The Employees’ Security Fund (ESF) Health and Welfare Medical Plan offers two levels of coverage: Plan “A,” and Plan “C.” The level of coverage that applies to you is determined by the collective bargaining agreement held with your employer. The information provided below provides the highlights of the ESF Health and Welfare Plan applicable to both levels of the Plan, unless otherwise noted. For a detailed schedule of covered expenses under each plan, please refer to the appropriate section of the Summary Plan Description.
Plan Overview
Your Eligibility
You are eligible after 26 consecutive weeks of full-time work. Thereafter, at least 26 weeks of contributions out of the past 52 must be received in order for you to remain eligible. If you are unemployed during all or any portion of this time, you must be registered as available for employment. To be eligible, you must complete an enrollment form and submit applicable documentation.
If you are a retired participant, you and your eligible dependents are only eligible for dental, optical, prescription drug and annual diagnostic medical benefits.
Dependent Eligibility
You can cover your spouse and children. Once you meet the eligibility requirements and enroll, you are able to cover your spouse and dependent children according to the rules of the Plan.
Find a Doctor for Plan C
If you are covered under Plan C, you will have lower out-of-pocket expenses when you use a provider who participates in the MagnaCare Preferred Provider Organization.
To find a MagnaCare network provider, use the MagnaCare Provider Locator tool. You can also obtain a list of participating providers by contacting MagnaCare at (800) 548-0138.
Find a Surgeon
You will have lower out-of-pocket expenses if you use a provider who participates in the MagnaCare Preferred Provider Organization. You can obtain a listing of these participating providers by contacting MagnaCare at (800) 548-0138 or www.magnacare.com.
Pre-notification
Plan C requires pre-notification of certain services including hospital admissions and any surgical procedure performed at a hospital or surgi-center (both in-patient and out-patient).
Plan A does not require pre-notifications.
Plan A and C Benefits
Covered Services
Plan A: In-patient and out-patient hospital charges, as well as, surgical and other benefits are covered.
Plan C: Most services are covered within the MagnaCare network. Physician’s office visits (for non-preventive care) are covered in and out of network and are subject to a $50 co-payment.
Prescription Drug effective 01/01/2024
Retail Pharmacy
The Express Scripts Network covers the cost of prescriptions, except for the applicable co-pay:
- Generic: $20
- Plan-Preferred Brand Name: $35
- Non-Preferred Brand Name: $60
Express Scripts Mail Service
If you are using a maintenance medication to treat illnesses such as high blood pressure or arthritis, you can have your prescription filled for a 90-day supply through the mail-order program. The cost to you is only the applicable co-pay:
- Generic: $70
- Plan-Preferred Brand Name: $115
- Non-Preferred Brand Name: $185
Dental
Use a network provider. If you and your eligible dependents use a dentist who participates in the DDS, Inc. panel, your out-of-pocket expenses will be limited and you will not have to submit a claim form.
The dental benefit includes:
- a $1,500 annual maximum on all dental work performed in a single calendar year(excluding pediatric); and
- a $50 annual deductible on services that are not preventative or basic.
To find a dentist who participates in the DDS panel, call (800) 255-5681 or log on to http://www.ddsinc.net/ (password: 3)
If you use a non-DDS provider, out-of-pocket expenses are your responsibility.
Diagnostic Medical Services through JIB Medical, P.C. or Other Facility
Get a free check-up. You and your eligible dependents can receive an annual physical exam for diagnostic purposes only. This exam is available through any of the following:
- JIB Medical, P.C.
- Diagnostic medical services available at an approved facility located in New Jersey or Long Island
Vision Benefits at JIB Medical, P.C. or Other Facilities
Free exams and eyeglasses. If you use JIB Medical at JIB, you and your eligible dependents can receive an annual eye exam and, if prescribed, one pair of eyeglasses at no cost. You do not need to file a claim for this benefit.
If you use an optical provider who belongs to either the Vision Screening Panel or the approved New Jersey panel, covered benefits will be paid in full. To obtain benefits from a panel provider please contact the Fund Office at (718) 591-1100 to request an optical voucher.
If you receive vision benefits outside the Medical Department, you will be responsible to pay any applicable expenses.