Teamsters Local 170 Health and Welfare Fund

Provider Summary of Benefits and Coverage

Provider Benefits List

The following is a list of the provider summary of benefits documents available to you on this site.

 

Summary of Benefits and Coverage

Network Blue New England Options v.5 (PDF Document Format)
Blue Choice New England 2 (PDF Document Format)
Blue Care Elect Preferred (PDF Document Format)

Fallon Direct Care Premium Value (PDF Document Format)
Fallon Select Care Supreme (PDF Document Format)
Fallon Select Care Premium Value (PDF Document Format)

 

Medical Plans

TIER 1 BENEFIT

Fallon Health Care – Select Care Supreme – Schedule of Benefits

Blue Choice® New England Plan 2 – Schedule of Benefits
Blue Cross Blue Shield POS – Benefit Description

Blue Care Elect® Preferred PPO – Schedule of Benefits (PDF Document Format)
Blue Care Elect® Preferred PPO – Benefit Description

Blue Cross Blue Shield – Pharmacy Benefit Handbook

TIER 2 BENEFIT

Fallon Health Care – Direct Care Premium – Schedule of Benefits
Fallon Health Care – Direct Care Premium – Member Handbook

Fallon Health Care – Select Care Premium – Schedule of Benefits
Fallon Health Care – Select Care Premium – Member Handbook

Network Blue® New England Options – Schedule of Benefits (PDF Document Format)
Network Blue® New England Options – Benefit Description (PDF Document Format)

 

Dental

Dental Blue – Benefit Description – For Active Members (PDF Document Format)

Dental Blue Freedom For Retired Members (PDF Document Format)

Dental Blue Freedom PPO (PDF Document Format)

 

Prescription Drug Benefit

Coverage Changes to BCBSMA Medical and Pharmacy Benefit (PDF Document Format)

Summary of Material Modifications (PDF Document Format)
Blue Cross Blue Shield Pharmacy Benefit Handbook (January 1, 2018)

NOTE: For Envision Benefits, please consult with the SMM dated October 30, 2014, where effective January 1, 2015. Pharmacy Benefits will now be administered by BCBS MA for BCBS members

Envision RX Benefit
Envision RX Benefit Formulary Change Notice

 

Life Insurance

Hartford Full-Time – Benefit Plan (PDF Document Format)

Hartford Part-Time – Benefit Plan (PDF Document Format)

 

HIPAA Notice of Privacy Practice

This notice describes how medical information about you may be used and disclosed and how you get access to this information.

View the latest privacy notice

HIPAA Notice of Privacy Practice