Level A Benefits for 2024
Professional Musicians Local 47 and Employers Health and Welfare Fund offers six medical benefit options for Level A eligible participants, and their dependents, who reside in California.
Review and compare each plan carefully as the benefits, out-of-pocket expenses and premium rates are different for each plan.
Level A Participants enrolled in one of the medical plans are also enrolled in Landmark Healthcare’s chiropractic and acupuncture benefit.
The following Summary of Benefits & Coverages (“SBC”) contain the same information as the Benefit Summaries. However, they are provided in a different format that is required by the Affordable Care Act (“ACA”) to allow members to compare various plans.
Level A Benefit Summaries
Medical Coverage
OPTION 1
Blue Shield High Deductible PPO - HSA Qualified Plan
Deductible $1,600/$3,200 – 90% In-Network / 70% Out-of-Network
High Deductible PPO Enrollment Guide
High Deductible PPO Benefit Summary
High Deductible PPO Benefit Modifications
High Deductible PPO SBC
High Deductible PPO Evidence of Coverage
Blue Shield Mobile App
Blue Shield’s Teledoc Service
Getting Started with Teledoc (video)
Coronavirus Information
Machine-Readable Files Notice
OPTION 2
Blue Shield Access+ HMO Network
$25 Office Visit co-pay / 25% Hospital co-pay
Access+ HMO Enrollment Guide
Access+ HMO Medical Benefit Summary
Access+ HMO Rx Benefit Summary
Access+ HMO Benefit Modifications
Access+ HMO SBC
Access+ HMO Evidence of Coverage
Blue Shield Mobile App
Blue Shield’s Teledoc Service
Getting Started with Teledoc (video)
Coronavirus Information
Machine-Readable Files Notice
OPTION 3
Blue Shield Trio HMO-ACO Network
$20 Office Visit co-pay / 25% Hospital co-pay
Deductible applies to some services.
HMO Trio Enrollment Guide
HMO Trio Medical Benefit Summary
HMO Trio Rx Benefit Summary
HMO Trio Benefit Modifications
HMO Trio SBC
HMO Trio Evidence of Coverage
Blue Shield Mobile App
Blue Shield’s Teledoc Service
Getting Started with Teledoc (video)
Coronavirus Information
Machine-Readable Files Notice
OPTION 4
Kaiser Permanente Traditional HMO
$30 Office Visit co-pay / $500 Hospital co-pay
Kaiser Permanente Enrollment Guide
Traditional HMO Benefit Summary
Traditional HMO SBC
Traditional HMO Evidence of Coverage
Kaiser Permanente Value Story
Coronavirus Information
Disclosure Part 2
Machine-Readable Files Notice
OPTION 5
Kaiser Permanente Deductible HMO
$20 Office Visit co-pay / $1,500 Deductible – 20% of some services
Kaiser Permanente Enrollment Guide
Deductible HMO Benefit Summary
Deductible HMO SBC
Deductible HMO Evidence of Coverage
Kaiser Permanente Value Story
Coronavirus Information
Disclosure Part 2
Machine-Readable Files Notice
OPTION 6
Kaiser Permanente
High Deductible HMO - HSA Qualified Plan
$30 Office Visit co-pay / $3,200 / $6,400 Deductible – 30% of some services
Kaiser Permanente Enrollment Guide
High Deductible HMO Benefit Summary
High Deductible HMO SBC
High Deductible HMO Evidence of Coverage
Kaiser Permanente Value Story
Coronavirus Information
Disclosure Part 2
Machine-Readable Files Notice
Dental Coverage
OPTION 1
OPTION 2
Vision Coverage
CALIFORNIA RESIDENTS ONLY
EyeMed
Benefit Summary - coming soon
Chiropractic / Acupuncture Coverage
Life and Accidental Death and Dismemberment Coverage
Prudential Financial
Prudential Financial underwrites life and Accidental Death and Dismemberment coverage. This benefit covers the participant only. Dependents are not eligible for this benefit.
Prudential Life Certificate
Life Application/Beneficiary Form
Level A Rates
Rates are valid through December 31, 2024
Blue Shield High Deductible PPO - HSA Qualified Plan
Deductible $1600/$3,200 – 90% In-Network / 70% Out-of-Network
Blue Shield HD PPO
+ DeltaCare HMO
+ Vision
+ Chiropractic / Acupuncture
Member Only
$500.00
Member +1
$1,683.00
Family
$2,786.00
Blue Shield HD PPO
+ Delta Dental PPO
+ Vision
+ Chiropractic / Acupuncture
Member Only
$500.00
Member +1
$1,723.00
Family
$2,877.00
Blue Shield Access+ HMO Network
$25 Office Visit co-pay / 25% Hospital co-pay
Blue Shield Access+ HMO Network
+ DeltaCare HMO
+ Vision
+ Chiropractic / Acupuncture
Member Only
$425.00
Member +1
$1,625.00
Family
$2,728.00
Blue Shield Access+ HMO Network
+ Delta Dental PPO
+ Vision
+ Chiropractic / Acupuncture
Member Only
$425.00
Member +1
$1,665.00
Family
$2,819.00
Blue Shield Trio HMO-ACO Network
$20 Office Visit co-pay / 25% Hospital co-pay
Blue Shield Trio HMO-ACO Network
+ DeltaCare HMO
+ Vision
+ Chiropractic / Acupuncture
Member Only
$300.00
Member +1
$1,279.00
Family
$2,165.00
Blue Shield Trio HMO-ACO Network
+ Delta Dental PPO
+ Vision
+ Chiropractic / Acupuncture
Member Only
$300.00
Member +1
$1,319.00
Family
$2,256.00
Kaiser Permanente Traditional HMO
$30 Office Visit co-pay / $500 Hospital co-pay
Kaiser Permanente Traditional HMO
+ DeltaCare HMO
+ Vision
+ Chiropractic / Acupuncture
Member Only
$290.00
Member +1
$1,213.00
Family
$2,074.00
Kaiser Permanente Traditional HMO
+ Delta Dental PPO
+ Vision
+ Chiropractic / Acupuncture
Member Only
$290.00
Member +1
$1,253.00
Family
$2,165.00
Kaiser Permanente Deductible HMO
$20 Office Visit co-pay / $1,500 Deductible – 20% of some services
Kaiser Permanente Deductible HMO
+ DeltaCare HMO
+ Vision
+ Chiropractic / Acupuncture
Member Only
$195.00
Member +1
$969.00
Family
$1,691.00
Kaiser Permanente Deductible HMO
+ Delta Dental PPO
+ Vision
+ Chiropractic / Acupuncture
Member Only
$195.00
Member +1
$1,009.00
Family
$1,782.00
Kaiser Permanente
High Deductible HMO - HSA Qualified Plan
$30 Office Visit co-pay / $3,200 / $6,400 Deductible – 30% of some services
Kaiser Permanente HD HMO
Member Only
$155.00
Member +1
$706.00
Family
$1,220.00
Kaiser Permanente HD HMO
+ DeltaCare HMO
+ Vision
+ Chiropractic / Acupuncture
Member Only
$155.00
Member +1
$728.00
Family
$1,263.00
Kaiser Permanente HD HMO
+ Delta Dental PPO
+ Vision
+ Chiropractic / Acupuncture
Member Only
$155.00
Member +1
$768.00
Family
$1,354.00
Dental & Vision Coverage Only
THE RATES LISTED BELOW ARE ANNUAL
DeltaCare HMO + EyeMed Vision
Member Only
$60.00
Member +1
$288.00
Family
$516.00
Delta Dental PPO + EyeMed Vision
Member Only
$600.00
Member +1
$1,308.00
Family
$2,148.00
Level A Enrollment Forms
If you have been notified that you are eligible for benefits, please print and complete this form. Enrollment forms are accepted at the Administrator’s office at Open Enrollment (November 20th through December 20th).
NOTE: Submitting an enrollment application is not proof of enrollment.