News & Changes

Active Members Summary of Benefits

Medical – Medical and Major Medical coverages are administered by Horizon Blue Cross Blue Shield of New Jersey.  This is a PPO Program (Preferred Provider Organization), where members are allowed to seek medical treatment with any doctor/hospital in the Blue Card PPO Network in their home state or outside of their home state, within the United States and Puerto Rico.    Members are urged to verify that their home state or out of state providers are participating in the Blue Card PPO Network of that state, prior to attaining treatment.  Please refer to the back of your Horizon Blue Cross Blue Shield PPO insurance card for helpful telephone numbers.  Below is a summary of your Medical out of pocket costs:

  • Copayments -  $25.00 Office Visit, $30.00 Specialist Visit
  • Annual Deductibles – $0 In-Network.  For Out of Network Basic Services and In-Network or Out of Network Supplemental Services (ambulance, durable medical equipment, etc.), there is a $500.00 individual / $1000.00 family combined deductible.  A 30% member coinsurance applies to the Out of Network Basic Services and a  20% member coinsurance applies to the Supplemental Services.
  • In-Network Coinsurance for Basic Services is 10%.  This means that the Plan pays 90% of the allowable charges and you are responsible for the remaining 10% of the allowable charges for Basic Services, with an annual $500.00 Out of Pocket Maximum (OOP) per person for In-Network Services.  The OOP does not include copayments and/or deductibles.

Mental Health and Substance Abuse Benefits – Your mental health and substance abuse benefits are administered by Managed Health Network (MHN).  These benefits provide access, when appropriate, to various types of individual and group care, such as sessions with counselors, psychiatrists or psychologists, acute care, partial hospitalization, intensive outpatient programs and day treatment programs.  Follow up treatment is also provided.  Members are responsible for a copayment for outpatient treatment.  Inpatient treatment requires pre-authorization and the annual In-Network Out of Pocket coinsurance applies, which is combined with the Medical coinsurance.  There is an Out of Network deductible applied to services where an Out of Network provider / hospital are utilized, which is also combined with the Medical deductible.  If you think you need help with a mental health or substance abuse issue, give them a call – 24 hours a day, 7 days a week at 800-327-6517.  

Prescription Benefits – Prescription coverage is administered by MagnaCareRx / PCA.  Your prescription discount card entitles you and your eligible dependents to purchase medications from your local pharmacy, through the RXDN Mail Order Program, or through the MagnaCareRx Specialty Pharmacy (please refer to the back of your prescription card for additional information and contact numbers).  Below is a summary of your prescription costs:

  • Retail Pharmacy (30 day Supply), 10% copayment, $5.00 minimum for generics, $15.00 minimum for formulary, $30.00 minimum for non-formulary prescriptions.  There is $75.00 maximum copayment for each retail prescription.
  • Mail Order Pharmacy (90 day Supply), 10% copayment, $10.00 minimum for generics, $30.00 minimum for formulary, $60.00 minimum for non-formulary prescriptions.  There is a $150.00 maximum copayment for each mail order prescription.
  • Specialty Pharmacy (30 day Supply), 10% copayment, $50.00 minimum, $100.00 maximum per each specialty prescription.

Vision Benefits – The Plan covers $250.00 per person every two years for a vision exam and one set of prescribed corrective lenses (either eyeglasses or contact lenses).  Laser vision correction is also covered with a $3,500 lifetime benefit for the member and one dependent over the age of 23.  These claims are processed by the Fund Office.

Dental Benefits – Your dental benefits are a fee-for-service arrangement.  The Plan pays benefits according to a Schedule of Covered Dental Procedures, which starts on page 58 of the Summary Plan Description (SPD).  These claims are processed by the Fund Office.

Short-Term Disability – The Plan’s Short-Term Disability (STD) benefits help protect you and your family from the financial consequences of illness or injury.  The weekly STD benefit is $120.00.  Benefits are payable if you are unable to work because of an injury or illness and are under the care of a licensed physician.  Please contact the Fund Office for an STD Form if you shall fall ill or are injured.  Please keep in mind that there is a 45 day timely filing period from the start of your disability.

Long Term Disability  –  The Plan’s long-term disability (LTD) benefits help protect you and your family from the financial consequences of a prolonged illness or injury.  LTD is offered to members who have completed 26 weeks of short-term disability benefits and are deemed totally and permanently disabled by a licensed physician.  The monthly LTD benefit is $400.00.  Please refer to your Summary Plan Booklet (SPD) for LTD Plan rules and regulations.

Self-Payment (Buy-In) – If the Participant has worked over 100 hours but less than 200 hours during a calendar quarter in any of the two calendar quarters prior to termination of benefits, the Participant has the option to buy the remaining hours at the applicable hourly Welfare Fund contribution rate.  A Self-Payment may be granted once per 12-month period.

Keeping the Fund Informed – The best way to ensure fast and accurate benefit payment and other services from the Fund Office is to make sure we have the most up-to-date information for you.  In particular, please contact the Fund Office whenever you or your spouse change names, change address, change marital status, dies, gains or losses other health coverage, whenever a dependent child becomes eligible (birth, adoption), or ineligible (reaches age 19, marries, etc..).

If you have any questions, please refer to your Summary Plan Description (SPD) and/or contact the Fund Office at 973-376-7230.

Please click here for further information

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