Employees Security Fund Medical, Prescription Drug and Dental Plan (for members of the Fixture, Manufacturing, or Supply Divisions) FAQs

Your co-pay is based on the status of your drug and the quantity (number of days supply) you receive. Your co-pays are shown on the ESF Medical plan page.

You can minimize your out-of-pocket expense by speaking with your physician about prescribing a generic or Plan preferred formulary drug for you whenever possible. You can find information about generic drugs and pricing details online at www.express-scripts.com or by calling Express Scripts Member Services at (800) 413-7402.

Generic drugs are manufactured after the original manufacturer’s patent expires. These drugs are safe, effective and FDA-approved to meet the same rigorous standards for quality, strength and purity as their brand-name counterparts. They are less expensive because the generic manufacturer does not have the investment costs of the developer of a new drug.

Plan-preferred brand-name drugs are those that do not yet have a generic equivalent available and are preferred based on safety, effectiveness and cost. An independent Medco committee of physicians and pharmacists determines which brand-name drugs are preferred. They are included on a drug list know as a formulary.

Non-preferred brand-name drugs are those that do not yet have a generic equivalent, but for reasons of effectiveness or cost, are not on your Plan’s formulary drug list.

In order to qualify for coverage, certain medications require pre-certification in order to determine the appropriateness of the drug in treating your condition. If you file your prescription through Express Scripts, their pharmacist will initiate the pre-certification review with your doctor. If you visit a retail drugstore, your pharmacist will let you know if your medication requires pre-certification. If so, your doctor must call a special toll-free number at Express Scripts to initiate a review. This process typically takes one or two business days. Once the review is complete, Express Scripts will notify you and your doctor of the decision. If the review is approved, you will receive a letter indicating the length of approved coverage. If the review is denied, the letter will include the reason for denial and instructions on how to submit an appeal if you choose.

The Plan does not cover weight-loss medications (such as Xenical® and Meridia®), erectile dysfunction medications (such as Cialis®, Levitra®, and Viagra®), fertility medications (such as Clomid® and Repronex®), non-sedating antihistamines (such as Allegra®, Clarinex®, and Zyrtec®) and vitamins. If one of these medications is medically necessary, you may call the Joint Industry Board Members’ Records Department at (718) 969-4030 to obtain a form for you and your doctor to complete and submit to the PHBP Medical Plan for medical review.

Yes. Once you have filled two prescriptions of the same drug at your pharmacy, you must then use the Express Scripts Mail service for your prescriptions. Failure to do so will result in your prescription being denied at the pharmacy.

Yes. The list of maintenance drugs is monitored by Express Scripts and changed periodically. For example, GI drugs (such as Nexium, Protonix, omeprazole) have been added to this list. Insulin is no longer on the list. Express Scripts will now advise you when your medication either goes on or comes off of the maintenance drug list. Once a drug comes off the list, you may purchase it at your retail pharmacy. Prescriptions for maintenance medications must be mailed to Express Scripts after the first fill and one refill.

If this occurs, you can call the Joint Industry Board Members Records Department at (718) 591-2000, Extension 2491 to obtain a form to initiate a review to determine if the preferred brand co-pay applies.

The vision benefit entitles you, your legal spouse and eligible children to an eye examination once each year by an optometrist or an ophthalmologist and, if prescribed, one pair of eyeglasses each year. You may receive vision care services in the following ways:

• Optical services (optometrist for examination and optician for eyeglasses) at JIB Medical, P.C.  If you go to JIB Medical, P.C., there will be no charge to you and you do not have to file a claim form with: 
  
      Electrical Industry Center,
      158-11 Harry Van Arsdale 
      Jr. Avenue, Room 201
      Flushing, NY 11365 
  
  To schedule an optical appointment, contact JIB Medical P.C. at (718) 591-2014 from Monday-Friday, 8:00 A.M. to 5:45 P.M. and Saturday from 8:00 A.M. to 3:00 P.M. Appointments should be made approximately 2 weeks in advance.
• You may also use a provider who belongs to the Vision Screening Optical Group. These providers offer optometric eye care to participants, their legal spouses and eligible children living in New York, New Jersey and Florida. Their service includes one eye examination by an optometrist and, if prescribed, a pair of eyeglasses (mono-focal or bi-focal) and a selection of frames once a year. If you use this method and you buy supplies or services for which you are not eligible or covered, you will be responsible to pay these charges, but you will receive a 20% discount. To use a Vision Screening provider, please contact the Fund Office at (718) 591-1100 to request an optical voucher. OR
• You may also use a panel optical provider located in New Jersey. Their service includes one eye examination by an optometrist and, if prescribed, a pair of eyeglasses (mono-focal or bi-focal) and a selection of frames once a year. If you obtain the benefit in this way there will be no charge to you. You do not have to file a claim form. Please contact the Fund Office at (718) 591-1100 to request an optical voucher for a New Jersey panel provider. OR
• You may have an eye examination by any other optometrist or ophthalmologist, licensed and practicing in the United States or its possessions. You may purchase eyeglasses, if necessary, from any licensed facility operating in the United States or its possessions. If you use this method, you must file a claim form with the Fund Office. The Plan will reimburse you or your optical provider according to the Plan’s fee schedule.

This benefit enables you, your legal spouse and eligible children to obtain, once each year, a physical examination for diagnostic purposes only. The Diagnostic Medical Benefit provided by the Plan is available in the following ways:

• You may use JIB Medical, P.C. located at: 
  
      Electrical Industry Center,
      158-11 Harry Van Arsdale Jr. Avenue, Room 201
      Flushing, NY 11365 
  
  To schedule an optical appointment, contact JIB Medical, P.C. at (718) 591-2014 from Monday – Friday, 8:00 A.M. to 6:00 P.M. and Saturday from 8:00 A.M. to 2:30 P.M. Appointments should be made approximately 2 weeks in advance.
• You may use the diagnostic medical services available at a facility located in New Jersey or Long Island through the following: 
  • Morristown Hospital is located at 100 Madison Avenue, Morristown, NJ 079
  • Professional Evaluation Medical Group (“PEMG”) is located in Manhattan, Nassau and Suffolk Counties. Call 516-935-4378 to make an appointment. It is not necessary to file a claim for this benefit. This is a paid in full benefit subject to Plan limitations as described below.

• You may also use any medical doctor or doctor of osteopathy licensed and practicing in the Unites States or its possessions. If you use this method, you must file a claim form. The Plan will reimburse you or your doctor up to a maximum of $125 for a person age 14 and over, and up to a maximum of $60 for a child under age 14.

Retirees who are eligible for Medicare must submit their charges to MagnaCare before submitting them to Medicare for payment.

Review the Plan C highlights brochure. For a complete listing of co-pays, please refer to your Summary Plan Description.

All hospital admissions of any type and all surgical procedures performed in a hospital facility or surgi-center require pre-notification through Anthem-Blue Cross. Anthem-Blue Cross must be notified of any Emergency Room visit within 24 hours after the visit occurs. In addition, some specialized radiology procedures such as SPECT and PET scans and CAT scan, MRI and MRA only if performed in a hospital facility require pre-notification through Anthem-Blue Cross. The toll-free number for any pre-notification through Anthem-Blue Cross is (844) 243-5566. Listen to the message prompts and press the selection for pre-notification. Specially trained nurses are available 24 hours a day, seven days per week.

It is the responsibility of the hospital to pre-notify all admissions by calling (844) 243-5566 once you have given them the information by presenting your ID card. Remind your provider to call for pre-notification when you know that you will be admitted. If it is an emergency visit, the facility may call within 24 hours after the admission. If the hospital or surgi-center fails to call and give Anthem-Blue Cross the required information, the facility will not receive payment from the Plan. The hospital/surgi-center can appeal to Anthem-Blue Cross to receive payment, but it must provide all of the documentation pertinent to the admission.

All claims, for services rendered by both MagnaCare and non-MagnaCare providers, must be submitted to MagnaCare at:

MagnaCare, Inc.
1600 Stewart ave #700
Westbury, NY 11590

MagnaCare providers will submit the claim directly to MagnaCare on your behalf. If you use a non-MagnaCare provider, you must submit an itemized bill attached to a claim form. Expenses must be considered appropriate for insurance purposes. They must be itemized and indicate diagnosis and procedure codes (ICD9 and CPT codes).

Please note that statements that include only a previous balance, a balance due or a collection agency notice are not acceptable.

If you believe you have a serious medical or surgical problem, such as a new onset of chest pain or severe pain in your abdomen that has been getting worse over the past several hours and you cannot reach your doctor, it is reasonable to go to the Emergency Room for assistance. The hospital must do a medical screening evaluation prior to determining your medical coverage (as mandated by federal law). After you are seen, advise the doctor/facility that they must call the Anthem-Blue Cross pre-notification number (844-243-5566) within 24 hours after the visit to provide information about your diagnosis and reason for seeking emergency medical care. This information is indicated on the back of your Anthem-Blue Cross card. Emergency room visits for non-emergency conditions will not be approved as medically necessary and will not be covered by the Employees Security Fund.

Examples of true emergencies include premature labor, significant bleeding from any site, broken bones, losing consciousness, new onset of seizures or seizures that are not being controlled and difficulty breathing.

As long as the admission is pre-notified and determined to be medically necessary through Anthem-Blue Cross, your in-patient or Emergency Room hospital bills will be covered. All applicable co-pays will apply to such admissions.

No. You can use your dental benefits in either of the following ways:

• You may use the dental facilities of DDS, Inc. (“DDS”), a closed panel of participating dentists who agree to accept the Plan’s dental allowances for covered services as payment in full. If you do this, you do not have to file a Dental Benefit Request Form. Call DDS at (800) 255-5681 for information.
• Or, you may use any licensed dental facility in the United States or its possessions. The cost of this treatment is paid for by the Plan up to the limits of the dental allowances for covered services. Any out-of-pocket expenses incurred as a result of using a non-DDS provider will be the patient’s responsibility.

Yes. You and your eligible dependents each have a $1,500 annual maximum on all dental worked performed in a single calendar year. All charges above the $1,500 annual maximum are the patient’s responsibility, regardless of whether or not the service was performed by a DDS provider or a non-DDS provider.

Yes. You and your eligible dependents each have an annual $50 deductible on services that are not preventative or basic.

Yes. All crown, bridge, prosthetics, osseous surgery or root canal services require pre-authorization. A DDS dentist will automatically obtain pre-authorization for you. To obtain pre-authorization for services provided by a non-DDS dentist, have your dentist list the required dental work and fees on a Dental Benefit Request Form. All relevant x-rays must be attached to this form. Sign the form, and send it to DDS, Inc., located at 265 Post Avenue Suite 340 Westbury NY, 11590.  DDS will then review the case, notify the dentist of the total amount that the Plan will pay for the dental work and the portion that the patient will be responsible for. X-rays will be returned to the dentist.

Preventative or basic services include:

• Examinations
• X-Rays
• Fillings
• Prophylaxis
• Pulp Cap Fillings
• Simple Extractions
• Cementing of Crowns and Bridges
• Palliative Treatment to Prevent Pain

Participants covered under this Plan may be covered up to 26 weeks when out on Workers’ Compensation or disability.