I don’t understand the difference between generic, Plan-preferred brand-name and non-preferred brand-name drugs.
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 Express Scripts 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.
Your co-pay is based on the status of your drug (generic, plan-preferred or non-preferred) and the quantity (number of days supply) you receive as well as your status as an active or retired Participant. Your co-pays are shown on the chart of covered services on the Medical Plan page.
Keep in mind that you can minimize your out-of-pocket expense by speaking with your physician about prescribing a generic or Plan-preferred drug for you whenever possible. You can find information about generic drugs and pricing details online at www.expres-scripts.com or by calling Express Scripts Patient Customer Service at (800) 818-0883.
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, if it involves maintenance medication. Once you have filled two prescriptions of the same drug at your pharmacy, you must then use the Express Scripts by Mail service for your prescriptions. Failure to do so will result in your prescription being denied at your local 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.
My doctor requires that I take a drug that is NOT Plan-preferred and for which there are no equivalent preferred brands or generics. Do I still have to pay the highest co-pay?
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.
If my doctor is monitoring the effectiveness of my medication, can I continue to get up to a 34-day supply from my local pharmacy until it is determined that a 90-day supply is necessary? (PHBP Medical Plan)
Yes. In this case, you can make a request to override the rule that only allows the first fill and one refill for a maintenance drug at a local pharmacy. Call the Joint Industry Board Members’ Records Department at (718) 591-2000, Extension 2491 to obtain a form to initiate a review.
Please refer to the chart of covered services on the Medical Plan page for co-pay amounts.
Under the PHBP Medical Plan, all hospital admissions and surgical procedures performed in a hospital facility or surgi-center require pre-certification through MagnaCare. Other services requiring pre-certification include:
- Specialized radiology procedures such as MRI, MRA, CAT, SPECT and PET Scans if determined by MagnaCare to be medically necessary to be performed in a hospital setting. If these services are not deemed to be medically necessary to be performed in a hospital, these services will not be covered in a hospital setting. They can be done in a free standing facility.
- Initiation of dialysis center placement
- Home health care or hospice in conjunction with a hospital discharge
- Durable medical equipment in conjunction with a hospital discharge
- Discharge planning
- Out-patient therapies, including physical, occupational, speech, cardiac, and respiratory therapies
The toll-free phone number for any pre-certification through MagnaCare is (877) 624-6210. Listen to the message prompts and press the selection for pre-certification.
Services that are not part of discharge planning require pre-certification directly through the Plan. These include:
- Home health care and hospice unrelated to a hospital discharge
- Sleep apnea treatment requests
- Durable medical equipment including but not limited to canes, crutches, wheelchairs and oxygen supplementation
To receive pre-certification for the above services, contact the Plan at (718) 591-2000, Extension 1350 or send a fax request to the Managed Care Coordinator at (718) 591-1107.
If you believe you have a serious medical or surgical problem, such as 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). Emergency room visits for non-emergency conditions will not be approved as medically necessary and will not be covered by the Pension, Hospitalization and Benefit Plan.
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 precertified and determined to be medically necessary through MagnaCare, your in-patient or Emergency Room hospital bills will be covered. All applicable co-pays will apply to such admissions.
It is the hospital’s responsibility to pre-certify all admissions by calling (877) 624-6210 once you have given them the information by presenting your ID card. Remind your provider to call for pre-certification 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 MagnaCare the required information, the facility will not receive payment from the Plan. The hospital/surgi-center can appeal to MagnaCare to receive payment but it must provide all of the documentation pertinent to your hospital admission. Scheduled procedures performed in a hospital should be pre-certified by the physician.
I am presently collecting Workers’ Compensation or disability. How long can I remain covered under the PHBP Medical Plan?
Participants covered under the PHBP Medical Plan who are on Workers’ Compensation can remain covered for up to two years from the date of their first Workers’ Compensation check, providing they are still collecting Workers’ Compensation. Participants who are on disability will remain covered for up to 26 weeks and may extend coverage up to two years if continuing proof of disability is provided.
Charges rendered by a Psychiatrist, PhD, or Social Worker ("MSW") are covered for active and retired eligible Participants for individual therapy. Reimbursement will be at the network allowance, less the co-pay.
All covered visits, both in and out-of-network, are subject to the $35 co-payment.
You may locate a MagnaCare participating mental health care provider by visiting their website at www.magnacare.com. or by calling them at (877) 624-6210.
A maximum of 30 office visits to a chiropractor will be covered in a calendar year for each family member.
My MagnaCare doctor visit was covered by the Plan, but MagnaCare denied the lab bill. Why did that happen and what should I do?
If you go to a physician for a non routine visit and diagnostic tests are prescribed by the physician, the tests are covered if the physician's visit is covered.
Sometimes in such cases, the physician does not put the diagnosis codes on the request you take to the drawing station, and the lab marks it as a routine diagnostic test. The claim may then get denied as a not covered routine test.
To guard against this possibility, please make sure the physician requesting the diagnostic tests is writing the appropriate diagnosis code on the request he sends you with and the drawing station records it.
In spite of all precautions, if you are in a situation where the physician's claim is paid but the diagnostic claim has been denied, please call the MagnaCare customer service line at 1-877-624-6210 and mention that you have a "diagnostic denial" claim issue. Please have ready the name of the physician you visited who prescribed the diagnostic tests and the date of the visit.
For in-network claims, you will be responsible for only four (4) co-payments of $35 per incident or illness.
Out-of-network claims are paid according to the MagnaCare fee schedule and are subject to the same co-payments as in-network claims. All remaining balances are the participant's responsibility.
You may locate a MagnaCare participating physical therapist by visiting their website at www.magnacare.com. or by calling them at (877) 624-6210.
All therapies must be pre-approved by MagnaCare. Please call (877) 624-6210. Claims will not be paid unless prior approval from MagnaCare is obtained.
How am I and my family covered if I am retired, living out-of-state and not yet eligible for Medicare?
In addition to hospital and out-of-network coverage, non-Medicare eligible retirees and their families that live in all states will have access to in-network medical, physician and surgical benefits. All retirees who have not become eligible for Medicare or who have non-Medicare eligible dependents should receive a card pertaining to the Preferred Provider Organization ("PPO") in their state. If you live out-of-state and have not received this card, you may call the Joint Industry Board, Members Records Dept. at (718) 591-2000, Extension 2491.
All Participants should call MagnaCare's dedicated Local Union No. 3 service line at (877) 624-6210. Submit claims to MagnaCare at P.O. Box 1001, Garden City, NY 11530.
I am having trouble finding an in-network provider on the MagnaCare website. Who can I call for help?
You can call MagnaCare Advocacy Services for assistance at (866) 624-6260.
Can I send co-pays or balances due from out-of-network claims that have been paid by MagnaCare to the Pension, Hospitalization and Benefit Plan for reimbursement?
No, but if you have a Health Reimbursement Account, you may submit to that Fund.
There is no need to submit claims when Medicare is your primary insurance for dates of service rendered on or after 8/1/2011. Secondary claims are paid by MagnaCare on an automatic crossover.
If I am a retiree, who do I call if I have questions about the crossover or outstanding Medicare secondary claims?
For dates of service on or after August 1, 2011, you should call MagnaCare's dedicated Local Union No. 3 service line at (877) 624-6210.
Yes, paper claims need to be filed for the following services: Covered services rendered by the Veteran's Administration; the shingles (Zostavax) vaccination; hearing aid devices; diabetic needles and syringes; foreign travel claims; and coordination of benefit claims.
