Make it bigger:

All In-patient stays for Active and Pre-Medicare participants MUST be pre-certified by the Fund’s Utilization Review company, HINES AND ASSOCIATES by calling them at 1-800-323-3454

The Plan covers a broad array of medical services for both Active Members and Retired Members. Active members who use in-network providers through Anthem Blue Cross and Blue Shield pay a modest co-pay that varies by service. Behavioral health and prescription drugs are covered under different programs.

If you choose an out-of-network provider, you will be responsible for 20 percent coinsurance after satisfying an annual deductible of $200 for an individual or $400 for a family. This applies to most medical services and behavioral health claims. The deductible does not apply to prescription drugs. The plan considers amounts submitted for out-of-network claims up to a maximum allowable charge that is based on the Medicare Resource Based Relative Value Scale. The annual limit for medical benefits for Active Members is $1.5 million for 2011 and 2012 and will increase to $2 million on 1/1/2013. The annual limit will be eliminated entirely as of 1/1/2014. The annual limit for medical benefits for Retired Members is $1.25 million. The annual limit for Retirees increases to $2 million in 2013 and is eliminated entirely as of 1/1/2014. Once a participant becomes covered under the Retiree Plan, their lifetime benefit usage is reset to zero.

Covered Medical Procedures:
The Plan covers only those procedures deemed to be effective and acceptable under current standards of practice. The list of approved procedures is constantly evolving with the development of new, more effective procedures. In some cases the same service may be payable, but with a different code or codes. The commonly used authority on determining whether a procedure should be covered is the listing maintained by Medicare which can be found at:

Submitting a medical claim
If you are an Active Member or a pre-Medicare retiree, you must file your claim though Anthem Blue Cross and Blue Shield (using your ID card), regardless of whether your practitioner is in-network or out-of-network. If the practitioner is in Connecticut, the claim should be submitted electronically at www.anthem.com. If your provider is located outside of Connecticut, your claim should be submitted through the local Blue Cross and Blue Shield office in that state.

Most Active Member claims are submitted via electronic means. However, you may submit a claim form for an in-state or out-of-state provider to:

Anthem Blue Cross and Blue Shield
National Account Division
P.O. Box 533
North Haven, CT 06473

Retired Members may submit claims for an in-state or out-of-state provider to:

Local 478 Health Benefits Fund
1965 Dixwell Avenue
Hamden, CT 06514-2475

Locate a medical provider:
Visit www.anthem.com and go to Find a doctor.