This section summarizes the various types of benefits available to you as a Non-Medicare eligible participant in the Goodyear Retiree VEBA Health Care Plan.
A complete description of the Plan benefits is contained in the Plan Document. In the event of any conflict between the summarized version of these benefits in this Trust Benefits section of the website and the Plan Document, the terms of the Plan Document shall govern.
Your medical benefits are provided through the Highmark Blue Cross Blue Shield National PPO Program. Under the PPO program you are not required to select a primary care physician and you have access to a large network of physicians, hospitals and other medical care providers throughout the country.
The PPO program offers both In-Network and Out-of-Network benefits. For a higher level of coverage, you need to receive care from a network provider. However, you can go outside the network and still receive care at the lower level of coverage. To locate a network provider near you, or to learn whether your current physician is in the network, call 1-800-810-BLUE (2583) or log onto Highmark’s Web site, www.highmarkbcbs.com.
Another important feature of the PPO program is that the plan encourages you to stay healthy by covering preventive care at 100%. Preventive care plays a key role in identifying potentially serious health risks at an early, more easily treatable stage. You are covered for a range of preventive care, including physical examinations and selected diagnostic tests. Preventive care is a proactive approach to health management that can improve your health status and save you medical expenses down the road. For more information on preventive care, please visit the Wellness and Prevention section under Trust Participant Resources.
Medicare Parts A & B Medical Coverage
When you become eligible for Medicare, you must enroll in both Medicare Parts A and B as soon as you become eligible in order to receive the maximum benefits under the Plan. When you are eligible for Medicare, the Plan pays claims as if you are enrolled in Medicare, whether or not you are actually enrolled. This means that if you are eligible for Medicare but are not enrolled, you will have significantly higher out-of-pocket medical expenses.
When you receive your Medicare card, you must send a copy to the Trust Administration Office.
Filing a Claim
If you receive services from a network provider, you will not have to file a claim.
If you receive services from an out-of-network provider, you may be required to file the claim yourself. If you need to file a claim yourself, you must request a claim form. These forms are available from the Trust Administration Office at 1 (866) 694-6477, or by calling the Highmark Member Service Department at 1 (888) 334-5027. Once you complete the claim form, you should attach all itemized bills to the claim form and mail everything to Highmark Blue Cross Blue Shield, PO Box 1210, Pittsburgh, PA 15230.
Explanation of Benefits (EOB) Statement
Once your claim is processed, you will receive an Explanation of Benefits (EOB) statement from Highmark. This statement lists: the provider’s charge; allowable amount; copayment; deductible and coinsurance amounts, if any, you are required to pay; total benefits payable; and the total amount you owe.
For information on how to read your Explanation of Benefits statement, click here.
If you have questions about your medical plan, need to request a new identification card, have an issue with a medical claim or need to locate a participating provider, the Highmark Members Services team can assist you. To reach a Highmark Member Services representative, please call 1 (888) 334-5027. This number is printed on the back of your identification card.
Prescription Drug Coverage
Your prescription drug benefit is administered by CVS Caremark. Prescription drug benefits will be provided if a Participant, as a result of an accident or sickness, incurs expenses for covered prescription drugs dispensed by any person or organization legally licensed to dispense drugs upon the order of a physician licensed to practice medicine, subject to the rules and limitations set forth by the Plan.
The Caremark Prescription Drug Plan offers you the choice of having your prescriptions filled from three different sources:
- at a participating network pharmacy, or
- at a non-network pharmacy, or
- through either the Caremark Mail Order service or at a participating CVS “Maintenance Choice” pharmacy.
Your required copayment amounts will vary, depending on which option you choose.
If you fill your prescription at a participating network pharmacy, your claim will be processed automatically and you will be required to pay only the applicable copayment amount, depending on whether you obtain a brand name drug or a generic version.
If you use a pharmacy that is not part of the Caremark network, you may have to pay the full cost of the drug at the pharmacy. In this case, you must complete a paper claim form and submit it to Caremark within three (3) years of the date you filled your prescription. You will not be reimbursed for the difference between the discounted rate and the cost you paid.
Mail Order Service for Maintenance Medications
If you take maintenance medications for the treatment of a long term or chronic medical condition, you must obtain those medications (after the initial 30 day supply and one 30 day refill) through the Caremark mail order pharmacy program, or you may take advantage of the CVS pharmacy Maintenance Choice Program
The Maintenance Choice program provides participants who are taking maintenance medications the opportunity to purchase up to 90-day supplies through a CVS retail pharmacy.
To locate a CVS pharmacy near you, go to www.cvs.com and click on Store Locator.
If you have any questions about your prescription drug plan, please contact CVS Caremark Customer Care at 1 (855) 654-0302.
The Trust provides you with coverage for a limited range of dental services through Delta Dental. You dental plan provides coverage for services such as:
- Periodontic Services – to treat gum disease
- Endodontic Services – includes root canals
- Oral Surgery Services – extractions and dental surgery
- TMJ Treatment – treatment of the disorder of temporomandibular joint
- Other Radiographs – other x-rays
Benefits for temporomandibular joint disorders (TMJ) are limited to those services normally provided by a dentist to relieve oral symptoms associated with malfunctioning of the temporomandibular joint, including appliance therapy and surgical correction. This does not include services that would normally be provided under medical care. Predetermination is required when TMJ treatment will exceed $250 or no coverage will be made.
All oral surgery services performed by a dentist are Covered Services, including IV sedation and general anesthesia when performed in conjunction with periodontic, endodontic, and oral surgery services.
Selecting a Dentist
To verify that a Dentist is a Participating Dentist or a Premier Dentist, you can use Delta Dental’s online Dentist Directory at www.deltadentaloh.com or call 1 (800) 524-0149.
If you have any questions regarding your dental benefits or need assistance with filing a dental claim, please contact Delta Dental at 1 (800) 524-0149.
Summary Plan Description
For more information about your benefits, please refer to the appropriate Summary Plan Description.