Flex FAQs Health Plans and Prescription Drug Coverage 1. Have the health plan choices changed? You have three health plan options for 2006 Blue Cross HMO (CaliforniaCare), Kaiser Permanente HMO and Blue Cross PPO. 2. I m not satisfied with my medical plan. Can I make changes? You can change your health plan during annual enrollment each fall with your change beginning January 1 of the following year. During the year, you can change your health plan choice only if you have a change in family status, such as getting married or having a child, as long as a change in your health plan choice is consistent with the type of family status change you have. See pages 7 and 8 of the 2006 Flex Benefits booklet in your enrollment package for more on changes in family status. 3. Can I choose one health plan for myself and a different health plan for my family? No. You must select one health plan option for yourself and any dependents you want to enroll. If the health plan you choose requires you to select a primary care physician (PCP) or primary medical group (PMG) to coordinate your care, you and your dependents can each have a different PCP/PMG. 4. What is the difference between an HMO and a PPO plan? An HMO pays benefits only when care is provided through the plan s network, unless you need emergency care when you re outside the plan s service area. With the Blue Cross HMO, you choose a primary care physician or primary medical group from the HMO network to coordinate your care. With the Kaiser Permanente HMO, you may also select a personal physician for each family member, and you can go to any Kaiser facility whenever you need care. A PPO plan provides coverage for both in-network and out-of-network care, with outof-network care paid at a lower benefit level. You don t have to choose a primary care physician or get a referral to see a network specialist. 5. For the Blue Cross PPO plan, does the out-of-pocket maximum include the deductible? No. The out-of-pocket maximum does not include the calendar year deductible. And it does not include any costs not covered by the plan like costs above reasonable and customary (R&C). 6. For the Blue Cross PPO plan, will any combination of expenses my family has meet the family deductible? You meet the family deductible when all family member s expenses for covered services from both network and non-network providers equal $1,000. For instance, a family of four would meet the family deductible if each person had $250 in covered expenses ($250 x 4 = $1,000). The only exception is that no person in the family can
have more than the individual deductible $500 count toward the family deductible. Once you meet the family deductible, the plan begins paying benefits for all enrolled family members. If any person in the family meets the individual deductible, the plan will begin paying benefits for that person even if the family deductible has not yet been met. 7. Will I have to file claims if I enroll in the Blue Cross PPO plan? For network office visits, you ll pay your $20 copayment and the provider will handle the paperwork for you. For other covered services, you ll pay your share of covered expenses, and the network provider will file claims for you. If you haven t met your calendar year deductible, your network provider may ask you to pay the cost of covered services and file a claim. For services from non-network providers, you will generally have to pay the cost of covered services and file a claim. Some non-network providers may file claims for you. 8. Do I have a vision benefit through Flex? Yes but the type of vision care benefits you have depends on your health coverage option. Generally, your health plan provides coverage for exams and a discount or allowance for lenses and frames. See pages 12 and 13 of the 2006 Flex Benefits booklet in your enrollment package or contact your plan directly for more details. 9. How can I find out if my health plan covers a particular service? You can contact Member Services for your health plan at the toll-free number on the inside front cover of the 2006 Flex Benefits booklet in your enrollment package for questions about how a specific service is covered. You can also obtain an explanation of plan coverage called an evidence of coverage booklet from the Employee Benefits Division. In addition, the health plan comparison chart on pages 12 and 13 of your 2006 Flex Benefits booklet shows how some services are covered by the health plans. 10. How do I find network providers for my health plan? You can search for a provider at www.lacity.mercerhrs.com by going to Provider Lookup on the left side of the screen. You can search for your current doctor by name or search for network providers by specialty. The system will prompt you to enter information needed to complete your search. You can also call the plan s Member Services number and request a provider directory or go to the plan s web site and search network directories. The toll-free numbers and web site addresses are listed on the inside front cover of the 2006 Flex Benefits booklet in your enrollment package. The Employee Benefits Division also has a limited number of directories available.
11. What happens if my doctor drops out of the network? If you are enrolled in the Blue Cross PPO plan, you ll need to choose another doctor from the PPO provider directory to receive network level benefits. Keep in mind that you can go to any doctor in the PPO network, and you don t have to choose a primary care physician. You can continue to see a doctor who has dropped out of the network, but you ll receive lower benefits for out-of-network care. If you are enrolled in the Blue Cross HMO and your primary care physician (PCP) drops out of the network, you must select another PCP or a primary medical group in the plan s network to coordinate your care. If you are enrolled in the Kaiser Permanente HMO and your doctor drops out of the network, you can see any doctor at a Kaiser facility. The two HMO options do not pay benefits if you go outside the network. 12. How do I change my primary care physician (PCP) or primary medical group (PMG)? During annual enrollment, you can change your PCP/PMG effective January 1, 2006 online or by calling the Benefits Request Line. To change your PCP/PMG at any other time during the year, call Blue Cross HMO Member Services at 1-800-227-3771. The change may not be effective until the beginning of the following month. It s a good idea to confirm with Member Services when the change will take effect. 13. What if my spouse/domestic partner and I both work for the City or I have dependent children with another City employee who is not my spouse/domestic partner? How will our health benefits be affected? You cannot enroll as both an employee and a dependent of your spouse/domestic partner. If your spouse/domestic partner chooses family coverage, you must choose Cash-in-Lieu in order to be covered as a dependent of your spouse/domestic partner. Only one spouse/domestic partner can enroll dependent children in health coverage. If you have dependent children with another City employee who is not currently your spouse/domestic partner, only one parent can purchase health coverage for the dependent children. 14. If I take Cash-in-Lieu and my spouse/domestic partner loses health coverage through his or her employer, can I enroll for Flex health coverage? Yes. This would be a change in family status. You must call the Benefits Request Line at 1-800-778-2133 within 30 calendar days of the date your spouse/domestic partner s coverage ends to enroll in Flex health coverage. If you don t call within 30 calendar days, you have to wait until the next annual enrollment. 15. If I change health plans during annual enrollment, will I receive a new health plan ID card? Yes. You will receive your new card by January 1, 2006.
16. When do I receive my health plan ID card after I enroll as a new hire? You ll receive your ID card about four to six weeks after you enroll. If you need health care before you receive your ID card, your doctor can contact Member Services for your health plan to confirm your coverage. Toll-free numbers for Member Services are listed on the inside front cover of the 2006 Flex Benefits booklet. 17. I lost my ID card. How can I get a new one? Call the toll-free number for Member Services for your health plan. Toll-free telephone numbers are listed on the inside front cover of the 2006 Flex Benefits booklet. 18. I am turning 65 and will be eligible for Medicare. Can I drop my Flex coverage and receive Cash-in-Lieu? When you enroll in Medicare at age 65, you cannot drop Flex coverage or enroll in Cash-in-Lieu unless you have other group health insurance, such as retiree coverage through another employer or you are covered as a dependent under a spouse or domestic partner s group plan in addition to Medicare. If your dependent turns 65 and enrolls in Medicare, you may drop that individual from Flex coverage within 30 calendar days of your dependent obtaining Medicare Part B medical insurance coverage. 19. I have Medicare and health coverage under Flex. Which plan pays first for the health care I receive? Under Federal law, when an individual has group health coverage through an employer with more than 20 employees and Medicare, the group health coverage is primary and the Medicare coverage is secondary. This means the group health plan pays first and Medicare pays second. 20. What are the changes to prescription drug coverage beginning January 1, 2006? The City is introducing tiered prescription drug copayments to help balance increasing medical costs while continuing to offer employees access to affordable prescriptions. For 2006, under all three health plans, you will pay copayments of: $5 for generic drugs $10 for brand name drugs For your copayment, you can receive: Up to a 30-day supply at a retail pharmacy or up to a 60-day supply by mail order for the Blue Cross HMO or Blue Cross PPO plans with an annual copayment maximum of $1,000 per person.
Up to a 100-day supply at both Kaiser Permanente pharmacies and for mail order/internet refills for the Kaiser Permanente HMO with no annual copayment maximum because of the larger supply available for a single copayment. 21. What s the difference between generic and brand-name drugs? The main difference is cost. The generic name of a drug is its chemical name. The brand name is the trade name under which it is advertised or sold. By law, generic and brand-name drugs must meet the same standards for safety, purity, strength, and effectiveness. When authorized by your doctor and permitted by law, a pharmacy is able to dispense a generic drug when one is available. This saves you money. When you need a prescription drug, ask your doctor whether a generic can be substituted for a brand-name drug. 22. Will I still have to pay the brand-name copayment if there isn t a generic alternative for my prescription? Yes, you will. 23. How may using the mail-order prescription service save me money? If you enroll in the Blue Cross HMO or PPO plan, mail order is typically more cost-effective than filling your prescription for maintenance drugs at a retail pharmacy. That s because you can receive up to a 60-day supply for the same copayment as a 30-day supply at a retail pharmacy. Also, your prescriptions will be mailed free of charge (unless you want expedited shipping). You can contact a pharmacist by phone Monday through Friday from 7 a.m. to 9 p.m. and Saturday from 7 a.m. to 2 p.m. Central time. You can also email a pharmacist 24 hours a day through www.precisionrx.com and receive a response within 24 hours on business days. If you enroll in the Kaiser Permanente HMO, your copayment is the same for a 100-day supply at a Kaiser pharmacy or by mail order/internet. Mail order may be more convenient for you to use for prescriptions you take regularly. When you order prescriptions by mail, you ll save time and make fewer trips to the pharmacy. To use mail order: For the Blue Cross HMO or PPO: Call 1-866-274-6825 or go to www.precisionrx.com/wpx For Kaiser Permanente HMO: Call 1-800-464-4000 or go to https://members.kaiserpermanente.org