Thursday, April 2, 2026

Frequently Asked Health Care Questions


Q. Will my child who is age 19 to age 26 be covered under the Plan? 
A. Effective January 1, 2011, the Plan will cover your children until age 26 (up from previous age limitations of 19 or 24 if a fulltime student) regardless of whether they are married, primarily dependent on you for financial support, living with you or enrolled in school.
Q. Who are my eligible dependents? 
A.
  • Your lawful spouse
  • Your natural children (until age 26 regardless of whether they are married, primarily dependent on your for financial support, living with you or enrolled in school).
  • Your legally adopted children
  • Your step-children
  • Child for whom you have been appointed legal guardian by court
  • Unmarried children-regardless of age-who are totally disabled
Q. When do I become eligible for benefits?
A.
Schedule 1 - 120 minimum qualifying hours (minimum 1 month worked)
Schedule 1A - 260 minimum qualifying hours (minimum 2 months worked)
Schedule 2 - 290 minimum qualifying hours (minimum 3 months worked)
Example of when coverage would begin:
RequirementsSchedule 1Schedule 1 ASchedule 2
Minimum Qualifying Hours120 hours260 hours290 hours
Minimum Qualifying Period1 Month2 Months2 Months
Coverage Begins3rd Month4th Month4th Month
Q. How do I find a physician or find out if my doctor participates in the Blue Shield network? 
A.

Visit the Blue Shield website, blueshildca.com/networkppo, and follow the easy online instructions below to find the type of provider you want. You may also call the Trust Fund Office toll free at 866-787-0162.

  • Go to blueshildca.com/networkppo
  • Select the type of provider that you are searching for
  • Click on Advanced Search to further filter your search, such as by name or specialty
  • Enter your city and state or ZIP code, then click Find now
  • The default distance/radius search is 15 miles. To expand or narrow the search radius, click zoom (+ or - ) in the map on the provider search results page.
  • To view the website in Spanish, go to blueshieldca.com/networkppo and click En Español at the top of the web page

Q. What address do I use to send my claims [Medical/Dental]?
A.
Medical:
Blue Shield of California
P.O. Box 272540
Chico, CA 95927-2540
Dental
Please contact your dental carrier for their claims address. 
Q. How do I find a provider for vision services through VSP?
A.By visiting www.vsp.com or contacting 800-877-7195. Benefit information is also available from the website or by contacting the phone number.
Q. How do I view my claims?
A.

In the navigation menu on the left side of this website click "Log On". After you log in your cliams information will be available by clicking "Your HW Claims Information" under the Member Information heading.

Note: Members will be able to view their claims and the claims of their minor dependents. Spouse and dependents over 18 will have to log in to view their claims. 

Q. I still have refills available on my current prescriptions, what do I do? What about mail order prescriptions?
A.Present your new id card at your regular pharmacy. Your pharmacist will verify your prescription with OptumRx and process accordingly. Call the OptumRx Help Desk at 1-800-573-0437 for further assistance.
Q. What if I become disabled? 
A. There is a disability freeze benefit that provides free coverage to you and your family when you are off work due to a disability or on the job injury. It freezes your reserve hour bank so you do not have to use these hours to give you coverage. This benefit will freeze your reserve hour bank for up to 12 months for the same disability.
Q. Why did the Trustee's change from WellDyneRx to OptumRx?
A. This decision was made because of cost and service issues with WellDyneRx. The Trustees have considered this decision carefully, and feel that making this change is in the best interest of the members and of the Plan.
Q. How do I get reimbursed if I paid out of pocket for a prescription?
A.Go to Forms and print the OptumRx Claims Form or contact OptumRx at 1-800-573-0437 and request form be mailed. Fill out completely and mail to the address given. Please allow 30 days for claims processing.
Q. How do I get a copy of the Preferred Drug List? 
A. You can visit OptumRx website at www.OptumRx.com 
Q. I lost my prescription id card, how do I get a replacement? 
A.  Call the OptumRx Help Desk at 1-800-573-0437 for assistance. 
Q. I just called my pharmacy for a refill and my prescription cost is different with OptumRx. Isn't my coverage the same? 
A. The plan benefit remains the same, but the preferred drug lists are not identical. There may be instances of higher costs under the new plan. We recommend that you discuss your situation with your physician to see if switching to one of the recommended drugs is appropriate. 
Q. I have a question about my co-pay? Who do I call? 
A. Call the OptumRx Help Desk at 1-800-573-0437. 
Q. How do I find a local pharmacy? 
A. Participating pharmacy information may be obtained by visiting the OptumRx website at www.Optum.com and clicking on ‘Find a Pharmacy’ or by calling the OptumRx Help Desk at 1-800-573-0437.  
Q. How do I get a Mail Order prescription? 
A. A mail order program is also available under the OptumRx drug program. 
Q. As a Kaiser member, can I get my eye exam and materials with Kaiser? 
A. As a Kaiser member, you may get your eye exam in a Kaiser facility. However, a claim must be submitted to the Trust Fund Office for materials, lenses and frames. 
Q. If I have Medicare, who does my provider submit the claim to? 
A. When Medicare is primary, your provider will need to submit to Medicare first. Upon Medicare's payment/denial, they will then need to submit to Sheet Metal Worker's. Sheet Metal Worker's is your supplemental insurance.  
Q. How long should I wait for claim status to show on the website? 
A. Normally, you will see claim status in about 15-25 days upon receipt of the claim. 
Q. What if I do not see the status of a claim I am checking on? 
A. One of the most common reasons for not being able to view a claim status is the provider has not submitted the claim. This may be due to a wrong address to where the provider is submitting the claim. Or it may have to be re-submitted. You may call your provider of service and inform them that they may need to re-submit a particular claim.  
Q. How do I know the reason on why a claim has not paid? 
A. You are able to view the Explanation of benefit for each claim that has been received. On this Explanation of Benefits (EOB), under Reason Code: it will explain the cause of why an entire claim was denied or a line item. If you need further explanation you may call the Trust Fund office. 
Q. What number do I call for claim status? 
A. 1-866-787-0162 
Q. What do I need to do in order to get a disability freeze? 
A. 
You need to get a note from your doctor or you can have your doctor fill out the disability certification form located under the "Forms" section and mail or fax it in to the Plan office. We will need the required information below in order to freeze your hours:
  1. Diagnosis
  2. Disability dates (From and To) if your doctor does not know when you will be returning to work, we will need an estimated date.
  3. Doctor's signature  
Q. What documents are required to add a new dependent to my Plan? 
A. 
Spouse – copy of your marriage certificate
Child – copy of your child’s birth certificate
If you are enrolling a newborn, a hospital certificate will be good for 90 days from date of birth, and then we will need a copy of the original birth certificate.
Step-child – Proof that you cover more than ½ of the child’s support. Acceptable documents may include proof of residency from child’s school, tax return claiming child, divorce papers stating that parent is required to provide health insurance.
Adopted child – A copy of the legal adoption papers from the court or a letter from the adoption agency stating the date the child was placed in the home if the legal process has not been completed yet. Upon completion of the legal adoption, the Plan office will need a copy of the legal adoption papers.  
Q. How do I add my new baby or spouse to my insurance plan? 
A. You must fill out an enrollment form. You can download one off of this website located under "Forms" and mail it into the Trust Fund Office. Please attach all required documentation (see below). 
Q. Whom should I call if I have questions about my eligibility?  
A. The Plan Office at: (925) 208-9992 or (866) 787-0162 
Q. How can I have my address changed? 
A. You can simply complete the Address Verification Change Form located on the website and mail it to the Pension Department at P.O. Box 1677, San Ramon, CA 94583.