cover PICA drugs. Certain prescription drugs you may not expect to be covered do fall into this category.
3. * NYC Health Plan Buyout Waiver: Members who opt to buy out of NYC Health Plans (or for retirees who drop out of NYC Health Plan coverage and opt for other coverage) are not eligible for PICA coverage.

* PICA is an outdated acronym for Psychotropic, Injectables, Chemotherapy & Asthma. Recent City plan changes have moved Psychotropic & Asthma coverage from the PICA program to the UFA SBF plan for coverage. Keep in mind though, that the above plan is still referred to as PICA.

Anesthesia Benefits

The Security Benefit Fund (SBF) anesthesia benefits are entirely independent of any basic NYC Health Plan benefits. However, SBF plan anesthesia benefits may, in many cases, be a supplemental reimbursement in addition to your NYC Health Plan coverage for maternity (obstetrical) anesthesia and/or other surgical anesthesia costs, as long as the claim is submitted within one year from date of administration of anesthesia, as follows:

Maternity (obstetrical) Anesthesia

(Retired members do not receive this benefit from the SBF. Retirees must check with their NYC Health Plan carriers for available coverage.)

1. Maximum Benefits for delivery of baby:
   1. $50, if a normal hospital delivery
   2. For Caesarean Section, Therapeutic Abortion or Miscarriage, make claims on Surgical Anesthesia Claim Form. Instructions follow in the Surgical Anesthesia section.
   3. In any case, if the anesthesia charge is less than the respective maximum limit, the benefit will equal—not exceed—the actual charge. If there was no cost, then no benefit will apply. In other words, in no case will reimbursement exceed the dollar amount of your uncovered bills.
2. Reimbursement procedure:

1. Obtain a Maternity Anesthesia Claim Form (green) from your Company Delegate, who keeps a supply on hand. The form also has filing instructions listed on the reverse side. Attach the following to it:
   • The bill for administering the maternity anesthesia, which must include your spouse’s name, date administered, and cost of anesthesia, and
   • The statement from Blue Cross/Blue Shield or the hospital bill for your spouse’s maternity confinement, and
   • The original statement from your NYC Health Plan showing payment towards the anesthesia bill.
2. Return Documentation: a completed form and the originals of necessary documentation must be returned to the SBF office within one year of the administration of anesthesia. If the patient is eligible, a check will be mailed from the SBF to your home.
3. *Increase Your Dependents: If this birth resulted in an additional dependent, and in order to ensure your new baby has coverage, it is strongly advised to forward a copy of the Certificate of Birth as soon as possible to the SBF office. However, the official Certificate of Birth may not be available for weeks. In that case, immediately send the SBF whatever documentation you may have so we can begin your new baby’s coverage right away. The hospital will usually give you a Certificate of Live Birth (must note baby name, footprints, weight, DOBand parents’ names). You can send this to the SBF right away and send the official Certificate of Birth once you receive it. Also, see the ‘Keeping Your Insurance Info Current’ section for the checklist of things you should do when adding a new dependent.

Surgical Anesthesia

Active members receive reimbursement for uncovered portions of surgical anesthesia in accordance with the schedule below. Retirees are not covered for SBF Anesthesia. Retirees must check with their NYC Health Plan carriers for available coverage. However, retirees who have been FDNY Surgical Assistance Fund members for two full years prior to retirement have coverage under the Surgical Assistance Fund (active members must pay additional for this benefit), which reimburses for surgery in accordance with its schedule. See Health Book (Insurance chapter: Surgical Assistance Fund) for more info.

1. Maximum Benefits:
   1. $400, if your NYC Health Plan did not cover your surgical anesthesia.
   2. $100 per procedure, $400 per year, for in-hospital oral surgery.
   3. $80 for Therapeutic Abortion or Miscarriage
   4. $125 for Caesarean Section
   5. Variable: If the member is not a member of the Surgical Assistance Fund or failed to file a claim with the Surgical Assistance Fund, he/she must enclose a detailed surgeon’s statement of the operative procedure or hospital transcript describing the surgery performed, which must include the patient’s name and date of operation.

1. Reimbursement procedure:
2. Obtain a Surgical Anesthesia Claim Form (blue) from your Company Delegate, who keeps a supply on hand. The form also has filing instructions listed on the reverse side. Attach the following to it:
   1. Anesthesia bill noting patient’s name and date of surgery, and
   2. the statement from your NYC Health Plan showing the amount it covered towards the anesthesia bill, and
   3. the payment slip from the Surgical Assistance Fund (if a member). If you are not a member, attach an operative report from the surgeon instead.
   4. Do not file if your NYC Health Plan paid the anesthesia bill in full.
3. Return Documentation: a completed form and the originals of necessary documentation must be returned to the SBF office within one year of the administration of surgical anesthesia. If the patient is eligible, a check will be mailed from the SBF to your home.

NYC Health Plans Coverage Note

Though both Maternity and Surgical SBF benefits are totally independent of any NYC Health Plan, keep in mind the following regarding two of the most used NYC Health Plans by our members:

1. GHI-CBP/Blue Cross: Anesthesia should be paid in full by GHI if using GHI-CBP doctors. If not, the SBF will cover the previously listed benefit limits as applicable.
2. HIP/HMO: Anesthesia should be covered in full by HIP/HMO when admitted to a hospital by a HIP/HMO physician. If you are billed, all claims must be addressed through HIP for full reimbursement. Do not file with the SBF.

Dental Programs

Overview

You quickly can look up dentists in your area that accept UFA SBF coverage, review info about your account and get many questions answered about the UFA dental program via a link on the UFA website. Active and retired members have a choice of the below SBF Dental Plans, which are explained in more detail on the following pages.

1. UFA Family Dental Plan: Pay-and-Reimburse Plan
2. UFA Preferred Provider Organization (PPO) Plan: No cost for many commonly used services (active only)
3. Dentcare: Pre-paid No Out-of-Pocket Dental Plan
4. Comprehensive Professional Systems (CPS): additional benefit for retirees only
5. Healthplex America 500 Dental Plan: additional benefit for Florida retirees only

Dental Plan Enrollment

New members have a 31 day period from their swear-in date to choose a plan. If a new member fails to choose a plan, he/she will have no coverage. Once enrolled in either plan, members will be allowed to change plans usually between October 15th and December 31st, as announced each Fall, with the new plan to become effective January 1st. However, members may change plans during other times ONLY for extraordinary reasons. A letter of explanation should be forwarded to the SBF for review. You must contact the SBF Office if you wish to change plans.

Dental Specialties by Definition

In order to make it easier for members to understand the SBF Dental Plan descriptions and coverage, the below list is provided as a reference to help clarify some of the dental terms (additional terminology on Healthplex website) as they relate to types of services that you may need. It is not a list of what is or is not covered by any UFA SBF Dental plan.

1. General Dental Practitioner: A dentist who performs all types of dental procedures, but has not received postgraduate training in any one area. General dentists provide Diagnostic, Preventive, Restorative, Endodontic, Periodontal, Prosthetic, and Oral Surgery, services. They may also provide orthodontic treatment, although this service is usually rendered by orthodontists.
2. Endodontist: A dental specialist whose practice is limited to treating diseases of, and injuries to, the pulp. Endodontists perform root canal therapy and other services related to the blood vessels and nerve tissue inside teeth.
3. Periodontist: A dental specialist whose practice is limited to treating diseases of the supporting and surrounding tissues of teeth. Periodontists perform scalings, gingivectomies and other surgery involving soft tissue and bone.
4. Prosthodontist: A dental specialist whose practice is limited to restoring natural teeth and replacing missing teeth. Prosthodontists treat patients with crowns, bridges and dentures.
5. Oral Surgeon: A dental specialist whose practice is limited to diagnosing and treating diseases, injuries, deformities and defects of the mouth. Oral surgeons remove erupted and impacted teeth and provide other surgical services to correct problems of the teeth, bone and soft tissue in the oral cavity.
6. Orthodontist: A dental specialist whose practice is limited to preventing and treating malocclusion of the teeth. Orthodontists use removable and fixed appliances (often called braces) to straighten and realign teeth.
7. Pedodontist: A dental specialist whose practice is limited to treating children. Pedodontists perform basic dental procedures such as prophylaxis, restorations, pulpotomies and stainless steel crowns.

UFA Family Dental Plan (Pay-and-Reimbursement Plan)

This Plan is self-insured by the UFA SBF. Members choose any dentist they want. There is no list. You pay the dentist for services rendered and submit a reimbursement form to Healthplex. You are reimbursed by check to your home in accordance with dental services and limits listed later in this section. (For retirees, there is a $1500 annual cap per family member). A member is eligible for Coordination of Benefits when his/her spouse is also a member and both have chosen coverage under UFA Family Dental Plan. Contact the SBF Office if you qualify. NOTE: UFA Family Dental Plan members are also entitled to use all benefits under the UFA Participating Provider Organization (PPO) Plan. See ‘UFA Participating Provider Organization (PPO) Plan’ later in this section.

1. Reduced Fee Schedule: See next page for schedule.
2. Services Not Covered & Plan Limitations: See next few pages for lists.
3. Orthodontic Services: See next few pages for list.
4. Pre-Certification Criteria: Pre-certification is required if the dental charges for a more proposed course of treatment are expected to exceed $200. This permits the review of the proposed Treatment Plan by a Healthplex (which manages the UFA Family Dental Plan) staff dental consultant in advance—and allows for resolution of any questions before—rather than after the work has been done. In addition, both you and your dentist will know in advance what is covered and what the plan will pay before treatment has begun.
5. Pre-Certification Procedures:
   1. If treatment is expected to exceed $200, the dentist must complete the Treatment Plan Form before starting treatment. The dentist should attach to the form x-rays upon which the treatment will be based. Mail the completed form and x-rays to Healthplex, Inc.
   2. Before any work is done, members should show to their dentist the reimbursement schedule that is in this book (or the reimbursement sheet, which is available in your Delegate’s SBF file). This will show which services are covered under the Dental Plan and the estimated allowance that will be paid by the Fund back to you.
   3. When treatment is complete, have the dentist date and sign the claim form (including the date on which authorized services were performed) and forward it to Healthplex, lnc.

iv. Orthodontics: The procedure for orthodontic pre-certification varies slightly, and is described under Orthodontics Services, which follows the reduced Fees Schedule and Services Not Covered/Plan Limitation lists on the next few pages.

1. Filing Dental Claims
   1. Dental claim forms may be obtained from your Delegate.
   2. Complete the member section of the claim form.
2. Bring claim form with you to your Dentist’s office. Have him/her complete all information required on the form.
3. A separate claim form must be filed for each family member.
4. Member must mail completed form to Healthplex, Inc.
5. Incomplete information will result in delay of payment.

vi. Any questions concerning eligibility, the plan, claims, allowances, procedures or payment should be directed to Healthplex. Make sure your home address that you write on any letters or Healthplex form is updated and current in the SBF system – otherwise replies from Healthplex will not reach you.

UFA Family Dental Plan Schedule of Active Covered Services*

All Allowances Include Necessary X-rays, Aftercare

DIAGNOSTIC & PREVENTATIVE SERVICES

• Examination and Prophylaxis $75.00
• Full mouth series of x-rays once every 5 years 90.00
• Four bitewings x-rays once during any 12 months 37.00
• Intra-oral occlusal (edentulous jaw) each film 34.00
• Tempero-mandibular joint film 63.00
• Anterior-posterior, head & jaws 63.00
• Cephalometric X-Ray 76.00

EXTRACTIONS

• Impacted teeth, partial bony impaction 145.50
  • full bony impaction 171.00
  • soft tissue impaction 121.00
• Other extractions, each tooth 31.00
• Difficult extractions requiring flap bone removal and sutures 81.50

FILLINGS

• Silver Amalgam, one surface 54.00
• Silver Amalgam, two surfaces 87.00
• Silver Amalgam, three surfaces 117.00
• Composite, acrylic, synthetic porcelain one surface 72.00
  • two or more surfaces 120.00

RESTORATIONS

• Gold inlays, two surfaces 185.00
• Gold inlays, three or more surfaces, maximum per tooth 236.00

CROWNS

• Three-quarter 222.00
• Full 295.00
• Full with veneer 311.00
• Shell crowns. 110.00
  • Jacket crowns to restore teeth (not repairable by fillings: 8 upper & lower front teeth only)
• Porcelain jacket 295.00
• Acrylic jacket 202.00
• Full cast with veneer 311.00
• Posts. 92.50
• Recementing inlays or crowns 20.00

PALLIATIVE

• Emergency visit for relief of pain 32.00

PERIODONTA

• Root scaling, curettage, medication and minor bite condition
  • Each treatment. 50.00
• Maximum for services in any
• 12 month period 280.00
• Gingivectomy, each quadrant (minimum 6 teeth per quad) 181.00
• Bacteriology examination 75.00
• Periodontal Prophylaxis. 40.00

REPAIR OF PROSTHETIC APPLIANCES

($100.00 maximum per year)

Acrylic denture

• Repairing body of broken denture 43.00
• Replacing broken teeth in denture
  • first tooth 36.00
  • each additional tooth 22.00
• Replacing clasp, clasp intact. 50.00
• Replacing broken clasp 86.00
• Replacing facing or crown or pontic 43.00

ROOT CANAL THERAPY

Removal of pulp and filing canal

• Anterior-first canal. 191.00
• Bicuspid-second canal 263.00
• Molar-third canal. 335.00

ORAL SURGERY (See Surgical Anesthesia section on prior pg.)

Fracture of jaw

• Lower jaw, closed reduction $280.00
• Upper or lower jaw open reduction 475.00
• Removal of cysts, with necessary Extractions. 111.00
• Apicoectomy 122.00
• Alveolectomy, maximum per jaw 72.00
• Alveolectomy, without extraction 66.00
• Biopsy 91.00
• Closure of oral-antral fistula. 160.00
• Removal of labial fraenum 120.00

SPACE MAINTAINERS

• Removable – bilateral. 330.00
• Fixed – unilateral 372.00

BEDSIDE CALL

• Call (home or hospital). 29.00

PROSTHETIC SERVICES

• Dentures full, either jaw, each 374.00
• Partial bilateral, acrylic or comparable base,
  • either jaw 2 or more full clasps & rests, each 389.00
• Partial bilateral, chrome cobalt alloy or gold base, 2 or more full clasps with occlusal rests, acrylic attachments & porcelain
  • or acrylic teeth, either jaw, each 410.00
• Adding teeth to partial denture top replace natural teeth not part of original denture
  • first tooth 65.00
• Each additional tooth 36.00
• Obturator (not including denture). 108.00
• Re-basing, one per denture in any 3-year period 101.00
• Fixed bridgework Abutments
  • 3/4 crown 222.00
  • full cast. 252.00
  • full cast with veneer (8 front teeth). 266.00
  • Inlay used as abutment

1. surfaces. 158.00
2. surfaces. 202.00

Pontics

• Tru-pontic. 202.00
• Removable bridgework
  • steel with clasps & lugs (Nesbell)
• one tooth 158.00
• two teeth 202.00
• three teeth 245.00

ORTHODONTIA SERVICES for dependent Children under age 19 only:

(Not including extraction of teeth performed as part of treatment)

• diagnosis and initial orthodontic appliances. 285.00
• active orthodontic treatment maximum per month 84.75
  • (maximum number of months of active treatment: 20 months)
• passive orthodontic treatment maximum
• per 6 months of treatment. 58.00
• (maximum number of months of passive treatment: 18 months)
• MAXIMUM TOTAL ALLOWANCE. $2145.00

* Not all covered services are listed on this schedule. Services not listed will be valued by report.

* Please note that the Family Dental Plan does not provide for assignment of benefits for out-of-network providers. Upon completion of your dental work, the reimbursement check will be mailed directly to you. Assignment of Benefits is available when services are rendered by a participation Healthplex PPO provider.

Services Not Covered: for UFA Family Dental Plan & PPO Plan

1. Dental anesthesia or anesthesia associated with oral surgery except when administered In-Hospital, (See Surgical Anesthesia, earlier in this chapter.)
2. charges in connection with a disease other than a non-occupational disease, or an injury other than a non- occupational injury;
3. charges for any dental services and supplies to the extent that benefits are payable under any one of the following items in respect of which any Employer of any member of the Employee’s family shall directly or indirectly have either contributed or made payroll deductions; any hospital, surgical or medical plan, any union welfare plan or any other employee benefit organization plan–for the purposes of this item (2), the Employee’s family comprises of the Employee, his spouse and the children of either:
4. charges incurred with respect to any individual while he is not a covered family member;
5. charges made by other than a dentist, or as to charges for treatment by other than a dentist, except that cleaning or scaling of teeth may be performed by a licensed dental hygienist, if such treatment is rendered under the supervision and direction of the dentist;
6. charges for services and supplies that are partially or wholly cosmetic in nature, including charges for personalization or characterization of dentures;
7. charges for prosthetic devices (including bridges and crowns) and the fitting thereof which were ordered while the individual was not a covered family member, or which were ordered while the individual was a covered family member but are finally installed or delivered to such individual more than thirty days after termination of coverage;
8. charges for the replacement of a lost or stolen prosthetic device;
9. charges for any services or supplies which are for orthodontic treatment (including correction of malocclusion) except as specially provided for in the Schedule of Covered Dental Services;
10. charges for any replacement of an existing partial or full removable denture or fixed bridgework, or the addition of teeth to an existing partial removable denture or to bridgework unless evidence satisfactory to the Security Benefit Fund is presented that:
    1. the replacement or addition of teeth is required to replace one or more additional natural teeth extracted after the existing denture or bridgework was installed and while the family member is covered under this plan, or
    2. the existing denture or bridgework was installed at least five years prior to its replacement and that the existing denture or bridgework cannot be made serviceable.
11. temporary fillings, crowns, bridges or dentures;
12. any type of periodontal splints;
13. implants (implants involving bridges, crowns or dentures are not covered);
14. prosthetic services involving appliances used solely to increase vertical dimension;
15. any orthodontic appliance other than the permanent appliance;
16. dental services other than those specifically listed as Covered Dental Services.

Plan Limitations: for UFA Family Dental Plan & PPO Plan

1. Fillings: No payment for a replacement of a filling by another filling (same surface or surfaces) or by a crown for a period of six months by the same dentist, except if tooth was subject to trauma from outside forces.
2. Endodontic Services: If Sargenti method or similar method of endodontic therapy is used, the reimbursement will be at one-half the schedule allowance for the conventional method of therapy.
3. Periodontic Services: Repeated periodontal surgery will not be covered for period of three years.
4. Prosthetic Services (Crowns, Bridges, Dentures)
   1. No replacement or interchange for a full or partial denture, crown or fixed bridge by another appliance–bridge, crown or denture for a period of five years.
   2. Overlay full upper and lower dentures will be paid for at the regular schedule of allowances for full upper and full lower and there will be no payment for any procedure on the abutment tooth or attachment tooth.
   3. All allowances for appliances include adjustment for a period of one year.
   4. Immediate dentures will be covered with the same limitation and exclusion applying to it as a permanent denture.
   5. When a fixed bridge and partial denture are inserted in the same jaw, only the partial denture will be covered and there will be no payments for the crown or the abutment teeth for the fixed bridge.
   6. No payment for crowns from attachment or clasp purposes except if the tooth is so broken down that it cannot be restored by a filling.
   7. Acrylic crowns must be laboratory processed and only paid as single crowns on the anterior teeth (cuspid to cuspid). Acrylic crowns will not be paid as bridge abutments.
   8. Veneer crowns will not be paid on molars except for the upper first molar. On all molars it will be paid, when covered, as a full crown.

Orthodontic Services: for UFA Family Dental Plan

1. Prior Services: If an appliance was inserted, and active months of orthodontic treatment have been rendered prior to the effective date of the contract then there will be no payment for the appliance. The months of active treatment will be subtracted from the total months of active treatment permitted by the contract.
2. Age Considerations (subject to plan schedule and limits): Dependents under the age of 19 are covered for Orthodontic services. In other words, the member is not covered, but his/her dependents that are under 19 years old are covered. NO dependent who has reached his or her 19th birthday is covered for orthodontics—under any circumstances.
3. Pre-certification: Once the dentist has submitted the Treatment Plan Form for orthodontics and the plan has been approved, claims for the monthly visits must be submitted every three months (quarterly) on a completed claim form to Healthplex, Inc. In addition, the Plan may request study models from the dentist before the orthodontic treatment is approved.
4. Cosmetics: Orthodontic Services for cosmetic purposes are not covered.

Free — UFA Participating Provider Organization (PPO) Plan

Free for most commonly used services. This PPO Plan is also managed by Healthplex, and has a network of over 3,500 participating dentists who will work for free, or at our reduced fee schedule. You you must bring your Healthplex ID card each visit to a PPO dentist. You may visit any dentist listed in the Healthplex PPO Directory of Participating Providers, which is mailed to all enrolled members’ residences, or you can visit the Healthplex website (For retirees, there is a $1500 annual cap per family member). This link can also be accessed through the UFA website. Different family members are not required to all go to the same PPO dentist. Also, you may receive treatment from non-PPO dentists and you will be reimbursed according to the UFA Family Dental Plan allowance schedule (See ‘UFA Family Dental Plan Schedule’ on prior pages). However, out-of-network dentists may charge higher fees and your out-of- pocket expenses could be more. Contact the Healthplex Customer Service Dept. or the UFA SBF Office if you need help.

1. Covered Free Services & Reduced Fee Schedule. See next page for schedule.
2. Services Not Covered: Same as UFA Family Dental Plan. See prior pages.
3. Plan Limitations: Same as UFA Family Dental Plan. See prior pages.

ACTIVE

UFA Preferred Provider Organization (PPO) Plan

Covered Free Services & Reduced Fee Schedule

RETIREE (except Florida)

DESCRIPTION Fees

• Diagnostic & Preventive Services
• Periodic Oral Exams 0.00
• Full Mouth X-rays 0.00
• Periapical – Single Film 0.00
• Panorex 0.00
• Cleaning of Teeth (polishing) 0.00
• Flouride Treatment. 0.00
• Emergency Treatment. 0.00
• Restorative
• Silver Amalgam, One surface. 0.00
• Silver Amalgam, Two surface. 0.00
• Silver Amalgam,Three surface 0.00
• Composite filling, One surface. 0.00
• Composite filling, Two surface. 0.00
• Composite filling, Three surface 0.00
• Oral Surgery
• Routine Extraction 0.00
• Surgical Extraction 0.00
• Soft Tissue Impaction 0.00
• Partial Bony Impaction 0.00
• Full Bony Impaction 0.00
• Alveolectomy w/o extractions 0.00
• Root Canal Therapy
• Root Canal Therapy, Anterior 0.00
• Root Canal Therapy, Bicuspid 0.00
• Root Canal Therapy, Molar 0.00
• Periodontics
• Scaling of teeth 0.00
• Perio Prophylaxis 0.00
• Anterior Composite-Three Surfaces. 0.00
• Gingivectomy, per quad 25.00
• Osseous surgery, per quad 50.00
• Prosthetics – Fixed, Removable
• Acrylic w/ High Noble Metal Crown 0.00
• Porcelain Crown 25.00
• Porcelain w/ High Noble Metal Crown 50.00
• Stainless Steel Crown (up to age 16) 0.00
• Cast Post. 0.00
• Acrylic w/ High Noble Meal Pontic. 0.00
• Porcelain w/ High Noble Meal Pontic. 50.00
• Porcelain w/ High Noble Meal Abutment. 50.00
• Full upper/lower denture, inc. adjustments 0.00
• Partial upper/lower denture, cast base. 0.00
• Replacement of Broken Tooth 0.00
• Orthodontics
• Lifetime Maximum 300.00
• Diagnostic & Preventive Services
• Periodic Oral Exams 16.50
• Full Mouth X-rays 34.00
• Periapical – Single Film 7.65
• Bitewing, Four Film 11.00
• Prophylaxis – Cleaning of Teeth 33.00
• Emergency Treatment. 19.70
• Restorative
• Silver Amalgam, One surface. 33.00
• Silver Amalgam, Two surface. 40.00
• Silver Amalgam,Three surface 48.50
• Composite filling, One surface. 34.00
• Composite filling, Two surface. 54.00
• Composite filling, Three surface 72.00
• Oral Surgery
• Routine Extraction 46.50
• Surgical Extraction 59.00
• Soft Tissue Impaction 97.00
• Partial Bony Impaction 111.00
• Full Bony Impaction 131.00
• Root Canal Therapy
• Pulpotomy 40.00 Root Canal Therapy, Anterior. 251.65
• Root Canal Therapy, Bicuspid 283.90
• Root Canal Therapy, Molar 316.15
• Periodontics
• Scaling of teeth 73.75
• Gingivectomy, per quad 86.00
• Osseous surgery, per quad 366.00
• Prosthetics – Fixed, Removable
• Porcelain w/ High Noble Metal Crown 421.00
• Stainless Steel Crown 49.00
• Cast Post. 113.50
• Recementation, per crown 26.50
• Porcelain w/ High Noble Meal Pontic. 463.00
• Porcelain w/ High Noble Meal Abutment. 421.00
• Full upper/lower denture, inc. adjustments 375.00
• Partial upper/lower denture, cast base 428.30
• Denture Reline (in office) 69.00
• Repair Broken Body of Denture. 37.00
• Replacement of Broken Tooth 31.50

Orthodontics

• 24 month case. 1782.00

Dentcare Plan (Pre-paid No Out-of-Pocket Plan)

You quickly can look up dentists in your area that accept Dentcare coverage, review info about your account and get many questions answered about Dentcare via a link on the UFA website. This optional plan is available to all members. With Dentcare, you must select one participating dentist from the plan list as your family dentist, then notify Dentcare (Healthplex) directly (not the SBF). The dentist selection booklet and FAQ booklet can be provided by your Company Delegate, or you can look up participating dentists on the UFA Website link to Dentcare (via Healthplex)— which always has an updated dentist list. Your family may only use the Dentcare dentist you choose. If you wish to change your Dentcare family dentist, you must again notify Dentcare directly (not the SBF). All necessary dental care, in accordance with the below Covered Services List will be provided for your eligible dependents without any cost— provided you use a Dentcare dentist. Dentcare consists of 5 basic areas of Dental Coverage. It is designed to cover all areas of Dentistry. If your family is also covered by another dental insurance, Dentcare dentists will waive charges up to amount covered. Dentcare will Coordinate Benefits with existing Medical/Dental programs, where in force. For additional info, you should contact Dentcare directly.

1. Covered Services & Pre-certification: Pre-certification by a Plan Dentist with the approval of the Dental Plan Director is necessary before any prosthetic services will be provided. If you disagree with the disposition of any claim, you may request a review. There is no cost to you or your family for any of the following services except as noted in Additional Charges, which, which immediately follows the following chart.

Patient Copayment Diagnostic & Preventive Services

• Oral Examination No Charge
• Full mouth x-ray No Charge
• Bitewing Series No Charge
• Single Films (periapical or bitewing) No Charge Cleaning of Teeth (prophylaxis/polishing) No Charge Fluoride Treatment No Charge
• Specialty Consultation No Charge Treatment in case of dental emergency No Charge

Restorative Dentistry

• Silver amalgam, one surface No Charge
• Silver amalgam, two surfaces No Charge Silver amalgam, three surfaces or more No Charge Composite filling, one surface No Charge
• Composite filling, two surfaces No Charge Composite filling, three surfaces or more No Charge

Oral Surgery ¹

• Routine extractions – per tooth No Charge
• Surgical extractions No Charge
• Soft tissue impactions No Charge
• Boney impactions No Charge
• Alveolectomy, per quadrant No Charge

Root Canal Therapy

• Pulp Capping, Direct No Charge
• Pulpotomy No Charge
• Root Therapy- Anterior No Charge
• Root Therapy – Bicuspid No Charge
• Root Therapy – Molar No Charge
• Apicoectomy No Charge

Periodontics

• Scaling of teeth, per quad No Charge
• Subgingival curettage, per quad **No Charge
• Gingivectomy, per quad No Charge
• Mucogingival surgery, per quad **No Charge
• Osseous surgery, per quad No Charge

Prosthetics – Crowns

• Acrylic with metal crown No Charge
• Porcelain crown No Charge
• Porcelain with metal crown *No Charge
• Stainless steel crown No Charge
• Post No Charge
• Recementation, per crown No Charge

Prosthetics – Fixed Bridges

• Acrylic w/ metal bridge crown or pontic No Charge Porcelain w/ metal bridge crown or pontic *No Charge Recementation, bridge No Charge

Prosthetics – Removable

• Full upper or lower denture, w/adjustments No Charge Partial upper or lower denture, cast base No Charge Denture adjustments No Charge
• Broken Body of Denture No Charge Replacement of Broken/Missing Teeth No Charge

Orthodontia – Dependent Children Only***

• Maximum case fee – 24 months No Charge

*Retiree fee is $50 for these two items

**Retirees only

***Children covered up to age 19, 23 if full-time student

Additional Charges:

1. Orthodontia: for lost or broken appliance $100.00
2. Broken Appointments: If specified by Plan Dentist for appointments not cancelled 24 hours in advance, there is a $30.00 charge.
   1. Time/Service Limitations:
3. Exams, recall x-rays, prophylaxis, scaling and fluoride treatment – Once every 6 mos.
4. Full mouth and panoramic x-rays – Once every 36 mos.
5. Crowns, bridges, dentures & periodontal surgery – Once every 60 mos.
6. Orthodontic treatment of Class II/Class III malocclusions – One 24 month case.

¹See Anesthesia Benefits section, Surgical Anesthesia sub-section (Maximum Benefits) for additional oral surgery anesthesia coverage info.

Emergency Care:

In the event you are unable to reach your own Dentcare dentist, Dentcare (Healthplex) provides 24 hour emergency service operators.

1. In cases of emergency, Dentcare covers a maximum of two visits per member per contract year, for services rendered by a Dentcare dentist. However, if the member has had regular check-ups, or is undergoing treatment, there is no limitation.
2. If the emergency occurs out-of-area, or in the unlikely event the member is unable to reach a Dentcare dentist, Dentcare will reimburse up to $25 per family member per contract year, upon presentation of bills for palliative care rendered by a non- Dentcare dentist until treatment can be obtained from your DENTCARE dentist.
   • • Exclusions & Limitations
3. Any dental services which were not rendered or approved by a participating dentist except in cases of out- of-area dental emergency
4. A service not furnished by a Dentist, unless the service is performed by a licensed dental hygienist under the supervision of a dentist or for an x-ray ordered by a dentist.
5. Treatment of a disease, defect, or injury covered by a major medical plan, Workmen’s Compensation Law, occupational disease law, or similar legislation.
6. General anesthesia, analgesia and any service rendered in a hospital environment.
7. Any dental procedures which are undertaken primarily for cosmetic reasons, or dental care to treat accidental injuries, congenital or developmental malformations.
8. Restorations, crowns or fixed prosthetics when acceptable results can be achieved with alternative methods or materials. In cases where the selection of a more expensive treatment plan is decided upon, the Plan will allow for the least costly alternative and the patient is responsible for all additional fees charged by the dentist.
9. Services which were started prior to the person becoming covered under this plan.
10. Implants, grafts, precision attachments or other personalized restorations or specialized techniques.
11. Broken Appointments – If specified by Plan Dentist for appointments not canceled 24 hours in advance, there is a $30.00 charge.
12. Replacement of any existing crown, bridge or denture, which can be made serviceable according to common dental standards.
13. Procedures, appliances or restorations whose main purpose is to: change vertical dimension; diagnose or treat conditions or dysfunction of the temporomandibular joint; stabilize periodontally involved teeth, or restore occlusion.
14. Treatment of unmanageable children or otherwise unruly patients. An attempt will be made to treat all patients. However, if a patient is untreatable by virtue of apprehension or any other reason, and is referred to another office for treatment, the responsibility for payment lies with either the patient or with the parents of the patient.
15. Services not listed in the Schedule of Benefits are not covered.

CPS Dental Plan — Retirees Only

CPS is offered automatically only to retired members and their covered dependents if they are enrolled with the UFA Family Dental Plan (not Dentcare). CPS overlays the UFA Family Dental Plan, with no additional paperwork for the member. Claims processing and member reimbursement follow the existing procedures. You still pay the dentist, fill

out the normal reimbursement claim form, and receive a check back in a few weeks, in accordance with the CPS rate schedule. The benefit lies in the fact that you are being charged a reduced set rate fee by the CPS dentist. Members in Dentcare are not eligible to utilize this alternative. When you use the CPS Dental network you will get:

1. a network of over 300 participating dentists, including specialists (mostly not the same names as Dentcare).
2. a reduced rate fee, which in some cases you will be reimbursed in full
3. all preventive treatments are fully reimbursed (e.g. exam, cleaning, ex-rays, etc.)

How do you enroll in CPS? If you are enrolled in the UFA Family Dental Plan, call the SBF Office for an up to date listing of participating dentists and the specific CPS dentist reduced rate fee schedule, or visit the UFA website SBF section. Then call the participating dentist you selected and make an appointment. Be sure to ID yourself as a UFA retired member or dependent. It’s that easy! If you have any questions concerning the CPS program, please call CPS directly.

Healthplex America 500 Dental Plan — Retirees Only

Effective April 1, 2010, retirees residing in Florida may elect Healthplex America 500 Plan. This plan offers an open access network, with no need for pre-selection of a dental provider. Members of the Healthplex America 500 dental plan are eligible to receive benefits immediately upon the effective date of coverage with:

• No waiting periods
• No deductibles
• No claim form to submit

Members can choose a participating provider on the Healthplex website or call the Healthplex member services department.

Call the SBF Office for an up to date listing of participating dentists and available Healthplex America 500 dentist reduced rate fee schedules.

Psychiatric, Counseling, Alcohol & Substance Supplemental Medical Benefits

The City of New York currently provides a choice of 9 different basic health plans, paid for (in whole or part) by the City of New York—which are totally independent of any SBF services. However, in certain instances, the SBF supplements the NYC Health Plans basic health insurance for those members belonging to GHI or HIP, as noted below. The FDNY Counseling Services Unit also offers help. SBF does not cover this for retirees. However, GHI & HIP retirees can purchase this coverage by checking off ‘Optional Benefits’ on the ERB form, prior to retirement.

Counseling Services Unit of the FDNY (CSU)

The CSU is a unit of the FDNY Bureau of Health Services (BHS). Its purpose is to assist members with the intention of restoring the member to a healthy state of mind so members may perform their duties safely. If you are experiencing any problems that you feel may be interfering with safely performing your duties, or causing a danger to your health, the CSU may be able to help you, and grant time off for you to address a particular issue. The CSU has assisted many members work their way through some of the following issues: dealing with serious injuries, death or serious illness of loved ones, marital problems, trauma stress, feeling down, depression, suicidal thoughts or other mental issues, referrals to therapists, and addressing substance/alcohol problems. See FDNY Book; BHS Chapter; Counseling Services Unit section for more info.

*Confidential Counseling Services – Don’t Want FDNY to Know? The UFA Health & Safety Office keeps note of programs available through outside counseling sources, where no person in the Dept., CSU, or the UFA will have any ability to know you are going for treatment anonymously. If you do not want to personally make the call for help, you can have your Delegate (or a concerned friend or family member) anonymously contact the UFA Health & Safety Office for you.

Other Psychiatric Treatment

The Mental Health Parity and Addiction Equity Act (MGPAEA) requires that New York State health plans cover mental health/substance abuse services in the same way as all other hospital and medical services. That means inpatient hospital care for substance abuse is now one of your basic benefits. It is no longer an optional rider. Check with your carrier to follow the correct guidelines for in and out-of-network coverage.

Detoxification/Drug Rehab

The Mental Health Parity and Addiction Equity Act (MGPAEA) requires that New York State health plans cover mental health/substance abuse services in the same way as all other hospital and medical services. That means inpatient hospital care for substance abuse is now one of your basic benefits. It is no longer an optional rider. Check with your carrier to follow the correct guidelines for in and out-of-network coverage.

Additional Benefits & Important Info

Doctors, Hospitals, Ambulances

1. Line-of-Duty Injury Hospital & Doctor Bills: Never give your home or firehouse address to a hospital or doctor for LODI injuries. If you do, all bills and collection notices and calls will come to you! Use FDNY BHS, 9 Metrotech Center, Brooklyn, NY 11201 on all LODI medical forms. This address is also on your UFA calendar for reference at any time.
2. Hospitals: AFLAC & Catastrophic Insurance Penalties: Do not under any circumstances mention to hospital personnel, or write on the forms, that you have Catastrophic or AFLAC plans. If you do, your medical insurance providers may refuse to pay for your treatment—and you will be harassed by hospitals for payment. Technically, these policies are not medical insurance, though your NYC Medical Plan providers may erroneously believe this to be the case.
3. Second Medical Opinions Free-Pro Bono Medical Panel: This group of highly regarded independent physicians, who are experts in their specialties, will render a second opinion to our members and their immediate families, without charge. The initial consultation will be provided free to uniformed members with non-service connected medical conditions and their legal spouses or minor children. (DO #53 of 1992) See Heath Book; Insurances & Free Benefits chapter; Health/Medical Help-Free section for more info.
4. Emergency Room Extra Doctor Fees: Empire Blue Cross/Blue Shield: For those members who are covered by Empire BlueCross BlueShield, please note that the cost of most physicians who see you in the emergency room — including for X-rays and pathology — is covered by your plan. However, not all hospital doctor services are completely covered. Be aware that if you are treated by a specialist called in by the hospital who is not a staff employee (which is not uncommon), you could be billed hundreds of dollars. If you get billed more than your copayment, call Empire BlueCross BlueShield.
5. Elective Surgery: Ten days prior to an elective surgery, or within 24 hours after an emergency admission, call NYC Healthline to avoid $500 in penalties. The phone # is also on the back of your NYC Health Insurance Plan Card.
6. Overseas Hospitals: (Empire Blue Cross/Blue Shield only) If you are traveling overseas, check Empire’s website for a list of participating hospitals in the country you plan to visit, or call Empire BlueCross BlueShield to save any out-of-pocket expense.
7. Free Family Transportation-Fire Family Transport Foundation: The FFT vehicle is intended to ensure that members who are seriously injured in the line of duty have their families transported to medical institutions in a way befitting their special needs. The FFT vehicle was donated to the Fire Department by the Fire Family Transport Foundation, Limited, a non-profit corporation founded by members of the Department. See ‘Heath’ Section; Insurances’ chapter; Health/Medical Help-Free section for more info.
8. Ambulance, TV & Phone Assistance – Welfare Fund: Helps cover costs for hospitalized LODI members for TV & telephone use. It will assist non-LODI members with its own ambulance or private ambulance service. See ‘Heath’ Section; Insurances’ chapter; Health/Medical Help-Free section for more info.
9. Hospital Room Services See above for info.
10. Appliances: HIP/HMO Riders for Appliances when approved by a HIP doctor are covered by SBF.
11. Private Duty Nursing: in-hospital when ordered by a HIP doctor is covered by SBF.

Wellcare/Preventive & Retirement Health Exams

1. Complete Medical Wellness Program: Any member or spouse (active or retired) who is between the ages of 45 and 65 will now be allowed to receive a complete medical exam for just the normal GHI co-pay. This is part of a wellness/prevention program that was worked out by the City unions. GHI also includes at discounted rates from selected providers/venders for: fitness club discounts, weight loss programs, acupuncture, massage therapy, nutrition programs / supplements and personal medical data credit card size disks. Other City Health Plan Providers may also provide Wellness coverage. See back cover pages of this chapter for Contacts section listing info of your specific Health Plan Provider.
2. Retirement Planning Medical Screening: It is highly recommended that members planning to retire receive full diagnostic medical exams for possible heart conditions and cancers, or any other disabilities that may be job related, but not so readily detectable. Many members have retired only to tragically discover days or months later that they have a serious or terminal illness that would have qualified for a Line-of-Duty pension had it been discovered before their retirement date. Some of these tests are covered under your plan, some are not. Spend the money to receive all recommended examinations and diagnostics. Once you retire, it is against the law for your pension to change to a disability pension unless you filed for a disability pension prior to your retirement date. See Retirement & Money Book; Retirement Planning section.

Inoculations & Immunizations

The Department’s immunization and inoculation program is an excellent free benefit that can save you and your family from severe illnesses and high medical costs. The BHS administers tuberculosis tests and updates other needed immunizations at no cost, including tetanus and Hepatitis B. The BHS maintains your immunization & inoculation records in its computer system and will provide any written documentation you request. You may want to bring your UFA Locker Medical Monitoring Card with you for your Annual Medical. The BHS will enter any inoculation dates into its system for you so the BHS can automatically remind you of needed boosters, etc. whenever you take your Medical.

Inoculations may also be for biological or chemical agents in response to terrorist attacks. These are often done on a schedule or by emergency announcements in various firehouses.

Hepatitis inoculation is a series of 3 or 4 injections which protects you and your family. It has been reported that the most accurate results (to see if you are protected from Hepatitis) are measured if the testing is done after a three month wait (after your last shot). About 20% of those taking the series require the 4th shot. Currently (2010), all newly hired firefighters are offered Hepatitis B inoculations. BHS Nurses will be sent to Probie School to administer the first two inoculations for Hepatitis B—if a probie is not immunized already. Probies will also receive inoculations for measles, rubella and mumps, if needed. Their third Hepatitis B inoculation is administered at their 5th Grade Medical or next Annual Medical. Booster inoculations will be administered to any member whose immunity levels are too low. If you are concerned about the prevention of these illnesses, contact the FDNY BHS to see if/when any program is active. It’s a generous benefit. Make sure you take full advantage of it!

Blood Program

Your individual Health Plan Insurance Carrier covers the cost of administering transfusions and pays blood processing fees for employees, retirees and eligible family members. It does not pay for the storage of your own blood for future use. Blood replacement fees are not covered by any health plan offered by the City. To help our community maintain the blood reserves required to avoid resumption of replacement fees, the Employee Blood Program sponsors a voluntary donor program for City employees, called the City Donor Corps. City Donor Corps members who donate once a year are entitled to certain benefits for themselves and family members. For further information, contact the FDNY Health Benefits Plan Unit.

Surgical Assistance Fund

The UFA/UFOA Surgical Assistance Fund (SAF) provides coverage from $10.00 to $650.00 per member per year, according to an established fee schedule to its members for surgical procedures only, and certain specified additional items. These benefits are provided at a cost of $15.00 annually for Family Group membership and $10.00 annually for

Single Group membership. This additional coverage is free for Retirees who were paying active members of the SAF for two years immediately prior to retirement. See Health Book; Insurance & Free Benefits chapter; Surgical Assistance Fund section for additional info about this fund.

Disabilities: Reasonable Accommodation Americans with Disability Act (ADA)

The ADA defines Disability as: “someone who has have a physical or mental impairment which substantially limits one or more major life activities; or has a record of such physical or mental impairment; or is regarded as having such a physical or mental impairment.” Disabled persons have certain employee rights under Federal Law. Under certain circumstances employers must provide work assignments to disabled employees if such positions can be reasonably accommodated. See Legal Book; Americans with Disabilities Act section of the Civil Rights & Freedoms chapter.

Cancer Insurance

When diagnosed with cancer, this plan provides benefits for hospital confinement, radiation and chemotherapy and surgery, among others. AFLAC pays cash directly to you as soon as you or a covered family member gets cancer. From that point on, cash benefits are paid for most treatments received during your struggle to get well. Premiums are paid through payroll deductions. You can keep the plan after you retire. See Health Book; Insurances & Free Benefits chapter; Primary Health/Medical section for comprehensive info.

Accident/Injury Insurance

The AFLAC Accident Plan helps cover expenses associated with an accidental injury. It pays you directly regardless of any other insurance you may have. Benefits include: accident hospital confinement, ambulance, accidental death and dismemberment and many others—including Line-of-Duty Injuries. Payroll deduction. There are no medical questions to answer and no money needed to join. See Health Book; Insurances & Free Benefits chapter; Primary Health/Medical section for comprehensive info.

Catastrophic Insurance

Catastrophic coverage picks up medical costs that exceed your NYC Health Insurance Plan cap, including Medicare.

See Health Book, Insurances & Free Benefits chapter; Primary Health/Medical section for comprehensive info.

Life (Death) Insurance

There are several optional and automatic enrollment life insurance plans offered or recommended by the FDNY & UFA. See Health Book; Insurances & Fee Benefits chapter; Life Insurances section for comprehensive info.

Death Benefit (SBF)

The death benefit is payable, in accordance with the below schedule, upon the member’s death from any cause at any time while eligible. Payment is made in a lump sum to the beneficiary designated by the Firefighter on the Security Benefit Fund enrollment card, provided this beneficiary is living at the time of the Firefighter’s death. If the beneficiary is not living on the first anniversary of the Firefighter’s death, payment is made to an alternate beneficiary. If the alternate beneficiary is not living, the death is payable to the Firefighter’s estate. Changes of beneficiary or alternate beneficiary may be made at any time by the Firefighter by contacting the SBF Office. The SBF office will mail a claim form to the Firefighter’s beneficiary in case of his/her death. Payment is made to the beneficiary upon submission of a completed claim form with certified death certificate.

1. Active Member, any age:	$10,000
2. Retiree, to age 49:	$10,000
3. Retiree, ages 50 to 69	$5,000
4. Retiree, age 70 and over	$2,500

Notifications for Benefits: Both the FDNY and the UFA initiate paperwork to process retiree death benefits once it has been published on an official Department Order. To notify Fire Department Headquarters of a firefighter death, please phone FDNY Death Notifications. Then notify the SBF to initiate necessary union benefits paperwork.

Contact List

UFA – Uniformed Firefighters Association

204 East 23rd Street, New York, NY 10010
General Tel Number & Emergencies: (212) 683-4832 (212-683-4UFA)
General Fax: (212) 683-0710
www.UFANYC.org

UFA SBF – Security Benefits Fund

(SBF): 3rd floor
Phone: (212) 683-4723 – Fax: (212) 683-0693
SBF Retiree Liaison: ext. 6577 (M-W-F)
SBFSTAFF@UFANYC.org

Group Life Insurance Office

3rd floor, Phone: (212) 683-4832, ext. 5903
UFA Trustee-On-Duty
Emergencies: (212) 683-4832
Trustees Fax: (212) 683-0690

UFA Health & Safety Office/Sergeant-at-Arms

Emergencies: (212) 683-4832
Non emergencies: (212) 545-6965 or 6964
Fax: (212) 683-4768
Email: Health&Safety@UFANYC.org

Dental Services – UFA Plan

Healthplex & Dentcare – www.healthplex.com
333 Earle Ovington Blvd., Suite #300, Uniondale, NY 11553-3608
Tel Offices (M-F, 9-5): (800) 468-0608, (516) 542-2200
Tel Customer Service (M-F, 8-6): (800) 468-0600

CPS Dental (CPS)

11 Hanover Square, New York, NY 10005
CPS Programs, Tel (M-F, 9-5): (212) 889-5858, Fax: (212) 889-8415

Florida Dental Healthplex America 500

Tel: (888) 200-0322

CVS Caremark – UFA Plan

(for Mail Order) CVS Caremark PO Box 94467 Palatine, IL 60094-4467
Website: www.Caremark.com
Customer Services: 866-832-0563

National Prescription Administrators (NPA) – PICA Drugs

Express Scripts/NPA (PICA Drug Administrator) Tel: (800) 467-2006 or (800) 233-7139
website: www.express-scripts.com

FDNY – N.Y.C. Fire Department

9 Metrotech Center, Brooklyn, NY 11201
FDNY General Phone: (718) 999-2000

FDNY Bureau of Health Services (BHS) / Medical Office

BHS General Number: (718) 999-1849/1850, Clinic Desk: (718) 999-1917
FDNY BHS Automated Citywide Medical Leave System: (718) 330-2204 (prompts you to provide certain identifying info (available 24/7)
FDNY BHS Postponement Desk: (718) 999-1918/19/20
FDNY BHS Medical Officer on Emergency Duty Fax: (718) 999-0035

LODI Prescription Drug Reimbursement:

Justine Lashkow, Head Nurse, (718) 999-0227
9 Metrotech Centre, 2nd floor, Brooklyn, NY 10012

FDNY Compensation Desk (for LODI Medical Bills)

• FDNY Compensation Desk, 9 Metrotech Center, Brooklyn, NY 11201
  • Inquiry Phone Number: (718) 999-1838 or 1839
• FDNY Counseling Services Unit (CSU): (212) 570-1693 or (212) 570-1696
• FDNY Health Benefits Unit: (718) 999-2196
  • Fax: (718) 999-7139
  • Camille Isaacs, 9 Metrotech Center, Brooklyn, NY 11201
  • for ERB (Employee Health Benefit Application)
  • for FDNY Health Desk (request of forms)
• Pension Benefits Unit: (718) 999-2324 (Pensions/Benefits Analyst)
  • Death Notifications
  • Retired FDNY Member (718) 999-2320/2321 Active FDNY Member (718) 999-2094/2095
• Surgical Assistance Fund (questions, forms) Kathleen Oliveri
  • Tel: (718) 999-1252 (VM available 24/7), Fax: (718) 999-0106
• Fire Family Transport: call Notifications Desk (Citywide Command Chief) (718) 999-2094
• Personnel Office: (718) 999-2164
• Welfare Fund of the FDNY: contact the Officer in Charge of BHS, (718) 999-1849/1850
• Employee Self Service: 212-487-0500 See next page
  •  www.nyc.gov/ess

NYC Health Benefits Program, Office of Labor Relations (OLR)

• Administrative Office, 40 Rector Street, 3rd Floor, New York, NY 10006
  • Phone: (212) 513-0470
  • NYC Website: www.nyc.gov/html/olr
• Domestic Partnership Liaison Unit, OLR: Active FFs (212) 306-7605, Retired FFs (212) 513-0470
• Express Scripts/NPA, NYC Health Benefits Program Tel: (800) 467-2006 or (800) 233-7139 (PICA Drugs)

Office of the City Clerk

• 1 Centre St, 2nd Floor South, New York, NY 10007
  Phone: (212) 669-8190

NYC Health Plan Carriers

• Aetna QPOS
  • 800-445-8742
  • www.aetna.com
• Aetna HMO
  • 800-445-8742
  • www.aetna.com
• CIGNA HealthCare
  • 800-832-3211
  • www.cigna.com
• Empire HMO (NY)
  • 800-767-8672
  • www.empireblue.com/nyc
• Empire HMO (NJ)
  • 888-476-6986
  • www.empireblue.com/nyc
• Empire EPO
  • 800-767-8672
  • www.empireblue.com/nyc
• GHI-CBP/Empire BlueCross/BlueShield:
  • GHI: 212-501-4444 | www.ghi.com
  • Empire: 800-433-9592 | www.empireblue.com/nyc
  • NYC Healthline: 800-521-9574 (for emergency hospital admission)
• GHI HMO
  • 877-244-4466
  • www.ghihmo.com
• HIP Prime POS
  • 800-447-6929
  • www.hipusa.com
• HIP Prime HMO
  • 800-447-6929
  • www.hipusa.com
• HIP/HMO
  • 800-HIP-TALK
• Heath Net
  • 800-441-5741
  • www.healthnet.com
•  Vytra Health Plans
  • 800-448-2527
  • www.vytra.com

AFLAC

Cancer (NY Customer Service) (800) 366-3436
Personal Accident Expense Plan (800) 366-3436

Catastrophic Insurance, Seabury & Smith/Marsh Affinity

Phone: Customer Service (800) 503-9230
Fax: (847) 503-9230, (847) 803-1653
1440 Renaissance Drive, Park Ridge, Illinois 60068-1400
Hours: M-F, 8:15am-5:00pm
e-mail: custsvc2@seaburychicago.com

Web: www.seaburychicago.com/plans/ufa (applications/brochures)

NYC Deferred Compensation Form

Request forms at (212) 306-7760, or visit www.nyc.gov/deferredcomp, click “Library” then choose “457/401(K)PlanChangeForm.pdf”
Send form to:
Deferred Compensation Plan
Bowling Green Station, PO Box 93, New York, NY 10274-009

Employee Self Service (ESS) for Paystub Info & Making Updates

The Employee Self Service (ESS) allows you to view and change your personal and dependent* info, benefits, tax, and certain payroll information on both the Intranet from work and Internet from home (in many cases you no longer have to fill out a paper ERB form to transfer, add or delete). You can see line by line details regarding deductions and OT, longevity, CFR and more that correspond with each biweekly pay period. NEW ENHANCEMENTS: Employee Self Service (ESS) now includes links to add, modify and cancel IRA and 529 College Savings Plan deductions. Employees can view, enroll in and update their NYS 529 College Savings Program and IRA payroll deductions by logging onto ESS and clicking on the applicable link. To access ESS go to www.nyc.gov/ess. Log-in using your self service ID and password. Then click sign-in. If it is your first time logging in use the seven-digit employee ID number found in the reference # box on your pay stub. Your initial password is the last two digits of your SSN and the eight digits of your birth date. The UFA highly recommends all members log-in ASAP, if you have not done so already, and change your initial password to keep your ESS information secure and confidential. *IMPORTANT NOTE: If adding or deleting a spouse or child, the on-line updates will be held as “pending” until hard copies of the correct documentation (per Dept policies) are received.

CAREMAlx.K

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December 22, 2011

[Plan Member Name] [Street Address] [City, State, ZIP]

Dear [Member Name]

We are pleased to continue administering your prescription benefit plan. CVS Caremark and the Security Benefit Fund (the Fund) of the UFA are working together to help minimize the effects of rising prescription drug costs.

Starting January 1, 2012, the Fund will be making important changes to your 2012 pharmacy benefit plan. These changes will include:

1. Moving to a three-tier member cost-share plan. This means there will be three different coinsurance*/copay levels based on whether your prescription is:
   • A generic drug-lowest member cost
   • A preferred (formulary) brand-name drug on the CVS Caremark Preferred Drug List-higher member cost
   • A non-preferred (non-formulary) brand-name drug-highest member cost
2. These copay levels will apply up to your annual family cost-sharing benefit threshold of $7,500 per year. (There will no longer be an annual family benefit maximum in this plan.)
3. For the first time, you and your family will have coverage above the $7,500 cost­ sharing threshold, Your share of the cost above this threshold through the end of the calendar year will be 35%; the UFA will pay 65%.
4. CVS Caremark’s Maintenance Choice® Program. If you are taking long-term** medications (ongoing medications for the treatment of chronic diseases or conditions, such as high blood pressure, high cholesterol or diabetes), starting on January 1, 2012, you can choose to receive your 90-day*** supplies by mail or pick them up at a CVS/pharmacy near you. Whether you choose delivery or.pick­ up, you will pay the same member costshare. This choice is being offered to you by UFA as a way to help you save money.
5. Brand-name drugs with generic equivalents will be dispensed automatically as generics by CVS Caremark.

*Copayment, copay or coinsurance means the amount a plan member is required to pay for a prescription in accordance with a Plan, which may be a deductible, a percentage of the prescription price, a fixed amount or other charge, with the balance, if any, paid by a Plan.

**A long-term medication is taken regularly for chronic conditions or long-term therapy. A few examples include medications for ,. I’: managing high blood pressure, asthma, diabetes or high cholesterol.***Quantities may vary depending on plan design: fg Your privacy is important to us. Our employees are trained regarding the appropriate way to handle your private health information.

87-24283a 112111

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1. If you or your doctor request a brand-name drug when a generic version of the brand-name drug is available, you will pay extra, equal to the difference in cost between the generic and brand-name medicine, plus the generic copay.

For your convenience, these changes are summarized on the following pages.

Moving to a Three-Tier Member Cost-Share Plan with Maintenance Choice

Now you have more options to choose from when filling your prescriptions. This chart shows your copay/coinsurance for each option. Keep this letter so you can refer to it when you decide where to fill your prescriptions.

Member cost share

35%;

Minimum $5 No maximum

35%;

Minimum $12.50

No maximum

Retail Refill limit

First fill and one refill at retail for long-term medicines. No limit on other medicines

None

Tier 1: Generic I $5		$12.50
Tier 2: Preferred brand(Drugs listed on the CVS Caremark Preferred Drug List)	25%;Minimum $15 Maximum $50	25%;Minimum $37.50 Maximum $125
Tier 3: Non-preferred brand(Drugs not listed on the CVS Caremark Preferred Drug List)	35%;Minimum $40 Maximum $100	35%;Minimum $100 Maximum $250

*Copayment, copay or coinsurance means the amount a plan member is required to pay for a prescription in accordance with a Plan, which may be a deductible, a percentage of the prescription price, a fixed amount or other charge, with the balance, if any, paid by a Plan.

**A long-term medication is taken regularly for chronic conditions or long-term therapy. A few examples include medications for managing high blood pressure, asthma, diabetes or high cholesterol.***Quantities may vary depending on plan design.

Your privacy is important to us. Our employees are trained regarding the appropriate way to handle your private health information. 87-24283a 112111

PPS-ULTR-0308 ^®

CAREMAfx.K

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Ask your doctor if a generic or preferred brand-name medicine, rather than a non­ preferred brand-name drug, would be appropriate for you. As always, it is up to your doctor to determine the most appropriate medicine for you. Remember that non­ preferred brands that are not listed on the CVS Caremark Preferred Drug List will be covered, but they will require the highest member cost share.

Fill limit for long-term medications

Your plan allows up to two 30-day fills of long-term medications at any pharmacy in our network (in addition to CVS pharmacies). After that, your plan will cover long-term medications only if you have up to 90-day supplies filled through mail service or at a CVS/pharmacy. The plan will not pay for more than two fills ofup to a 30-day supply each for long-term medications at a retail network pharmacy.

With Maintenance Choice, you can avoid paying more for your long-term prescriptions. All you need to do is have up to 90-day supplies filled through mail service or at a CVS/pharmacy.

Automatic Generic substitution

If your doctor prescribes a brand-name drug that has a generic version, which is chemically equivalent to the brand drug, CVS Caremark will dispense the lower-cost generic.

When a generic version of a brand-name drug is available and your doctor prescribes the brand-name medicine and designates “Dispense As Written” on the prescription, or you request the brand-name medicine from the pharmacy, you will pay the generic coinsurance amount, plus the difference in cost between the brand-name and the generic medicine. As a reminder, your generic copay for a retail prescription is $5;

$12.50 for a mail service prescription.

Your next step: Ask your doctor to consider prescribing a generic drug to save on your member cost share. Your doctor is most qualified to balance drug cost and drug therapy considerations.

Annual Family benefit threshold

Your family benefit threshold will be $7,500 per year.

Coverage Above the Annual Family Benefit Theshold

If you exceed the maximum benefit threshold before December 31, 2012, your coverage will continue. You will be responsible for 35% of the cost of your covered drugs (minimum of $5 per medication at retail and $12.50 at mail) above the threshold, with no maximum annual family limit.

*Copayment, copay or coinsurance means the amount a plan member is required to pay for a prescription in accordance with a Plan, which may be a deductible, a percentage of the prescription price, a fixed amount or other charge, with the balance, if any, paid by a Plan.

**A long-term medication is taken regularly for chronic conditions or long-term therapy. A few examples include medications for managing high blood pressure, asthma, diabetes or high cholesterol.***Quantities may vary depending on plan design.

Your privacy is important to us. Our employees are trained regarding the appropriate way to handle your private health information. 87-24283a 112111

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06086

ExtraCare® Health Card

You can reduce your costs for certain over-the-counter (OTC) drugs and other health­ related items when you use your ExtraCare Health Card to buy them. Specifically, you can save 20 percent on CVS/pharmacy Brand OTC medicines by using your ExtraCare Health Card.¹ The card also provides savings on many other health-related items you and your family use every day.² These items include vitamins, pain relief, cough and cold remedies, and more. You can use your card at CVS/pharmacy stores by presenting the key tag at the register. To use your card online at CVS.com, enter your ExtraCare Health Card number into your member profile and log in to start shopping.

Questions? Visit www.caremark.com or call us toll-free at 1-866-832-0563. We appreciate the opportunity to help you better manage your health.

Sincerely,

Your Customer Care Team CVS Caremark

PPS-ULTR-0308

1. Excludes prescriptions.
2. Excludes pharmacy items paid for in whole or in part by state and/or federal health care programs. This includes programs such as Medicare and Medicaid. Not valid on prescriptions purchased in New Jersey or New York. In Louisiana, not valid on any prescription for a controlled substance.

*Copayment, copay or coinsurance means the amount a plan member is required to pay for a prescription in accordance with a Plan, which may be a deductible, a percentage of the prescription price, a fixed amount or other charge, with the balance, if any, paid by a Plan.

**A long-term medication is taken regularly for chronic conditions or long-term therapy. A few examples include medications for managing high blood pressure, asthma, diabetes or high cholesterol.***Quantities may vary depending on plan design.

Your privacy is important to us. Our employees are trained regarding the appropriate way to handle your private health information. 87-24283a 112111 -=-

®