2021 Catalog of Benefits - CCPOA Benefit Trust Fund - CCPOA Benefit Trust Fund
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2021
Catalog of Benefits
rank & file supervisor retired
CCPOA Benefit Trust Fund
www.ccpoabtf.org
A guide to benefits offered by the CCPOA Benefit Trust Fund to CCPOA members and their families.
Table of Contents
ADB $5,000 Accidental Death . . . . . . . . . . . . . . . . . . . . 5
BL Basic Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . 5
USL U.S. Legal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
D Dental. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
MP CCPOA Medical Plan. . . . . . . . . . . . . . . . . . . . . . 13
VSP Vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
CB Co-Ben Consolidated Benefits . . . . . . . . . . . . . . . . . . 21
ADD Accidental Death & Dismemberment . . . . . . . . 22
T Triada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
DBP Disability Benefit Plan . . . . . . . . . . . . . . . . . . . . . . 30
PB Piggyback . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
LDF Legal Defense Fund . . . . . . . . . . . . . . . . . . . . . . . 36
STL Supplemental Term Life . . . . . . . . . . . . . . . . . . . . 37
A Applications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-1
Important Note from the Trust: This CCPOA Benefit Trust Fund Catalog of Benefits provides a general summary of the benefits offered by and through the Trust. Benefits
provided through carriers are described here by the carriers. If there is a conflict or discrepancy between any of the described benefits, the Summary Plan Description/Program
documents or Certificates control and will apply. To obtain a copy or view the documents, please contact the Trust at (800) IN UNIT 6.
The Trustees reserve the right to amend, modify or terminate the Programs at any time. Contact the Trust for more information on any of the Programs.
Important Note from New York Life: This brochure explains the general purpose of the insurance described, but in no way changes or affects the policy as actually issued. In
the event of a discrepancy between this brochure and the policy, the terms of the policy apply. All benefits are subject to the terms and conditions of the policy. Policies
underwritten by New York Life Insurance Company detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in full or
discontinued. Complete details are in the Certificate of Insurance issued to each insured individual and the Master Policy issued to the policyholder. This program may vary
and may not be available to residents of all states. Bates # 1679695
TWO TOWERS logo is a registered trademark of CCPOA Benefit Trust Fund.
CCPOA Benefit Trust Fund | 1-800-In-Unit-6 | www.ccpoabtf.org 3
BTF Program Availability
rank & file supervisor retired
ADB $5,000 Accidental Death • •
Basic Life Insurance
BL
(No Application Required)
• • •
USL U.S. Legal • • •
D Dental • •
VSP Vision • • •
MP CCPOA Medical Plan • • •
Accidental Death
ADD • • •
& Dismemberment
T Triada Insurance • • •
DBP Disability Benefit Plan • •
Legal Defense Fund
LDF
(No Application Required)
• •
PB Piggyback • • •
STL Supplemental Term Life • • •
IMPORTANT: You must be a
member of the CCPOA to take
advantage of the benefits in this
catalog.
It’s not too late! You can download more information on all
Simply complete the CCPOA Union our programs including complete plan doc-
application online: www.ccpoa.org
uments from our website:
If you have any questions regarding www.ccpoabtf.org
other benefits available to members,
please contact the CCPOA at:
800-821-6443 or visit
www.ccpoa.org
CCPOA
755 Riverpoint Drive
West Sacramento, CA 95605-1634
4 CCPOA Benefit Trust Fund | 1-800-In-Unit-6 | www.ccpoabtf.org
BL
Basic Life Insurance
Your
Monthly Cost rank & file supervisor ccpoabtf.org
$0.00
What Is It? Who Can Apply?
$20,000 Life Insurance Rank and File; Supervisor
As of 1/1/08, a $20,000 Accidental Death & Enrollment is automatic.
As a BU6 member, you are automatically Dismemberment benefit has been added
entitled to a $20,000 group life insurance to the CCPOA member coverage (does not What Does it Cost?
benefit and an automatic $10,000 life apply to spouse benefit.) $0.00 out-of-pocket member cost.
insurance benefit for your spouse.
Underwritten by:
There is no underwriting or premium New York Life Insurance Company
because the Association has paid for it 51 Madison Avenue, New York, NY 10010
through collective bargaining.
RETIRED BASIC LIFE
What Is It? This insurance is provided to all former Who Can Apply?
$10,000 Life Insurance Active BU6 members who join the Retired Retired Chapter Members
You must be a member of the CCPOA Chapter within 90 days of retirement. If Enrollment is automatic with your
Retired Chapter to be eligible for you join after 90 days there is a one year monthly dues..
programs offered through the Trust. wait for the retired basic group life
As a member of the CCPOA Retired insurance. This wait does not apply to What Does it Cost?
Chapter, you are automatically entitled to other retiree programs offered through the $0.00 out-of-pocket member cost.
a $10,000 group life insurance benefit and Trust.
an automatic $2,000 life insurance benefit Underwritten by:
for your spouse. Reduces at age 60 to New York Life Insurance Company
$5,000 member ($1,000 spouse). 51 Madison Avenue, New York, NY 10010
on Group Policy form GMR.
There is no underwriting or premium
because it is part of your Retired dues.
Note: If you are covered as a member, you cannot be covered as a dependent of another member.
ADB $5000 Accidental Death
Your
Monthly Cost rank & file supervisor ccpoabtf.org
$0.00
What Is It? Who Can Apply? What Does it Cost?
A free benefit that pays your beneficiary Rank and File; Supervisor $0.00 out-of-pocket member cost.
$5,000 upon your death as a result of an Coverage effective upon CCPOA
accident. enrollment deductions.
CCPOA Benefit Trust Fund | 1-800-In-Unit-6 | www.ccpoabtf.org 5USL
CCPOA Legal Plan
Active Retired
ccpoabtf.org
Monthly Cost Monthly Cost rank & file supervisor retired
uslegalservices.net/ccpoa
$0.00 $13.99
What Is It? Who Can Apply?
Family Defender Legal Plan Rank and File; Supervisor; Retired
The Family Defender Program is a pre-paid legal program that What Does it Cost?
addresses many of the most common legal matters people have. ACTIVE: $0.00 out-of-pocket member cost
For most cases, 100% of your legal fees are paid. RETIRED: $13.99/mo
As an active CCPOA member you are automatically enrolled in the
program. There are no applications to fill out.
The Family Defender Legal Plan How Does it Work?
U.S. Legal Services is one of the oldest providers of legal program • Contact CCPOA Family Defender Program at U. S. Legal
benefits in the nation. Established almost 40 years ago, U.S. Legal Services, to receive an assignment to a Network Attorney.
Services is recognized for providing full service, full indemnity • Contact attorney for initial consultation.
legal programs for you and your family members who are eligible
• Attorney obtains authorization and verification of benefits to be
dependents.
paid by U.S. Legal.
U.S. Legal has attorneys throughout the nation. U.S. Legal has over • You may be responsible for Court Costs, Fines, Filing Fees.
7,800 law firms and over 10,000 contracted attorneys, and more To get started, call the CCPOA Benefit Trust Fund and
than 500 law firms in California. request your Legal Program ID. 1-800-In Unit-6
You may get offers for other legal services. Don’t spend money for what you already have! Designed
exclusively for CCPOA, the Family Defender legal program is specifically for you and your family members
who are eligible dependents. It’s like having an attorney on retainer 24/7.
Legal Highlights: Covered Benefits Discounted
24 Hour Emergency *Enforcement and Debt Collection Defense Estate Planning/ Benefits
Services Modification of Support Administration Property Felony Defense
Document Preparation 331⁄3 % discounted fees
Advice and Consultation Juvenile Defense and Review Traffic Violations (Participant only)
(office or telephone) All other Non-Covered Matters
Codicil Insurance Law Landlord/Tenant Law
Letters and Telephone Calls 331⁄3 % discounted fees
(Tenant only)
Concealed Carry/ Misdemeanor Defense Identity Theft:
Adoption Use of Deadly Force Personal Protection
Senior Defender® - By contacting customer
Advance Health Bankruptcy Elder Law Attorneys Real Estate Transactions service, each member has
Care Directive (Chapters 7 and 13) (primary residence) access to fully managed
Power of Attorney identity theft restoration
*Child Support/Child Custody Domestic Violence Defense Revocable Living Trust
Name Change services that will be supported
*Contested Divorce DUI/DWI first offense Living Will as necessary by a Certified
(Participant only) Formation of Business Fraud Examiner (CFE) and a
Consumer Protection Simple or Complex Will Certified Identity Theft Risk
Entity Guardianship
*Uncontested Divorce for Participant and Spouse Management Specialist.
(Participant only) Personal Injury Immigration
Simple Testamentary Trust
Contract Preparation
*20 hours per year/event;
and Review 331⁄3% discounted fees thereafter
rank & file supervisor
Retired members must enroll
All Active Members through the Trust.
are already enrolled. Fill out the application and mail today.
6 CCPOA Benefit Trust Fund | 1-800-In-Unit-6 | www.ccpoabtf.orgWills & Trusts Money Help?
Don’t put it off. The Family Defender has the tools you need for All part of the program.
Estate Planning - planning for surviving spouse, planning for
single person, including tax strategies and techniques. Members are entitled to no cost telephonic consultation with
Certified Credit Counselors. A complete financial assessment will
Covered Services include a review and analysis of your household income,
• Estate Planning expenses, assets and liabilities.
• Living Wills
Members also have access to a range of online tools.
• Powers of Attorney
• Wills and Codicils Members are entitled to receive an income tax
(including Simple Support Trust for Minor Children) planning related consultation with a tax
• Estate Administration professional on each separate tax issue.
Preparation of all personal income tax documents
Revocable Living Trust are prepared by a CPA at no charge, including a
Drafted by experienced participating or network attorney. free review of prior year’s return.
• A/B revocable trust provisions (as needed) plus the
following:
• Credit counseling • Housing advisory
• Two (2) Durable Powers of Attorney for Financial services – home
Management,
• Debt and budgeting
assistance ownership, mortgages
• Two (2) Advance Health Care Directives, and refinancing
• Retirement planning
• Two (2) Pour-Over-Wills, Bill of Sale and • Capital gains
• Two (2) Transfer Deeds.
• College planning
• Inheritance
• Investment strategies
Covered In Full • Divorce
CCW Defender: U.S. Legal Services App
Concealed Carry / Use of Deadly Force Representation CCPOA members now have access to U.S. Legal’s new Member
Portal & Mobile App. Register now at the web address, and have
DUI… access to both.
Coverage for first offense DUI/DWI.
Document Preparation How do you reach U.S. Legal?
and Review: CCPOA Member Line: 1-844-896-5297 (LAWS)
This service covers the preparation of personal
legal documents including: Financial & Tax Benefits: 1-844-958-5297 (LAWS)
• Prenuptial Agreement
Identity Theft: 1-866-869-5297 (LAWS)
• Quit Claim Deed
• Personal Affidavit
Web: uslegalservices.net/companies/CCPOA/
• Promissory Note When you call, you will be matched with an appropriate
attorney for your location and legal issue.
• Bill of Sale
• Personal Contract Customer Service
Monday-Friday – 6 a.m. to 5 p.m. PST
• Lessee Agreement
Financial Coaches
Monday-Friday 6 a.m. – 8 p.m. PST
Domestic Violence Defense: 888-724-2325
This service covers representation for Covered Persons in defense
of domestic violence charges. Representation includes court After Hours Service
hearings, injunction hearings, restraining orders, and disposition. Weekends and Monday-Friday
24 Hour Emergency: 844-896-5297
Staff members are always on call.
CCPOA Benefit Trust Fund | 1-800-In-Unit-6 | www.ccpoabtf.org 7D
Dental Plans
Active ccpoabtf.org
Monthly Cost rank & file westerndental.com
$0.00 ccpoabtf.firstdentalhealth.com
What Is It? Who Can Apply?
The CCPOA Dental Plan offers two (2) types of coverage to choose Rank and File; Supervisor (CoBen)
from:
What Does It Cost?
• Western Dental Plan: The most cost effective option. All new Active: $0.00 monthly
C/Os are automatically enrolled in the Western Dental Plan for Supervisor: Your dental benefit is part of your CoBen.
the first year of coverage. Many choose to stay, as Western Starts at $37.00 monthly
Dental Plan provides a wide variety of services and locations,
including over 3,000 private practices. Many services are What Does It Cover?
covered 100%. There is no calendar year maximum. Complete documentation for the Western Dental Plan and
Primary Dental are available on our website.
• Primary Dental: Coverage when you want a wider range of
dental providers. Choose any provider you wish, Primary Dental If you have any questions about costs and coverage we URGE you
pays a percentage of the costs. to have your dentist contact the Trust and request a written
pre-authorization BEFORE any procedure to avoid financial
• First Dental Health: is a cost saving network that is a part of surprises down the road.
Primary Dental Plan. Select a First Dental Health provider
and save.
Call (800) 334-7244 or visit ccpoabtf.firstdentalhealth.com to
find a provider.
Rank & File Members Retired Members
Western Dental or have Dental Benefits through
Primary Dental CalPERS.
$0.00 covers the entire family. See page 12
Supervisor Questions regarding your
dental coverage?
CCPOA
Dental CoBen Contact Western Dental Benefits
Supervisor members are eligible Division toll free number:
for either plan: 1-800-992-3366
Primary Dental Western Dental First Dental Health questions
Member = $37.00 Member = $15.77 contact the Trust:
Member+1 = $79.00 Member+1 = $26.02 1-800-468-6486
Family = $135.00 Family = $36.91
8 CCPOA Benefit Trust Fund | 1-800-In-Unit-6 | www.ccpoabtf.orgWestern Dental Plan
Western Dental Plan is the
cost saving choice!
Since 1998 Western Dental Plan has been the cost-effective dental
plan offered through the Trust. YOU DON’T NEED TO SWITCH.
Get it your first year. Keep it
To take advantage of all the Western Dental Plan offers, you must
be assigned to one of the contracted Independent Private throughout your whole career.
Practice Dental Providers or a Western Dental Center.
The Western Dental Pan provides you with preventive care at no CCPOA Members
cost to you, and low or no co-payments on major services, Questions regarding in most areas
including Implants. must have
your coverage?
Western Dental
The Western Dental Plan has no claim forms to complete, no Want to receive a
deductibles to meet, and no annual maximum to limit the amount Plan for the first
of covered treatment you can receive each year. list of contracted year of
providers? employment.
After completion of the
Now serving CCPOA Members with Private Contact 12 months, members
Practice locations in Blythe, Cal-City, may choose to stay
Susanville and Crescent City!
Western Dental Plan enrolled or elect the
Primary Dental
1-800-992-3366 Program.
Look for more dental offices in your area by
visiting: www.westerndentalbeneits.com
Western Dental Plan has enhanced its benefits
to include more coverage to its CCPOA members.
Newly Added Benefits
• Tooth colored fillings for back teeth are now • General Anesthesia with Plan approval
a covered benefit with a copayment
• Deep sedation/general anesthesia
• Gingival irrigation (per quadrant) first 15 minutes
• Deep Sedation/general anesthesia • Zoom Whitening (where available)
subsequent 15 minutes
• No annual maximum
• Dental Implants Services (available only at
the Western Dental Implant Centers) • Online access
• Orthodontic coverage Adults and • Comprehensive dental benefits with no
Children (copayment reduced) deductibles and no claims forms
• Crowns- Porcelain on Molars, noble • Full network of private practice dentist
and high noble metal and Western Dental owned and
(additional copayment applies) operated centers
Many procedures are covered 100%
CCPOA Benefit Trust Fund | 1-800-In-Unit-6 | www.ccpoabtf.org 9D
Dental Programs
CCPOA Primary Dental Program
Primary Dental & First Dental Health PPO/EPO Network
A cost-savings alternative to traditional dental insurance
A cost-savings alternative to traditional dental insurance
FIRST DENTAL HEALTH PPO/EPO NETWORK
CCPOA Primary Dental is traditional style insurance, where you can choose any dental provider, with the insurance
covering the bulk of the costs and you paying the difference.
By using a First Dental Health provider, you pay discounted fees for a variety of dental services and procedures.
Choose from one of First Dental Health’s two cost saving networks: PPO and EPO. This provides you with different
levels of savings, depending on the provider you select.
What does PPO mean? What does EPO mean?
Preferred Provider Organization. Exclusive Provider Organization.
PPO providers follow a contracted fee schedule for the The EPO program provides the patient with a greater
service they provide. reduced fee for service, in this smaller, exclusive network.
That means no surprises when it comes to the costs. That means using an EPO dentist costs you even less.
CCPOA Finding a dentist is easy.
Primary Dental & To find a First Dental Health provider in your
First Dental Health area, simply log onto the website at
ccpoabtf.firstdentalhealth.com
CCPOA Primary Dental = Go to any dentist
+
First Dental Health = Reduced Fees Pre-Authorization for
Primary Dental
If your dental work will cost more than $300, ask your
dentist to report the anticipated treatment and charges
Questions regarding the before work is started.
First Dental Health Network? The pre-authorization is prepared by the CCPOA Benefit
Trust Fund and returned to your dentist with the amount to
Contact be paid by the Program.
You will receive a copy of the pre-authorization by mail.
First Dental Health
1-800-334-7244
10 CCPOA Benefit Trust Fund | 1-800-In-Unit-6 | www.ccpoabtf.orgPrimary Dental
Non-Contracted Provider: First Dental Health Providers:
Calendar year maximum: $2000/ per person
Combined Dental & Orthodontic Deductible: Calendar year maximum: $2000/per person
Per calendar year Deductible: None
Individual: $50 Family: $150 Services are payable based on Contract Rate through
First Dental Health EPO/PPO
Deductible is waived on Preventive/Diagnostic Services
Services are payable based on CCPOA allowable amount
This is not a guarantee of payment but a summary of benefits available through the CCPOA Primary Dental
Program. Benefits are subject to eligibility, terms, conditions, and limitations of the participant’s dental coverage in
force at the time the services are actually rendered. Certain services are subject to review.
Preventive/Diagnostic Basic Services: 90% Singles Crowns, Inlays, Orthodontic Services:
Services: 100% Restorative Services: Onlays & Build-ups: 80% - No age limit
Prophy: Three times in the Posterior Composite & PREP DATE - 50% to lifetime benefit $1,000
calendar year (anytime) Amalgam Fillings Covered - Porcelain crowns placed on including adjustments &
Once every 6 months per molars will be paid as a full retainers
Fluoride: Unlimited for
tooth cast crown.
dependents 14 and under. (Ortho must be billed
Endodontic Services: Root 5-year replacement monthly or quarterly as they
Sealants: No age limit, on
canal Therapy limitation become due)
permanent unrestored
posterior molars only - Once Periodontal Services: Root
Prosthodontic (Major) Services Not Covered
every 36 months Planning & Scaling: Once
every 24 months “All four Services 50% - PREP DATE TMJ
Bitewings: Unlimited, unless
quads OK in same day “ Initial preparation &
done with Panographic or Occlusal guards/Night
more than 10 PA’s. Periodontal cleanings that installation of bridges guards
are in conjunction with an Crowns attached to a
Panographic: Unlimited Implants/Implant Abutment
active periodontal disease bridge
while taken alone.
will be limited to two Analgesia/Nitrous oxide
FMX: Once every 36 months cleanings per year and only Initial preparation &
installation of partial or Arestin
for the l8-month period
Exams: Unlimited. First exam complete dentures
following treatment of the Coordination of Benefits:
of the calendar year is (including repairs)
periodontal disease. Standard
payable at 100%, ALL exams
after will be at 90% with no Oral Surgery: Extraction of Prior extractions are covered
deductible. teeth & minor oral surgery. 5-year replacement Additional Information
(Including D9310 & D9430) (Medical does not have to limitation Pre-authorization is
be billed first)
Space Maintainers: Congenitally missing teeth suggested over $300, but
Unlimited for dependents 18 General Anesthesia: If are covered not Mandatory.
and under. provided in conjunction with
Dependant children may be
a covered oral surgery
Emergency Palliative covered up to age 26
procedure & only if
Treatment: Unlimited with no regardless of student status.
determined by the
other treatment on the
Administrator to be
same day.
Medically Necessary.
CCPOA Primary Dental Waiting period
A nine-month waiting period from the effective date of coverage
applies for new hires and their family members for This is a partial list of the benefits, exclusions, and limitations
under the Primary Dental Program. For a complete listing, see
covered dental services at 80% and 50%. the Summary Program Description.
CCPOA Benefit Trust Fund | 1-800-In-Unit-6 | www.ccpoabtf.org 11D
Dental Programs
Retired BU6 Members have
Dental Benefits through CalPERS.
Contact your Personnel Office before
retirement to ensure you have Your Retired
uninterrupted dental coverage. Dental
What are the Dental Options? Coverage is
Changing.
Here’s a quick rundown…
CCPOA dental programs
The qualifications for
State Dental coverage:
Retired State are not currently available
to Retired Members.
Employees
You are eligible if you retire within 120 If you are a retired State employee, you When you retire, and if you want
days of your separation; and, you are are eligible to continue enrollment in the to continue dental coverage,
eligible to receive a CalPERS retirement State’s Dental Program if you retired you may choose a State-
benefit. within 120 days after your date of sponsored Dental Program.
separation and you receive a retirement
If you meet the above criteria, but did not allowance from CalPERS. If you are Your dental program changes
enroll in a Dental Program at the time of enrolled in a State-sponsored Dental when you retire. Your personnel
your retirement, it is possible to join Program, your personnel office will specialist will help you with
later, during the State’s annual open automatically submit the STD. 692 to the transition and explain
enrollment period (usually held in the CalPERS to continue your dental the differences between
Fall for the next year). enrollment into retirement. Retired your current dental program
employees who did not continue dental and the State’s Dental
coverage into retirement may enroll Program for Retirees.
Can I continue my during the annual dental open
CCPOA Primary or enrollment period.
Western Dental as a
Other options to If you are a retired
Retired Member?
explore when
No. These programs are only available to State employee and
you as an active member of CCPOA. considering retirement
• Coverage under a spouse’s dental have any questions
Can I add or drop program regarding your
• Military dental and/or health coverage
family members? (Tri-Care)
eligibility, contact
Yes. You can do so when you initially CalPERS
enroll, during the annual open
enrollment period, and within 60 days Health Benefits
from the date a change in your family Services Division
occurs (marriage, divorce, new baby).
TOLL FREE at:
To make changes to your dental program 1-888-225-7377
once you are retired, contact CalPERS.
12 CCPOA Benefit Trust Fund | 1-800-In-Unit-6 | www.ccpoabtf.orgMP
CCPOA Medical Plan
Your Monthly Cost ccpoabtf.org
rank & file supervisor retired
See Chart blueshieldca.com
What Is It? Who Can Apply?
The CCPOA Medical Plan provides you Rank and File; Supervisor; Retired What does it cost
and your family a great plan with good
rates and extensive care. The CCPOA What Does It Cover? when I go
Medical Plan has affordable rates, Complete documentation is available on to the doctor?
Teladoc®, NurseHelp 24/7SM and a large our website.
network of providers, and providing The following documents are available for Low Cost
members with network Chiropractic download:
benefits. Preventative Care
• E-Z Plan Summary. A quick, easy to read
overview of the Medical Plan. $15 Office Visits – No Charge
The CCPOA Medical Plan is available only for Preventive Care visits
• The Evidence of Coverage (EOC). The
to CCPOA members and administered
complete medical plan document, $0 Prenatal Visits
through Blue Shield of California.
Active and Retired versions.
$0 Pre and Postnatal Care
Sign-up for the Medical Plan occurs once a • Prescription Drug Plan (PDP) for
(through age 2)
year during Open Enrollment, or upon Medicare (EOC).
graduation from the Academy as a new • Drug Formulary.
$0 Allergy Testing
Correctional Officer. $0 Immunization
$15 Chiropractic Visits – up to
20 visits per year at this
low rate. Additional visits
Medical Plans for Supervisors 25% off!
As a supervisor, you do not receive three separate State contributions $15 Audiological Exam
for your health, dental and vision benefits. $15 Bio-Feedback Visits
Instead you receive a “Consolidated Benefit,”
a single monthly contribution from the State, Low Cost
to help cover the cost of all three benefit programs. Prescriptions*
$10 Tier 1 - 30 day supply
$25 Tier 2 - 30 day supply
Which Medical Plans are Mail Order Prescriptions
Starting at $20-90 day supply
available to Retirees? * Due to the large variety of medications,
prescriptions are divided into Rate Tiers. A
As a CCPOA retired chapter member living in a covered area, you are majority of widely used generic and brand
eligible for the CCPOA Medical Plan. After age 65, you can participate name drugs fall into these two Tiers.
Contact Blue Shield Customer Service for
in the CCPOA Medical Plan’s Medicare Supplement.
complete information.
Medical enrollment is through CalPERS during either
Open Enrollment or at the time of retirement. X-Ray/Lab
If you don’t reside in a covered area or need information on vesting $0 X-Ray and Lab visits
and state contributions, please visit or call CalPERS.
CCPOA Benefit Trust Fund | 1-800-In-Unit-6 | www.ccpoabtf.org 13MP
CCPOA Medical Plan
NurseHelp
GET THE MOBILE APP
24/7
Need medical advice right now, for no
extra charge? With NurseHelp 24/7SM,
Download the Blue Shield of California you can talk with registered nurses any
SM
mobile app for iPhone from the App Store time, day or night, to get answers to
or for Android from Google Play.™ your health-related questions.
Experienced nurses can help you
figure out how you can care for
yourself, evaluate treatment options,
Whether you are using the mobile website or the mobile and determine whether to see a
app, each offers the same experience and access to more doctor.
features than ever before.
Say you have a sick child and it’s the
Your features and plan details may vary depending on your
middle of the night. Before you head
specific plan type. out to the nearest urgent care, you can
call or go online and chat with a
registered nurse about symptoms and
treatment. By reviewing the situation
with a registered nurse, you can
On-line. Anytime. decide whether care needs to be
BACK BENEFIT! immediate, or maybe you can wait
Find a Doctor at
Chiropractic and your until the morning to see your child’s
Medical Plan blueshieldca.com regular pediatrician.
Get immediate answers and
The CCPOA Medical Plan is one of the reliable information about:
only plans offering chiropractic benefits. Go to: • Minor illnesses and injuries
20 visits per year at only $15 per visit. blueshieldca.com/ccpoanetwork • Chronic conditions
The system will bring up a listing of • Medical tests and medications
To take advantage of this benefit, services
doctors that meet your • Preventive care
must be provided by an American
specifications.
Specialty Health Plans of California To use NurseHelp 24/7, just call:
participating provider. Follow these 877-304-0504 or
directions to find a provider near you: visit blueshieldca.com and log in to
get additional information.
• Go to www.blueshieldca.com
• Click Find a Doctor at top of page. With either option you will get
• Choose Alternative Care, log-in to your confidential, personalized assistance.
account, and let the prompts guide you
to finding a Chiropractor near you.
Need help with your
Blue Shield benefits?
(800) 257-6213
14 CCPOA Benefit Trust Fund | 1-800-In-Unit-6 | www.ccpoabtf.orgHighlights
Announcing Teladoc’s
Off-Work Note
When you are on a telephonic or video consult with a Teladoc
physician, and if it is appropriate, you may request an Off-Work
Note, if you are diagnosed with a respiratory and infectious illness
such as bronchitis or seasonal flu. If in the doctor’s judgment you
are not able to work for the next 24 hours, the doctor may grant
your request for an Off-Work Note.
For other diagnoses and injuries you will need to see your
Personal Physician for an Off-Work Note.
The Off-Work Note covers a day off work for a 24-hour period. If
you need to be off work for more than a 24- hour period, you will
be directed to follow up with your Personal Physician. To receive
the Off-Work Note, you will need to have access to a fax machine
or the Internet. A $0 copayment will be required when you request
a Teladoc physician consultation. There is no additional cost to
receive the Off-Work Note.
If you do not have
access to a computer
Call 1-800-Teladoc (835-2362) to set up your account by phone at
no charge.
Blue Shield of California is pleased to provide you with Teladoc®, Questions?
an added medical benefit that allows you to resolve many of your If you have questions about the Off-Work Note or Teladoc, please
medical issues—anytime day or night—through the convenience contact your dedicated Member Services team at (800) 257-6213.
of phone and online video consultations. Representatives are available to assist you Monday through Friday,
7 a.m. to 7 p.m.
Quality Medical Care
All Teladoc doctors are U.S. board certified, state-licensed in
California and average 15 years of practice experience. With your
consent, Teladoc consultation information can be sent to your Teladoc is Affordable:
primary care physician.
Your Copay $0 for 2021
Anytime/Anywhere
Talk to a doctor anytime through the convenience of phone or
online video consultations. Teladoc doctors can diagnose and even
prescribe medication, if necessary, for many conditions including
allergies, cold and flu symptoms, ear infection and more.
At a price you can afford
Teladoc is a convenient and affordable alternative to costly urgent
care and ER visits for non-emergency medical care. You also save
the time spent driving to and sitting in a waiting room.
CCPOA Benefit Trust Fund | 1-800-In-Unit-6 | www.ccpoabtf.org 15CCPOA Medical Plan
CCPOA MEDICAL PLAN CCPOA MEDICAL PLAN
COVERAGE HIGHLIGHTS COVERAGE HIGHLIGHTS
CATEGORY CCPOA MEDICAL CATEGORY CCPOA MEDICAL
Calendar Year Deductible None Hospice No Charge
HOSPITAL PRESCRIPTIONS*
* Due to the large variety of medications, prescriptions are divided into Rate Tiers.A
Inpatient majority of widely used generic and brand name drugs fall into Tiers 1 & 2. Contact
(includes blood and blood products - Blue Shield Customer Service for complete information.
$100 per admission
collection and storage of autologous
blood)
No Charge - Tier 1
$50 - Tier 2 and above
Outpatient (other than surgery) No Charge Prescription Drug Deductible
(not to exceed $150/
family)
Outpatient Surgery (surgery performed in a
$50 Starting at $10 - Tier 1
Hospital or Outpatient Surgical Prescription Drugs Obtained at a
(not to exceed 30-day
Pharmacy
supply)
Ambulance Service No Charge
Starting at $20 - Tier 1
$75 (co-pay waived if
Mail Service Prescription Drugs (not to exceed 90-day
admitted as an inpatient
Emergency Care/Services supply)
or for observation as an
outpatient)
MENTAL HEALTH
Urgent Care Visits $15/visit Inpatient $100 per admission
PHYSICIAN SERVICES Outpatient $15/visit
Office Visits $15/visit CHIROPRACTIC SERVICES
Allergy Testing/Treatment No Charge $15/visit - up to 20 visits per
Chiropractic Examination
calendar year15
Inpatient Hospital Visits No Charge
Surgery/Anesthesia No Charge Diagnostic Services for Chiropractic Care No Charge
Diagnostic X-ray/Lab No Charge
Durable Medical Equipment Chiropractic Appliances (up to a maximum of
No Charge No Charge
(including orthoses and prostheses) $50 is covered during a calendar year)
Home Health Services (prior authorization $15/visit - up to 100 visits MEMBER’S MAXIMUM CALENDAR YEAR COPAYMENT
required; custodial care not covered) per calendar year
$1,500 per Member
Physical/Occupational/Speech Maximum Calendar Year Co-pay
No Charge (excluding pharmacy)
Therapy
(See each plan’s EOC for other
items not counted toward co-pay max limit) $4,500 per Family (3 or more
No Charge - up to 100 days per members enrolled)
Skilled Nursing Care
calendar year
Live down South?Work up North?
Live/Work Rule
Pick which location works best for you and your family.
You may be assigned to an institution away from where you live. Or maybe the doctor you use is
closer to work than home. Use the address that gets the coverage you want.
Use either your home or work location when applying for your coverage.
16 CCPOA Benefit Trust Fund | 1-800-In-Unit-6 | www.ccpoabtf.orgFacility City County
CCPOA Service Area Avenal State Prison
California Health Care Facility
California Medical Facility
Avenal
Stockton
Vacaville
Kings
San Joaquin
Solano
California State Prison, Corcoran Corcoran Kings
California State Prison, Sacramento Represa Sacramento
California State Prison, Solano Vacaville Solano
California Substance Abuse Treatment Facility Corcoran Kings
Central California Women’s Facility Chowchilla Madera
Deuel Vocational Institution Tracy San Joaquin
Folsom State Prison Represa Sacramento
Pleasant Valley State Prison Coalinga Fresno
San Quentin State Prison San Quentin Marin
Valley State Prison for Women Chowchilla Madera
California City Correctional Facility California City Kern
California Correctional Institution Tehachapi Kern
California Institution for Men Chino San Bernardino
California Institution for Women Corona Riverside
California Men’s Colony San Luis Obispo San Luis Obispo
California Rehabilitation Center Norco Riverside
California State Prison, LA County Lancaster Los Angeles
Calipatria State Prison Calipatria Imperial
Centinela State Prison Imperial Imperial
Chuckawalla Valley State Prison Blythe Riverside
Ironwood State Prison Blythe Riverside
Kern Valley State Prison Delano Kern
North Kern State Prison Delano Kern
R.J. Donovan Correctional Facility San Diego San Diego
Wasco State Prison Wasco Kern
California Correctional Center Susanville Lassen
Correctional Training Facility Soledad Monterey
High Desert State Prison Susanville Lassen
Mule Creek State Prison Ione Amador
Pelican Bay State Prison Crescent City Del Norte
Salinas Valley State Prison Soledad Monterey
Sierra Conservation Center Jamestown Tuolumne
Youth Facility City County
O.H. Close Youth Correctional Facility Stockton San Joaquin
N.A. Chaderjian Youth Correctional Facility Stockton San Joaquin
Ventura Youth Correctional Facility Ventura Ventura
CCPOA Benefit Trust Fund | 1-800-In-Unit-6 | www.ccpoabtf.org 17VSP
CCPOA Vision Plan: Active
Rank & File Supervisor Retired
ccpoabtf.org
Monthly Cost Part of CoBen Starting Monthly at rank & file supervisor retired
$0.00 $0.00 $1.98 See Chart vsp.com
What Is It? Who Can Apply?
CCPOA Vision Service Plan Rank and File; Supervisor; Retired
VSP provides high quality vision care to CCPOA members. There What Does it Cost?
are no claim forms or membership cards. ACTIVE: $0.00 out-of-pocket member cost.
The actual cost of the VSP plan $16.01/mo.
Benefits include 2 pair of frames and lenses each year, or coverage The State contributes $8.27 and the Trust provides the balance.
for contact lenses, plus additional discounted services.
SUPERVISOR: The Trust’s VSP “Second Pair benefit” is in addition
Plan services are different for Active, Retired and Supervisor to your CoBen “Basic Vision” plan.
members. Supervisors pay $0 for this additional coverage.
RETIRED: Plans start at $1.98/mo. See next page.
Rank & File: VSP Copays VSP Highlights
With VSP doctors, you’ll enjoy quality, personalized care. Your VSP
FIRST PAIR doctor will get to know you and your eyes, helping you keep them
Exam.........................................................$10.00 healthy year after year.
Prescription Glasses ................................$25.00
Contacts ..................................No Copay Applies Besides helping you see better, routine eye exams can detect
SECOND PAIR symptoms of serious conditions such as diabetes, glaucoma,
cataracts and even tumors. Eye exams for children spot problems
Prescription Glasses ................................$35.00
that can hinder learning and development.
Contacts .............................No Copay applies
Close to you. Big selection.
VSP network doctors are in medical offices and shopping centers
close to your home and work. They have a large frame and contact
lens selection, whether you prefer classic styles or the latest
Supervisors fashions. Plus, most offer evening and weekend hours and accept
As a Supervisor you are AUTOMATICALLY drop-ins. New patients are always welcome!
enrolled in the state funded vision plan,
which is also provided through VSP. Effortless Benefits.
Choose a VSP doctor at vsp.com or call 800-877-7195
Your first pair of glasses is through this plan. Make an appointment and tell the doctor you are a VSP member.
That’s it! No ID cards or filling out claim forms.
Vision coverage through the Trust
provides you a SECOND PAIR benefit. Costco Members
Supervisors pay $0 Costco is a VSP “Out of Network” provider. Using your VSP benefits
at Costco is easy. Simply tell Costco you have VSP and would like
for this additional coverage. to use your Out of Network Benefits. Check with VSP for your
Open Access Allowances.
Visit www.calhr.ca.gov for
information on this coverage. Satisfaction Guaranteed.*
Your monthly premium for VSP coverage is part of It’s true: Your satisfaction is guaranteed. You’ll always receive
your CoBen benefit. first-class customer service at VSP. If you’re not completely
satisfied with your service or eyewear, just let us know and we’ll
make it right.
18 CCPOA Benefit Trust Fund | 1-800-In-Unit-6 | www.ccpoabtf.orgVSP
CCPOA Vision Plan: Retired
CCPOA Retired Standard Plan Retired Exam Plus Plan
Under the CCPOA Benefit Trust Fund Vision Program, once you An economical plan, with coverage starting at $1.98 monthly.
enroll, your vision coverage continues - there is no set expiration
Exam covered in full every 12 months
date. And with a rich frame allowance and contact lens allowance,
the Trust program provides you with the most coverage for your Exam Plus Plan has no copay
dollar.
Exam covered in full ..................................... every 12 months Prescription Glasses Discounts
Prescription Glasses Lenses Contacts
Lenses covered in full ................................... every 12 months 20% savings when a complete 15% savings on the contact lens
pair of glasses is purchased. exam fitting and evaluation.
Single vision, lined bifocal and lined trifocal lenses. Tints and
This exam is in addition to your
photochromic adaptive lenses.
Polycarbonate lenses; Progressive Lenses (with co-pay) Frames vision exam to ensure proper
20% savings when a complete fit of contacts.
Frame............................................................... every 24 months pair of glasses is purchased.
Frame of your choice covered up to $ 175.
Plus, 20% savings on any out-of-pocket costs.
OR
Contact Lenses ............................................. every 12 months
When you choose contacts instead of glasses, your $120 allowance
applies to the cost of your contacts and the contact lens exam
The new way to get your glasses online. Visit eyeconic.com to
(fitting and evaluation). This exam is in addition to your vision
try on your new frames virtually, link up your VSP benefits,
exam to ensure proper fit of contacts.
upload your prescription and have your glasses delivered
If you choose contact lenses you will be eligible for a frame 24 right to your doctor’s office, home, or place of work. Includes
months from the date the contact lenses were obtained. free shipping and returns.
EYEWEAR + EYE CARE
Retired: What Does It Cost? It’s easy to use your VSP benefit.
Create an account at vsp.com. Review your vision benefit and
RETIRED STANDARD PLAN access your eligibility and coverage information, including
Member Only...............................................$9.20 how to apply your benefits at Eyeconic.
Member + 1 Dependent ..........................$13.19
Member + Family............................................$23.54 Find superior eye care near you. The decision is yours—
choose a conveniently located VSP doctor or any out-of
RETIRED EXAM PLUS PLAN
network provider. Visit vsp.com or call 800.877.7195 to find
Member Only...............................................$1.98
the best provider for you.
Member + 1 Dependent ............................$2.72
Member + Family..............................................$4.65
Check out Eyeconic and browse the frame brands you love.
Retired: VSP Copays You can connect to your VSP benefits, upload your
Exam ...........................................................$10.00 prescription and order your glasses following your WellVision
Prescription Glasses...................................$25.00 Exam.®
Contacts.....................................No Copay Applies
Eyeconic is available to all members.
rank & file supervisor retired
*VSP guarantees services from VSP network doctors only. In the event of a conflict between this
information and your organization’s contract with VSP, the terms of the contract will prevail.
CCPOA Benefit Trust Fund | 1-800-In-Unit-6 | www.ccpoabtf.org 19The 2021 VSP Benefits Your coverage from a VSP Doctor.
rank & file supervisor retired
Benefit Description
Copay Frequency Copay Frequency Copay Frequency
Focuses on your eyes and Every 12 Every 12 Every 12
WellVision Exam $10 $10 $10
overall wellness months months months
Frames & Lenses: $25 $25 $25
$120 standard allowance $85 standard allowance $175 standard allowance
Frames
Every 12 months Every 12 months Every 24 months
Lenses: Single Vision Included $0 $0 $0
Lenses: Bifocal Included $0 $0 $0
Lenses: Trifocal Included $0 $0 $0
Kids Included $0 $0 $0
Lenses: Polycarbonate
Adult $31 - $35 $31 - $35 $0
Lenses: Tints; Photochromics Included $0 $0 $0 Every 12
months
Lenses: Standard progressive $0 Every 12 $0 Every 12 $0
months months
Lenses: Premium progressive $95 - $175 $95 - $175 $50
Lenses:
Upgrade to Custom Coatings - $85 $41 $41 $41
Anti-Reflective Coating
Lenses - Scratch Resistant $17 - $33 $17 - $33 $17 - $33
Lenses - UV Protection $16 $16 $16
Contact Lens $110 allowance for contacts & $120 allowance for contacts &
$0 $0 exam - Every 12 months
(instead of glasses): exam
Necessary Contact Lenses $0 $0 $0
2nd Pair Benefit
Frames $120 allowance
Single vision, lined bifocal, and
lined trifocal lenses; Tints, Photo- $35 Frame
Lenses chromatics. and Lenses $35 Frame
Polycarbonate lenses and Lenses
Every 12 Every 12
for dependent children. months months
Standard Progressive Lenses Covered in full $0
Contact Lens $110 allowance for additional
$0 $0
(instead of glasses): contacts and contact lens exam
This is just a partial list of VSP Benefits.
Visit the Trust website to download
VSP Data Sheets, specific to your plan.
Any questions?
Please call VSP at 800-877-7195
20 CCPOA Benefit Trust Fund | 1-800-In-Unit-6 | www.ccpoabtf.orgCB
Co-Ben (Consolidated Benefits)
Supervisors must be CCPOA Members to receive benefits through the Trust.
Consolidated Benefits (CoBen)
As a supervisor, the State does not send three separate If the combined monthly total is less than your CoBen allowance,
contributions for your health, dental and vision benefits. Instead you receive the excess amount as taxable cash in your monthly pay
you receive a single monthly contribution from the State, a check. If the combined monthly total is more than your CoBen
“Consolidated Benefit,” to help cover the cost of all three benefit allowance, you pay the difference, which shows up as a pretax
programs. deduction on your monthly pay check.
The amount of your allowance is based on whether you choose All employees are automatically enrolled in the state's vision plan.
coverage for yourself only, yourself plus one dependant, or yourself Therefore, you need to add in the cost of this coverage when
plus two or more dependants. calculating the total cost of your benefits. For employees in CoBen,
enrollment in the vision plan is mandatory.
2021 Co-Ben Allowance
Employee = $693.00 | Employee + 1 = $1,340.00 | Family = $1,723.00
2021 Medical Rates (Before CoBen)
HMO and PPO Plans Employee Only Employee + 1 Family
$830.60 $1,665.05 $2,248.06
CCPOA NorCal
Medical Plan SoCal
684.86 1,373.51 1,856.05
PERS Choice (PPO) 849.23 1,698.46 2,208.00
PERS Select (PPO) 527.39 1,054.78 1,371.21
PERS Care (PPO) 1,111.87 2,223.74 2,890.86
Blue Shield Access+ 938.96 1,877.92 2,441.30
Kaiser 761.62 1,523.24 1,980.21
Here’s an Example of CoBen* in action:
Employee + 1
CCPOA Medical Plan Southern California Member
$1373.51
Total CoBen
Primary Dental Benefit Allotment:* Employee
Dental Plan Employee + 1
$79.00
Premium: - Emp+1 = Contribution:
$121.15
$1461.15 $1,340.00
Supervisor VSP
VSP Vision Plan
$8.64
Supervisor VSP is more robust than Questions? Call the CCPOA Benefit Trust Fund
State “Vision Premier” – and costs less! 1-800-In-Unit-6
Use as example only. Your actual costs may very.
*Due to the nature of the collective bargaining process, changes may alter contribution amounts and dependent vesting levels.
The CoBen allowance for Excluded employees is determined by CalHR. Published rates as of0 9/02/20. Check calhr.ca.gov to see if updated rates are available.
CCPOA Benefit Trust Fund | 1-800-In-Unit-6 | www.ccpoabtf.org 21ADD
Group Accidental Death and
Active Retired
Starting Monthly at Starting Monthly at rank & file supervisor retired ccpoabtf.org
$1.25* See Chart $1.60 See Chart
What Is It? What Does It Cover?
AD&D helps bridge the financial gap that occurs when a AD&D pays a dollar amount on accidental death or loss of limbs.
breadwinner meets accidental death, or an accident results in loss (See chart.) Additional benefits include an education benefit for a
of sight or loss of limbs. In addition, it provides financial surviving spouse, funds to help with day-care for young children
assistance to train or retrain you or a loved one for a new career. and funds for adaptive home and vehicle alterations.
Who Can Apply? How Does It Work?
Rank and File; Supervisor; Retired You pick an amount of coverage to buy (Principal Sum.) Your
monthly payment remains constant, but the amount of coverage
does reduce as you age. When a claim is paid-out it is based on a
percentage of the Principal Sum, the type of injury, and your age.
What Does It Cost? Select your Principal Sum from the following table:
rank & file supervisor retired
CURRENT MONTHLY COST VIA PAYROLL DEDUCTIONS MONTHLY COST VIA RETIREMENT BENEFIT DEDUCTIONS
Principal Sum Member Only Family Plan Member Only Family Plan
*25,000 1.25 1.50 1.60 2.13
50,000 2.50 3.00 3.19 4.25
75,000 3.75 4.50 4.79 6.38
100,000 5.00 6.00 6.38 8.50
125,000 6.25 7.50
150,000 7.50 9.00
175,000 8.75 10.50
200,000 10.00 12.00
225,000 11.25 13.50
250,000 12.50 15.00
In addition to your own coverage, family coverage provides the following insurance for your dependents:
Death Benefit Coverage
rank & file supervisor retired
Member 100% Principal sum 100% Principal sum
60% of Principal Sum ( if NO children) 50% of Principal Sum ( if NO children)
Spouse
50% of Principal Sum ( if children) 40% of Principal Sum ( if children)
15% of Principal Sum ( if spouse) 10% of Principal Sum ( if spouse)
Child
20% of Principal Sum ( if NO spouse) 15% of Principal Sum ( if NO spouse)
Children must be unmarried under age 21 (23 if full time student).
ADD.012016
22 CCPOA Benefit Trust Fund | 1-800-In-Unit-6 | www.ccpoabtf.orgDismemberment Insurance
Who is eligible to enroll?
rank & file supervisor retired
All active full-time CCPOA members are eligible. CCPOA Retired Chapter dues paying member
Your spouse, under age 69 and unmarried dependent children under age 21. Your spouse under age 75 and unmarried dependent children under age 21.
Unmarried children who are full-time students and primarily dependent on Unmarried children who are full time students and primarily dependent on
you for support are also eligible to age 23. you for support are also eligible to age 23.
Note: If you are covered as a member, you cannot be covered as a dependent of another member.
When am I covered?
You are covered 24 hours a day. Anywhere in the world.* On the job or at home.
Benefits are payable in addition to any other insurance you have.
rank & file supervisor retired
Your coverage will be effective (subject to approval of your application by Retired CCPOA members (and new retired members) enjoy a continuous
the CCPOA Benefit Trust Fund and New York Life), upon the first (1st) day of open enrollment period. If your application is received before the 1st of the
the next calendar month immediately following the month for which a current month, your coverage will become effective on the first day of the
payroll deduction is made for the AD&D premium, provided that you are month immediately following the pay period from which the first premium
actively at work and a CCPOA member on that date. deduction is taken from your CalPERS retirement benefit.
If you are not actively working, or a CCPOA member when coverage would
normally take effect, the effective date will be deferred until you return to
active full-time work and/or become a CCPOA member.
* Subject to U.S. Government regulations on restricted countries.
Note: you do not receive temporary or conditional insurance just because you submit an application.
Can I change my coverage once I’ve enrolled?
Yes — by simply completing a new enrollment card. This change will become effective on the first of the month on or following the pay
period from which the first premium deduction is made.
If I retire, can I still keep my coverage?
Yes — there is a Retiree AD&D program available to CCPOA Retiree Chapter members.
You must request a Retired AD&D application from the Trust, and pay the initial premium within 31 days of the date this coverage
terminates. If you are no longer a member of the CCPOA you cannot continue your coverage and it will be terminated.
Contact the CCPOA Benefit Trust Fund for details.
30-DAY FREE LOOK
If you are not completely satisfied with the terms of
your Certificate of Insurance you may return it,
without claim, within 30 days.
Your coverage will be invalidated and you will
receive a full refund - no questions asked.
CCPOA Benefit Trust Fund | 1-800-In-Unit-6 | www.ccpoabtf.org 23ADD
Group Accidental Death and
What Does It Pay?
Dismemberment Benefit Coverage
rank & file supervisor retired
If an injury results in any of the following losses within 365 days after the accident, the plan will pay the following:
Life
Both hands or Both Feet or Sight of Both Eyes
One Hand and One Foot
100% of the Principal Sum
Speech and Hearing
Either Hand or Foot and Sight of One Eye
Movement of Both Upper and Lower Limbs (Quadriplegia)
Movement of Both Lower Limbs (Paraplegia) 75% of the Principal Sum
Movement of Both Upper and Lower Limbs of One Side of the Body (Hemiplegia)
Either Hand or Foot
50% of The Principal Sum
Sight of One Eye
Speech or Hearing
Thumb and Index Finger of Either Hand 25% of The Principal Sum
Additional Benefits for Active & Retired
Spouse Education Benefit Common Disaster Benefit
If your dependents are covered under the family plan and you die, and the Principal Sum is If you and your spouse die as a result of injuries received in
payable, the plan will pay your spouse an Education Benefit. This benefit will be the lesser the same accident and a Principal Sum is payable under
of 5% of your Principal Sum, or, the maximum amount of $5,000.00. the Accidental and Dismemberment Benefit for each death,
To qualify for this benefit, your spouse must enroll in an Occupational Training Program for the benefit for your spouse will be increased to equal the
the purpose of earning an independent income. Enrollment must take place within one year lesser of your Principal Sum or an amount which, when
of your death, and expenses must be incurred within two years of your death. added to your Principal Sum, equals $300,00 for Active
If the Principal Sum is payable because of your death, and no covered spouse survives, the and $200,000 for Retired members.
plan will pay the minimum amount of $1,000.00, according to the terms of the beneficiary
section.
Expenses incurred means actual tuition charged and cost of materials required for the
Occupational Training Program. It does not include room and board.
Occupational Training Program means any education, professional, or trade training which
prepares your spouse for an occupation for which he or she would not otherwise qualify.
The total limit of liability for any one person for all losses due to the same accident will not be more than the Principal Sum.
Rates and/or benefits may be changed. The premiums shown reflect the current rates (as of January 1,
2021) and benefit structure. Premiums may be changed by New York Life on any premium due date, but
not more than once in any 12-month period, and on any date on which benefits are changed. Your rate
may change only if they are changed for all others in the same class of insureds under this group policy.
For example, a class of insureds is a group of people with all the same issue age and gender. Rates shown
are deducted from your CalPERS retirement benefit. Benefit option amounts are subject to change by
agreement between New York Life and the Trustees.
Benefit option amounts are subject to change by agreement between New York Life and the Trustees.
These pages are intended to describe only principal features of the Group Accidental Death &
Dismemberment Insurance offered through the CCPOA Benefit Trust Fund, and is not a contract. A complete
description including features, limitations, exclusions, rates and conditions is contained in the Certificate of
Insurance issued to each plan participant. If there is a conflict between any of the described benefits, the
Summary Program Description/Plan documents or certificates control and will apply. This plan is
underwritten by New York Life Insurance Company under Group Policy G29312-0/FACE on Policy Form GMR
– ER et.al and for Retirees, Group Policy G-29313-0/FACE on Policy Form GMR
24 CCPOA Benefit Trust Fund | 1-800-In-Unit-6 | www.ccpoabtf.orgDismemberment Insurance
AD&D Benefit Highlights: Active Members
Education Student Education Benefit — This benefit is payable every Spouse Education Benefit — To qualify for this benefit, Expense Incurred means actual
If your dependents year in which the student meets the criteria (up to $10,000 your spouse must simply enroll in an Occupational tuition charged and cost of materials
are covered under the per year for four years), provided the dependent submits proof Training Program for the purpose of earning an required for the Occupational
family plan and you of his or her student status each year. independent income. Training Program — not including
die, and the Principal Pays lesser of 5% of your Principal Sum or the maximum Enrollment must take place within one year of your death, room and board.
Sum is payable, the amount of $10,000. The student must show proof that, on and expenses be incurred within two years of your death. Occupational Training Program
program will pay the the date of your death, he or she was a covered dependent Pays the lesser of 5% of your Principal Sum or, Expense means any education, professional
following: and: Incurred for Occupational Training or, the maximum or trade training which prepares
• A full-time, post-high school student in a school for higher amount of $5,000. your spouse for an occupation for
learning, or which he or she would not otherwise
If the Principal Sum is payable because of your death, and qualify.
• A student in 12th grade and will be a full-time, post-high no covered spouse survives, the program will pay the
school student in a school for higher learning within 365 minimum amount of $1,000, according to the term of the
days. beneficiary section.
If an Education Benefit would be payable, but no person
qualifies as a student, the plan will pay the minimum amount
of $1,000, according to the terms of the beneficiary section
Day Care The Day Care Benefit — The lesser of 5% of your Principal Sum or the maximum amount of $40,000.
If your dependents To receive this benefit, an eligible dependent must be under age 13 and:
are covered under the • Be enrolled in a licensed Child Care Program at time of death, or
family plan and you
die, and the Principal • Will be attending such a program within 365 days.
Sum is payable, the This benefit is payable every year (up to $10,000 per year for four years),
program will pay a provided the dependent child continues to be enrolled in child care and is under age 13.
Day Care Benefit to If a Day Care Benefit would be payable, but no person qualifies as an eligible dependent, the program will pay the minimum amount of $1,000,
each eligible according to the terms of the beneficiary section.
dependent.
Common If you and your spouse die as a result of injuries received in the same accident, and a Principal Sum is payable under the AD&D Benefit for each death, the
Disaster spouse benefit amount will be increased to an amount that equals the lesser of: (a)the Insured Employee’s Principal Sum; (b) or an amount which, if added to
the Insured Employee’s Principal Sum, would equal $300,000. The maximum additional benefit increase possible is $200,000.
Coma If you or your covered dependent become comatose within 31 days of a covered accident and remain continuously Coma means complete and
comatose beyond the Waiting Period of 31 days, the plan will pay 1% of the Comatose Maximum Benefit Amount for each continuous unconsciousness and
month you or your covered dependent remains in a coma. inability to respond to external or
Comatose Maximum Benefit Amount equals the Principal Sum less all other payments under the policy for injury. internal stimuli.
Adaptive Home • 2.5% of yours or your covered dependent’s Principal Sum This benefit will be payable only if: Private Automobile means a four-
and Vehicle • The actual costs; or • Such home alterations are made by a person or wheeled, private passenger car,
If you or your covered • $2,500 for the one-time cost of alterations incurred within persons with experience in such alterations and station wagon, pick-up truck, van or
dependents suffer a recommended by a recognized organization associated jeep-type automobile which is not
two years from the date of the accident to you or your being used as a Common Carrier.
loss other than death covered dependents to principal residence, and/or private with the Injury, and/or
and a Principal Sum automobile; to make the residence accessible or the private • Such vehicle modifications are carried out by a person Common Carrier means a
is payable, the automobile drivable for you or your covered dependents. or persons with experience in such matters and conveyance operated by a concern,
program will pay the approved by the Motor Vehicle Department. other than the Policy holder,
lesser of: organized and licensed for the
transportation of passengers for hire
and operated by an employee of that
concern.
Seat Belt If you or your dependents suffer a loss payable under the AD&D benefit, the program will pay an additional benefit of 10% Seat Belt means an unaltered belt,
of the Principal Sum, to a maximum of $10,000. The injury must have occurred while you were a passenger in or the lap restraint, or lap and shoulder
licensed operator of a registered automobile who was not intoxicated, impaired or under the influence of alcohol or drugs.; restraint installed by the manufac-
and occurred while wearing a Seat Belt, as verified in the police accident report. turer of the automobile.
At Work New York Life will pay an additional $25,000 benefit if an Actively-At-Work means you are performing all the regular duties of your occupation on a full-
Accidental insured’s death is a Covered Loss resulting from an injury that time basis at your regular place of employment or while on a Business Trip. Actively-at-Work
Death occurred while at full-time work. does not include everyday travel to and from work.
Business Trip means a bona fide trip while on assignment at the direction of your employer for
the purpose of furthering the business of your employer: a) which begins when you leave your
residence or place of regular employment, whichever last occurs, for the purpose of beginning
the trip; and b) which ends when you return to your residence or place of regular employment,
whichever first occurs.
Repatriation If you or your covered dependent dies outside your state of permanent residence, and the Principal Sum is payable, the plan will pay a Repatriation Benefit. This
benefit will be the lesser of 5% of your Principal Sum or $5,000.
Line-Of-Duty Member - If you are killed while at work, New York Life will pay an additional $125,000 benefit if an INSURED EMPLOYEE’S death is a Covered Loss and occurs
Death Benefit while he or she is performing the duties of his or her occupation.
CCPOA Benefit Trust Fund | 1-800-In-Unit-6 | www.ccpoabtf.org 25You can also read
