The Plan uses the Blue Cross of California as the Preferred Provider Organization. Self-Funded PPO Plan’s health coverage meets the minimum value standard for the benefits it provides.
Active Employees and Pre-Medicare Retirees
The Plan provides benefits for drugs or medicines, including insulin, that relate directly to the treatment of an illness of injury and that cannot be legally dispensed without a prescription and that by law must bear the legend “Caution – Federal law prohibits dispensing without a prescription”.
The Plan provides benefits through a contract with Maxor Plus which contracts for prescription drugs and insulin at discounted rates resulting in savings to the Participant and to the Plan. The Plan uses a copayment structure that reduces out-of-pocket costs when using generic drugs and preferred brand name drugs. When a prescription is filled at a participating Retail Pharmacy, the copayment will be at one of these tiers:
- Generic Drugs: The copayment is $10 for each prescription (up to a 30-day supply);
- Formulary Preferred Brand-Name Drugs: The copayment is 20% with a $15 minimum and a $25 maximum for each prescription (up to a 30-day supply);
- Non-Preferred Brand-Name Drugs / All Other Drugs: The copayment is 30% with a $30 minimum and a $75 maximum for each prescription (up to a 30-day supply).
For questions concerning Retail pharmacy prescription benefits, contact:
Maxor Plus Customer Service: 1-800-687-8629
Hospital, surgical, medical, short-term disability, and dental claims should be reported promptly to the Administrative Office, which has the forms for submitting proof of claim. Self-Funded Medical Plan claims are paid by the Plan Administrator. Therefore, your claim forms and bills should be submitted to this office. Claims personnel are available to answer any questions you may have. However, oral information and answers are not binding upon the Trustees and cannot be relied on in any dispute concerning your benefits.
Claims should be reported promptly to the Plan Administrator. Claims will be paid according to the Summary of Benefits, subject to any deductible. Remember that in certain cases you may apply the expenses incurred in the last three (3) months of one year against the deductible for the following calendar year.
The Plan will review each claim for approval or adjustment. After the claim is reviewed, and upon completion of the treatment, one of two actions will occur:
1. You will be reimbursed for the Plan’s share of the cost, provided benefits were not assigned; or
2. The provider will be reimbursed for the Plan’s share of the cost.
Claims received more than twelve (12) months after the expense is incurred will not be paid.
The Plan reserves the right and opportunity to examine the person whose injury or sickness is the basis of claim as often as it may reasonably require during the pendency of the claim.
The Plan reserves the right to allocate the deductible amount to any eligible charges and to apportion the benefits to you and any assignees.
Only benefits based on charges incurred may be assigned, and only the right to directly receive payment for covered services as provided for under the Plan is assignable. No other right a participant or beneficiary may have under this Plan, or under any applicable law, is assignable. Benefits may be assigned only to the institution or person that provides the services or supplies for which the benefits are payable. The Plan will not be responsible for the validity of an assignment. Satisfactory proof of the assignment must be given to the Plan before assigned benefits will be paid. If the Plan makes a payment before the proof of assignment is received, the Plan is released from all further liability for that claim payment.
No action at law or in equity shall be brought to recover on the Plans prior to the expiration of sixty (60) days after proof of loss has been filed, nor shall action be brought at all unless brought within two (2) years from the expiration of the time within which proof of loss is required by the Plan.