Members

TeamstersCare/Dental Blue Freedom

Dental Blue Freedom Summary of Benefits 2025 Full Dental Fee Schedule 2025 Abbreviated Dental Fee Schedule

Member Forms

Request for a Certificate of Creditable Coverage Change of Address Form Change of Beneficiary Form Request for Additional Information/Possible Third Party Claim Form Blue Cross Blue Shield Fitness & Weight Loss Reimbursement Form Authorization to Release Health Information Glossary of Health Coverage and Medical Terms

Pharmacy Forms

Chantix Reimbursement Form Prescription Drug Direct Payment Claim Form for Retirees Age 65 and Over Express Script Claims Form Q&A About Prior Authorization

Summaries of Benefits & Coverage

BCBS SBC ACTIVE HMO BLUE NEW ENGLAND BCBS SBC ACTIVE BLUE CARE ELECT PREFERRED BCBS SBC MSTS HMO BLUE BCBS SBC MSTS BLUE CARE ELECT PREFERRED BCBS SBC EARLY RETIREE HMO BLUE BCBS SBC EARLY RETIREE BLUE CARE ELECT PREFERRED

Summary Plan Descriptions

SPD – Active Members SPD – MSTS SPD – Active Dental/Vision Program SPD – Early Retiree Medical Program SPD – Over Age 65 Retiree Prescription Drug & Retiree Clinical Services and Vision Program

Member Notices

TeamstersCare Notice of Privacy Practices (HIPAA) Notice of Creditable Coverage Summary Annual Report TeamstersCare a Grandfathered Plan Under the Affordable Care Act Medicaid and the Children’s Health Insurance Program (CHIP) Notice Patient Protection Disclosure No Surprise Billing Notice

Providers

Please include a copy of most recent office notes with each prior authorization.

Continuous Glucose Monitoring Systems Prior Authorization Form General Medication Prior Authorization Request Form Medication Assisted Treatment Prior Authorization Form PCSK9 Inhibitor Prior Authorization Request Form Specialty Medication Prior Authorization Request Form Testosterone Replacement Prior Authorization Request Form Weight Loss Agents Prior Authorization Request Form Q&A About Prior Authorization

Enrollment Materials

Active Members

BCBS SBC ACTIVE HMO BLUE NEW ENGLAND BCBS SBC ACTIVE BLUE CARE ELECT PREFRRED Benefit Highlights Active HMO Benefit Highlights Active PPO Davis Vision – Benefit Summary Davis Vision Provider List Davis Vision Welcome Letter Dental Blue Freedom Fee Schedule Dental Blue Freedom Benefit Summary Summary Plan Description Active Summary Plan Description Insert Updated Address TCare in-House Audiology Brochure TCare Dental Brochure TCare EAP Brochure TCare Pharmacy Brochure

MSTS (Moving/Storage & Trade Show) Members

BCBS MSTS SBC Blue Care Elect Preferred BCBS SBC MSTS HMO Blue Benefit Highlights MSTS HMO Benefit Highlights MSTS PPO Davis Vision Benefit Summary Davis Vision Provider List Davis Vision Welcome Letter Dental Blue Freedom Fee Schedule Dental Blue Freedom Benefit Summary Eligibility Highlights MSTS Pharmacy ESI Mail Order Form Summary Plan Description MSTS TCare in-House Audiology Brochure TCare Dental Brochure TCare EAP Brochure TCare Pharmacy Brochure MSTS

Dental, Vision & In-House Audiology

Welcome Letter Benefit Highlights Davis Vision Benefit Summary Davis Vision Provider List Davis Vision Welcome Letter Dental Blue Freedom Fee Schedule Dental Blue Freedom Benefit Summary Summary Plan Description Dental Vision Summary Plan Description Insert – In-House Audiology Summary Plan Description Updated Address TCare in-House Audiology Brochure TCare Dental Brochure

Early Retiree Medical Program

80-Hour Contribution Limit Notice BCBS ERMP SBC Blue Care Elect Preferred BCBS ERMP SBC HMO Blue New England Benefit Highlights Early Retiree HMO Benefit Highlights Early Retiree PPO Comparison of Active vs Early Retiree Program Davis Vision Provider List Davis Vision Welcome Letter Deferral Rules Pension Auto Deduction Form Pharmacy ESI Mail Order Form Summary Plan Description ERMP Summary Plan Description Insert New Address TCare in-House Audiology Brochure TCare Dental Brochure TCare EAP Brochure TCare Pharmacy Brochure TCare Retiree Brochure

Retiree Prescription Drug or Clinical Services & Vision Program

80-Hour Contribution Limit Notice Benefit Highlights Retiree Clinical Services & Vision Benefit Highlights Retiree Prescription Drug Davis Vision Provider List Davis Vision Welcome Letter Pension Auto-Deduction Authorization Summary Plan Description RRX-RDV Summary Plan Description Insert New address TCare in-House Audiology Brochure TCare Dental Brochure TCare EAP Brochure TCare Pharmacy Brochure TCare Retiree Brochure
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