Generally, if you use in-network providers, your provider will submit your claims for you. Remember to present your Blue Shield of California PPO or Delta Dental PPO identification card each time you receive services and verify that the providers participate in the network.
If you enrolled in DeltaCare USA DHMO, make sure you go to your assigned dental office and present your DeltaCare USA ID card. If you need an ID card, contact Delta Dental USA at (800) 422-4234.
Once you enroll in Vision Service Plan (VSP), you do not need an ID card to make an appointment. Simply tell your provider you have VSP.
When you use non-network providers and pay in full upfront, you must submit an itemize bill or superbill, proof of payment and, if any, an Explanation of Benefits (EOB) from your primary plan.
If you use an out-of-network provider and you paid in full upfront, you must submit an itemize bill or superbill, your proof of payment and if any, an Explanation of Benefits from your primary plan to the Fund Office.
See the Prescription Drug Benefits section for instructions on how to file a Prescription Drug claim.
Important Note: Claims received more than 12 months from the service date will generally be denied. In some cases, Plan representatives will request more information from the patient or provider before the claim may be processed. Replies to Fund Office requests must be sent within 12 months.
If you need a Blue Shield of California ID card, contact the Fund Office.
If you enrolled in Delta Dental PPO and need an ID card, contact Delta Dental USA at (800) 422-4234.
If you enrolled in DeltaCare USA DHMO and need an ID card, contact Delta Dental USA at (800) 422-4234.
Once you enroll in Vision Service Plan (VSP) and need an ID card, contact VSP at (800) 877-7195. Note: you do not need a VSP ID card to make an appointment. Simply tell your provider you have VSP.
The Health & Welfare Plan has a $250 deductible per covered person (up to a $750 family maximum) for covered health care services each calendar year. Once the deductible is met, the Plan will pay for any further Medically Necessary covered services based on the Blue Shield of California PPO Network Rate or the Allowable Charge, whichever applies.
In addition, some benefits have separate deductibles:
Your Plan’s vision benefit does not have a deductible.
HRA allowances reimburse you (on a tax-free basis) for eligible health care expenses you and your covered dependents incurred that were not paid through your medical, dental, vision and prescription drug benefits or other coverage —such as deductibles, copayments, premiums and certain non-covered expenses. Note: Since January 1, 2020, non-prescription drugs and menstrual care products are also reimbursable via HRA.
Other examples of qualified expenses are non-covered prescription eyeglasses, contact lenses or hearing aid costs. Vitamins, supplements and holistic medicines are non-reimbursable via HRA. Refer to IRS Publication 502 for the most recent list of qualified expenses.
Refer to the Summary Plan Description (HRA section beginning on page 22) or contact the Fund Office for more information.
Your HRA claim may be missing an HRA Request for Reimbursement Form or additional supporting documentation such as the itemized bill or an Explanation of Benefits (EOB) from your primary insurance. Or your claim may first need to be processed through your primary benefits (such as your medical, dental or vision coverage). Contact the Fund Office for more information.
All eligible participants must enroll in Vision Service Plan (VSP) to have vision coverage. To enroll, complete a Vision Enrollment Form and submit to the Fund Office.
If you didn’t enroll within 60 days of when you became eligible under the Health & Welfare Fund, coverage under VSP begins the month following the date your properly completed form is received by the Fund Office. Note: Benefits are not retroactive to the date when you were first eligible.
Visit vsp.com or call (800) 877-7195 to learn about your vision coverage. For more information, see the Vision Coverage section of the the Benefit Summary in the Forms & Documents page of this site.
VSP has the most extensive vision care network in the country, with more than 34,000 licensed opticians, ophthalmologists and optometrists. Visit vsp.com or call (800) 877-7195 to find an in-network provider in your area.
If you use out-of-network providers, your out-of-pocket costs will typically be higher. You would also pay in full at time of service and submit claims/receipts directly to VSP for reimbursement.
No. Simply call a VSP network provider to schedule an appointment and let them know you have VSP coverage. The network provider and VSP handle the rest. If you want an ID card, create an account at vsp.com and log in to print one online.
There are no deductibles. Click here for a chart that shows coverage details and copayments for most in-network vision services.
In a serious or life-threatening emergency, call 9-1-1. If you are uncertain or experiencing any of these vision related symptoms, contact your eye doctor for help. If you don’t have an eye doctor, call VSP’s Customer Care Team at (800) 877-7195 and they’ll help connect you with an eye doctor who’s able to provide you with emergency eye care. This includes urgent eye care needs, like sudden vision changes or vision loss, eye trauma, pink eye/conjunctivitis, or other symptoms that interfere with day-to-day activities.
One of your vision plans will be considered primary. Your primary plan must pay toward your vision care first. Then, your other vision plan(s) pay toward whatever portion is remaining. Your vision plan cannot pay more than 100% of the cost of your treatment. Contact VSP for more information.
Generally, if you use in-network providers, your provider will submit your claims for you. Remember to present your Blue Shield of California PPO identification card each time you receive services and verify that providers participate in the network.
If you are enrolled in DeltaCare USA DHMO, make sure you go to your assigned dental office and present your DeltaCare USA ID card. If you need an ID card, contact Delta Dental USA at (800) 422-4234.
If you are enrolled in Vision Service Plan (VSP), you do not need an ID card to make an appointment. Simply tell your provider you have VSP.
Important Note: Claims received more than 12 months from the service date will be denied. In some cases, Plan representatives will request more information from the patient or provider before the claim may be processed. Replies to any Fund Office requests must also be completed within 12 months.
If you are enrolled in DeltaCare USA DHMO and need an ID card, contact Delta Dental USA at (800) 422-4234.
If you are enrolled in Vision Service Plan (VSP) and need an ID card, contact VSP at (800) 877-7195. Note: you do not need a VSP ID card to make an appointment. Simply tell your provider you have VSP.
The Pensioners & Surviving Spouses Health Plan has a $250 deductible per covered person for covered health care services each calendar year. Once the deductible is met, the Plan will pay for any further Medically Necessary covered services based on the Blue Shield of California PPO network rate or the allowable charge, whichever applies.
- Prescription drugs have a separate $50 deductible per covered person each calendar year, and - Hearing aids have a separate $50 deductible per covered person per device each calendar year.
If enrolled, your Plan’s dental and vision benefits do not have deductibles.
The Plan partners with Blue Shield of California with the goal of lowering and controlling patient ot-of-pocket costs while expanding the network of contracted providers available. Blue Shield provides network access and some administrative services only. The Southern California Pipe Trades Pensioners & Surviving Spouses Health Fund determines, administers and pays Plan benefits. Note: Blue Shield of California does not administer the Fund’s prescription drug, dental, or vision benefits.
You and your spouse or domestic partner become eligible to purchase vision coverage at the same time you become eligible for Pensioners & Surviving Spouses Health Fund benefits. You may not purchase vision coverage without medical coverage. Contact the Fund Office for details.
You may elect to purchase vision coverage no later than 60 days from your initial eligibility date or during an annual open enrollment period. If you do not enroll then, you won’t have vision coverage. Contact the Fund Office for coverage details.
Pensioners who did not enroll in vision coverage when first eligible may only enroll during the annual open enrollment period in late fall for coverage that begins the following January 1. Download a Vision Enrollment Form or get a copy from the Fund Office or your local union during the open enrollment period. Vision coverage begins January 1 following the date your properly completed form is timely received by the Fund Office.
Once enrolled, you may not cancel coverage for you or your covered spouse or domestic partner until the open enrollment period (scheduled in late fall for changes effective the following January 1). If you cancel coverage, you may not re-enroll for vision coverage until the next open enrollment period in the following year. Any cancellation will apply to you and your covered spouse or domestic partner.
Visit vsp.com or call (800) 877-7195 to learn about your vision coverage. For more information, see Vision Coverage of the Benefit Summary. .
Monthly premiums for vision coverage are shown below. Keep in mind that premium amounts may change.
Pensioner or Survivor (Single Coverage): $4.76
Pensioner and Spouse/Domestic Partner (Dual Coverage): $9.54
Note: This amount is in addition to the monthly premium for your medical coverage. Both medical and vision premiums must be deducted from your Southern California Pipe Trades Retirement Fund pension benefit, if any. If you are not receiving a pension benefit (or if the pension benefit is not enough to cover the premiums), your premiums must be automatically deducted from a bank account. Checks are not accepted. Contact the Fund Office for details.
There are no deductibles.
The Plan partners with Blue Shield of California with the goal of lowering and controlling patient out-of-pocket costs while expanding the network of contracted providers available. Blue Shield provides network access and certain administrative services only. The Southern California Pipe Trades Health & Welfare Fund determines, administers and pays Plan benefits. Note: Blue Shield of California does not administer the Fund’s prescription drug, dental, or vision benefits.
If you are dissatisfied with a decision the Fund Office makes, you may appeal to the Board of Trustees by filing a written appeal with the Fund Office within 180 days after you receive the decision. Upon request you or your representative may review Plan documents and receive, free of charge copies of all documents, records and other information relevant to your claim for benefit. You or your representative may submit with your appeal, written comments, documents and other information you deem pertinent to your claim. Personal appearances on appeals are at the discretion of the Appeals Committee of the Board of Trustees. If you need additional time, you may request an extension which will be granted if your written request is received before a decision is made on your appeal. You will be informed in writing of the decision on your appeal. Carefully read and follow the appeal provisions found in the SPD.
Once your application and all required documents are received and reviewed, the Fund Office mails your retirement packet, which includes your health and benefit enrollment forms. The Pensioners & Surviving Spouses Health Fund provides medical & prescription benefits that you pay for through monthly premium. This monthly premium is based on your individual score which is based on your age and pension credits at the time of your initial retirement. When enrolling in pensioner health fund benefits, eligible participants may also purchase coverage in pensioner dental and vision options.
Benefit information varies by Trust Funds. Please make a selection.
