OKLAHOMA HIGHER EDUCATION EMPLOYEE INSURANCE GROUP FREQUENTLY ASKED QUESTIONS UPDATED 7/9/2010

Transcription

1 GENERAL QUESTIONS OKLAHOMA HIGHER EDUCATION EMPLOYEE INSURANCE GROUP Can participants have dual cverage with primary cverage under Blue Crss and Blue Shield f Oklahma (BCBSOK) and anther Blue Crss plan they are n thrugh their spuse? Yes, BCBSOK crdinates with ther Grup Blue Crss Plans (including Oklahma) the same way it wuld with anther carrier. Can tw OKHEEI/University emplyees cver themselves plus each ther r can bth f them cver a dependent child, giving them duble cverage fr medical, dental, r visin? N, just as it was with OSEEGIB, duble OKHEEI cverage will nt be allwed. Is it pssible fr the emplyee t enrll in the High Optin medical plan and cver a dependent n the Basic Optin medical plan? N. If dependent cverage is selected, it must always be the same cverage as the emplyee selects. Hw can I find a physician r hspital that is in the BCBSOK netwrk? T find a PPO prvider, yu can access the nline prvider directry at and click n the Search fr dctrs, dentists, hspitals and ther health care prviders with ur Prvider Finder link n the left side f the page. The Netwrk Type fr yur grup is BlueChice. T lcate a prvider utside f Oklahma, click n the same link and then in the bttm left crner click n Find U.S. Prviders Outside f Oklahma in the Mre Searches sectin. Once there, until yu have yur BCBSOK ID card, click n Guest and then d yur search fr PPO/EPO prviders. What freign cuntries are in the Blue Crss Netwrk? BCBSOK has cntracted prviders in ver 185 cuntries utside the US. T lcate thse prviders yu can call BLUE r visit the Prvider Finder n ur Web site at Please nte that yu must have a member number t access the directry fr the BlueCard WrldWide netwrk, s yu wn t be able t access this functin until yu have received yur Blue Crss and Blue Shield ID Card. Can participants g t a natinally recgnized treatment center such as MD Andersn r the May Clinic and have in-netwrk benefits? Yes, as lng as thse treatment centers are in the BlueCard PPO Netwrk, yu will have the same in-netwrk benefits as yu d fr seeing lcal BlueChice prviders. Bth MD Andersn and May are in the BlueCard PPO Netwrk. T find netwrk prviders, please visit ur Web site at Hw d I find a Netwrk Dentist? Please visit and g t Search fr dctrs, dentists, hspitals, and ther health care prviders with ur Prvider Finder. Click n Find a Dentist at the bttm left crner and select the netwrk: BlueCare Dental (frmerly LINCS Dental Cnnectin Traditinal). Will the lifetime max start frm $0 fr participants/dependents that have r have had Blue Crss cverage? Yes, lifetime max will begin at $0 regardless f previus r current ther cverage. Will the lifetime max ever be increased? We will cnsider increasing the lifetime maximum fr the grup after ne year f being n the BCBSOK plan. What services require precertificatin? What is the prcess? Any inpatient hspital stay, hme health r hspice care, skilled nursing facility services, and private duty nursing care. Sme utpatient surgeries and diagnstic imaging services require precertificatin as well.

2 If yu use a BlueChice PPO prvider in Oklahma fr yur services, yur prvider will autmatically request precertificatin fr yu. The member is respnsible fr btaining precertificatin fr services received utside f Oklahma r frm an ut f netwrk prvider. Are dependent children still cvered up t the age f 25 regardless f student status? Due t ne f the natinal Health Care Refrm prvisins, as f May 2010, children can be cvered up t age 26. Cverage will terminate at the end f the mnth in which they turn 26. D children have t be cnsidered dependent n the emplyee in rder t be cvered? N. Due t Health Care Refrm, children can be cvered up t age 26 regardless if they re primarily r even partially dependent n the emplyee. They can be n their wn, married, etc. Imprtant Nte: Rutine maternity cverage is nly a benefit fr emplyees and spuses, s these type f services wuld nt be cvered fr a child enrlled under the subscriber. Additinally, spuses and children f dependent children are nt eligible fr cverage under the emplyee s Plan. Can dependents be enrlled in dental r visin if they are nt cvered n the BCBSOK medical plan? Yes, and yu can cver yurself and yur dependents n the medical plan, but nt dental r visin if yu s chse. Will I have t file my wn claims fr medical services? N, prviders that are in-netwrk will file the claims with BCBSOK. If a prvider is ut-f-netwrk, they may require yu t file the claim yurself. Claim frms can be fund at and shuld be mailed t: Blue Crss and Blue Shield f Oklahma, PO Bx 3282, Tulsa, OK When will I receive my ID card? Yu will receive new ID cards n r befre January 1, Fr single cverage yu will receive ne card; fr family cverage yu will receive tw cards. Once yu ve received yur initial ID card(s), additinal cards can be rdered nline thrugh Blue Access fr Members r by calling custmer service. ID cards will list the emplyee s name nly. Spuse and dependent infrmatin will nt be n the card. If I dn t sign-up fr cverage when first eligible and later want t enrll, will there be any restrictins? Yes, if yu dn t enrll during the upcming/initial enrllment perid (January 1, 2010), yu cannt sign-up until the next annual pen enrllment which ccurs each year, unless yu have a qualified status change during the plan year. In additin, if yu d nt enrll during this time (January 1, 2010), yu may als be subject t pre-existing cnditins. Blue Crss and Blue Shield has waived pre-existing cnditins fr all emplyees and eligible dependents that enrll fr January 1, PRE-EXISTING CONDITIONS Here is mre infrmatin n pre-existing cnditins: A cnditin (whether physical r mental), regardless f the cause f the cnditin, fr which medical advice, diagnsis, care r treatment was recmmended r received within the six-mnth perid ending n the enrllment date. In rder t be taken int accunt, the medical advice, diagnsis, care, r treatment must have been recmmended by r received frm an individual licensed r similarly authrized t prvide such services under state law and perating within the scpe f practice

3 authrized by the state law. A pre-existing cnditin des nt include pregnancy, nr can it be applied t a newbrn r adpted child under age 18, as lng as the child became cvered under the certificate within 31 days f birth r adptin. Pre-existing Cnditin Exclusin A 12-mnth r 18-mnth perid during which n benefits will be prvided fr a cnditin fr which medical advice, diagnsis, care r treatment was recmmended r received within the six-mnth perid befre the enrllment date. Yur benefits under this certificate are subject t a pre-existing cnditin exclusin perid. Hwever, the pre-existing cnditin exclusin will nly apply t yu and/r a dependent if the fllwing cnditins are met: Six-mnth Lk-back Rule The pre-existing cnditin exclusin must relate t a cnditin (whether physical r mental, and regardless f the cause f the cnditin) fr which medical advice, diagnsis, care, r treatment was recmmended r received within the six-mnth perid ending n the subscriber's enrllment date. In rder t be taken int accunt, the medical advice, diagnsis, care, r treatment must have been recmmended r received frm an individual licensed r similarly authrized t prvide such services under state law and perating within the scpe f practice authrized by state law. The six-mnth lk-back perid is based n the six-mnth "anniversary date" f the enrllment date. Length f Pre-existing Cnditin Exclusin Perid The exclusin perid cannt extend fr mre than 12 mnths (18 mnths fr late enrllees) after the enrllment date. The 12-mnth r 18-mnth "lk frward" perid is als based n the anniversary date f the enrllment date. Reductin f Pre-existing Cnditin Exclusin Perid by Prir Cverage In general, the pre-existing cnditin exclusin perid must be reduced by the individual's days f "creditable cverage" as f the enrllment date. Creditable cverage includes cverage frm a wide range f specified surces, including grup health plans, mst individual health insurance cverage, Medicare, and Medicaid. Hwever, days f creditable cverage that ccurs befre a significant break in cverage (63 r mre cnsecutive days) will nt be cunted in reducing the pre-existing cnditin exclusin perid. In additin, the pre-existing cnditin exclusin perid will be waived fr an individual with prir creditable cverage thrugh a health maintenance rganizatin, and wh enrlls under this certificate withut a significant break in cverage. Eliminatin f Pre-existing Cnditin Exclusin fr Pregnancy and fr Certain Children A pre-existing cnditin exclusin cannt apply t pregnancy. In additin, a pre-existing cnditin exclusin perid cannt be applied t a newbrn, an adpted child under age

4 18, r a child placed fr adptin under age 18, if the child becmes cvered within 31 days f birth, adptin, r placement fr adptin. Ntice t Subscribers The plan may nly impse a pre-existing cnditin exclusin with respect t a subscriber by ntifying the subscriber, in writing, f the existence and terms f any pre-existing cnditin exclusin under the plan and f the rights f the subscriber t demnstrate creditable cverage. The plan will assist the subscriber in btaining a certificate f cverage frm any prir health plan r issuer, if necessary. The plan may, withut waiving the abve prvisins, elect t prvide benefits fr care and services while awaiting the decisin f whether r nt the care and services fall within the abve pre-existing cnditin limitatins. If it is later determined that the care and services are excluded frm the subscriber's cverage, the plan will be entitled t recver the amunt it has allwed fr benefits under this certificate. The subscriber must prvide the plan with all dcuments it needs t enfrce its rights under this prvisin. MEDICAL BENEFIT QUESTIONS (Cverage amunt answers are based n use f in-netwrk prviders fr the BlueChice PPO High Optin medical plan) What will the dctr s ffice c-pay be? $25 What will the annual deductible be fr 2010? Deductible amunts will remain the same as what they were n HealthChice in D dctr s ffice visits and pharmacy c-pays apply t the deductible r ut-f-pcket maximum? N, they d nt apply and will remain separate. Will Blue Crss pay less f the allwed charges than HealthChice (c-insurance levels)? N, Blue Crss als pays 80% f allwed charges after the annual deductible has been met. What are the mental health benefits fr 2010? Mental health will be paid as any ther illness. Is smking cessatin cvered? Yes, tw full 90 day curses f any FDA apprved tbacc cessatin drug are cvered. Over the cunter drugs and ther smking cessatin related services are nt cvered. What is cvered fr family planning? Sme services related t the diagnsis and treatment f infertility are cvered, as well as prescriptin drugs fr treatment f infertility. Family planning services prvided in a physician s ffice, including surgical prcedures fr sterilizatin, injectins, IUDs, and internally time-released implants are als cvered. Prescriptin drugs fr birth cntrl are cvered under the pharmacy benefit. Artificial inseminatin, embry transplant, invitr fertilizatin, surrgate parenting, vum transplant, dnr semen, gamete intrafallpian transfer (gift), zygte intrafallpian transfer (zift), and reversal f vluntary sterilizatin are all excluded.

5 Are benefits under therapeutic/chirpractic services mechanical tractin CPT cde and electric muscle stimulatin CPT cde cvered by BCBSOK? N, they are nt a cvered benefit. Fr mre infrmatin regarding medical plicy fr these prcedures, yu can visit and g t prviders then medical plicy. D I have t select/designate a primary care physician (PCP)? N, this is nt a managed care r HMO plan, s yu can select yur prvider at the time f service. Are referrals required t specialists r can I self-refer? BCBSOK des nt require a primary care physician referral t see a specialist; hwever, the specialist may require a referral frm yur regular physician befre seeing yu. If I have specific questins n whether specific medical treatment will be cvered under ur plan, wh shuld I cntact? Once yu are enrlled in the plan (after January 1, 2010) yu may cntact BCBSOK directly using the custmer service phne number listed n the back f yur ID card. They will ask fr yur name and member id in rder t reference yur plan s cverage infrmatin. What if I m in the middle f treatment n January 1 with a HealthChice in-netwrk prvider that isn t in the BlueChice netwrk? Once yur BlueCrss cverage is effective, cntact Custmer Service t discuss a transitin f care plan. BCBSOK will wrk with yu t make sure yu receive the apprpriate care yu need fr yur medical situatin. If it is determined that yu need t cmplete yur treatment with yur existing prvider, BCBSOK will cver thse eligible charges at the in-netwrk benefit level. Payment will be made based n the BCBSOK allwable amunt, which means the prvider culd balance bill yu fr any charges that exceed ur allwed amunts. Is there any cverage available thrugh BlueCrss fr weight lss surgery? N, weight lss services, including surgery, will nt be cvered under the benefits f the Plan, just as they aren t cvered thrugh the OSEEGIB High and Basic Optin benefits. DENTAL BENEFIT QUESTIONS (Cverage amunt answers are based n use f in-netwrk prviders) If my child has met part f the waiting perid fr rthdntia, will I have t start ver with Blue Crss? BCBSOK will waive the entire 12 mnth waiting perid fr rthdntia fr thse eligible dependents enrlled n January 1, This will apply whether the dependent is in the middle f treatment n 1/1/10, r if the dependent starts treatment sme time during Fr thse that enrll after 1/1/10, there will be a 12 mnth waiting perid fr rthdntia cverage. Hw d I find a Netwrk Dentist? Please visit and g t Search fr Dctrs & Hspitals in yur area. Click n Find a Dentist at the bttm left crner and select the netwrk: BlueCare Dental (frmerly LINCS Dental Cnnectin Traditinal). Des Blue Crss cver dental implants? Yes, subject t prfessinal dental review and necessity fr the prcedure. A predeterminatin f benefits is highly recmmended. If apprved, benefits will be paid under the Majr Care prvisin f yur benefits.

6 I have a missing tth that wn t be replaced until after the change t Blue Crss. Will that be cvered? Blue Crss will cver these services in accrdance with the benefits f the plan, prvided the tth was lst while yu had dental cverage thrugh OSEEGIB. Verificatin f that may be required thrugh yur Dentist and emplyer. PRESCRIPTION QUESTIONS What insurance carrier administers the Rx plan? The prescriptin drug plan is administered by Prime Therapeutics. If yu elect BCBSOK medical cverage, yu autmatically are cvered under the prescriptin drug plan. Will my prescriptin c-pays change fr 2010? N, they will remain the same; hwever BCBSOK s frmulary (drug list) des differ frm HealthChice, s yur c-pay amunt may change due t hw yur specific prescriptin drug is classified. Hw are mail-rder r 90 day prescriptins cvered? Members will pay ne c-pay fr a 90- day supply f maintenance medicatins purchased thrugh mail rder r at a retail pharmacy. The quantity limit fr a 90 day prescriptin is 300 units, rather than the current limit f 100 thrugh the HealthChice Plans. What medicatins are excluded frm the Blue Crss plan? BCBS des nt have a specific exclusin list fr just medicatins. Any medicatin used t treat cnditins listed n ur standard exclusin and limitatins list wuld nt be a cvered benefit. Des ur plan have a prescriptin drug frmulary? Yes, the Prime Therapeutics plan utilizes a frmulary. A frmulary is a list f brand-name prescriptin drugs that are available thrugh Prime Therapeutics at the preferred brand cpayment. If yu fill a brand-name prescriptin drug that is nt n the frmulary, yu pay the nn-preferred brand cpayment. T see if yur prescriptin is n the frmulary r if there is a generic available, access ur website at click n Members then Prescriptin Drug Infrmatin t find the BCBSOK drug frmulary. If my dctr says I cannt take a drug that is Generic r Preferred, can I get the Nn Preferred drug at the Generic r Preferred c-pay? N, yu wuld pay the applicable c-pay fr a nn-preferred prescriptin drug. If a drug is nt listed n the frmulary, is it cvered? Yes, as lng as the prescriptin is FDA apprved fr yur cvered medical cnditin. Due t the numerus drugs n the market tday, the frmulary (drug list) nly includes all f Tier 2 drugs and a partial listing f Tier 1 and 3 drugs. What card d I need t shw at the Pharmacy? Is it the same as my medical insurance card? Yu will receive an ID card frm BCBSOK which is fr bth yur medical and prescriptin drug cverage. Hw can I find a participating retail pharmacy in my area? Prescriptins can be filled at any participating retail pharmacy and thrugh the Prime Therapeutics mail rder prgram. T find a participating retail pharmacy, visit and click n Search fr Dctrs,

7 Dentists, Hspitals & ther prviders in yur area. Next, click n Find a Pharmacy in the Mre Searches sectin f the screen. Next, click n Other BCBSOK Prescriptin Drug Plans Prime Therapeutics Netwrk, then Find a Pharmacy near the tp right crner f the Prime Therapeutics screen. What is the prcess fr step therapy and preauthrizatin? BCBSOK requires preauthrizatin r step-therapy n sme medicatins. After January 1, 2010 when yur BCBSOK benefits becme effective, there will be a 90-day grace perid when yu will nt be required t btain pre-authrizatin r underg step therapy. After the 90-day grace perid, apprximately April 1, 2010, pre-authrizatin and step therapy will be required fr certain drugs. Example: If yu are currently taking Prevacid, r will start taking Prevacid between January 1, 2010 and March 31, 2010, yu will nt be required t btain pre-authrizatin r underg step therapy fr this medicatin as lng as yu get the prescriptin filled during the first 90 days. Hwever, if after the first 90 days f 2010 yu begin taking Prevacid, r if yu wait until that time t get an existing prescriptin refilled fr the first time in the year, yu will be required t start the preauthrizatin and/r step therapy prcess. What is step therapy? Step therapy helps ensure yur safety while managing the cst f specific medicatins. Step therapy typically targets high-cst drugs and drug classes f drugs, which shuld have careful assessment f patient selectin r prir treatment befre prviding the drug. Drugs included in this prgram require that a prerequisite drug be tried befre the step therapy drug will be apprved fr cverage. If the member meets the initial step therapy criteria, then the requested medicatin will be cvered autmatically under the member s current prescriptin benefit. T see a list f drugs and drug grups subject t step therapy, review BCBSOK s drug frmulary. Visit click n Members, then Prescriptin Drug Infrmatin. On the drug frmulary, what des SP stand fr? On the BCBSOK drug frmulary, SP stands fr Specialty Pharmacy. Specialty pharmacy medicatins are used t treat chrnic and/r cmplex medical cnditins such as multiple sclersis, hepatitis C, and rheumatid arthritis. BCBSOK s specialty pharmacy prvider is Triessent. Specialty drugs can be btained fr a maximum f a 30 day supply and they are sent directly frm Triessant t yur hme r t yur health care prvider.