- Can participants have dual coverage with primary
coverage under Blue Cross and Blue Shield of Oklahoma (BCBSOK) and another Blue
Cross plan they are on through their spouse? Yes, BCBSOK coordinates with
other Group Blue Cross Plans (including Oklahoma) the same way it would with
another carrier.
- How can I find a physician or hospital that is in the
BCBSOK network? To
find a PPO provider, you can access the online provider directory at www.bcbsok.com and click on the “Search for
doctors, dentists, hospitals and other health care providers with our
Provider Finder” link on the left side of the page. The Network Type for
your group is “BlueChoice®”. To locate a provider outside of Oklahoma, click on
the same link and then in the bottom left corner click on “Find U.S.
Providers Outside of Oklahoma” in the More Searches section.
- What foreign countries are in the Blue
Cross Network? BCBSOK has contracted providers in over 185 countries
outside the US.
To locate those providers you can call 1.800.810.BLUE or visit the
Provider Finder on our Web site at www.bcbsok.com. Please note that you must have a member number to
access the directory for the BlueCard WorldWide® network, so you won’t be
able to access this function until you have received your Blue Cross and
Blue Shield ID Card.
- Can participants go to a nationally recognized
treatment center such as MD Anderson
or the Mayo Clinic and have in-network benefits? Yes, as long as those treatment
centers are in the BlueCard® PPO Network. Both MD Anderson and
Mayo are in the BlueCard PPO Network. To find network providers, please
visit our Web site at www.bcbsok.com.
- Will the lifetime max start from $0 for
participants/dependents that have or have had Blue Cross coverage? Yes, lifetime max will begin at
$0 regardless of previous or current other coverage.
- Will the lifetime max ever be increased? We will consider increasing the
lifetime maximum for the group after one year of being on the BCBSOK plan.
- What services require
precertification? What is the process? Any inpatient hospital stay,
home health or
hospice care, skilled nursing facility services, and private duty nursing
care. Some outpatient surgeries and diagnostic imaging services require
precertification as well.
If
you use a BlueChoice PPO provider in Oklahoma
for your services, your provider will automatically request precertification
for you. The member is responsible for obtaining
precertification for services received outside of Oklahoma or from an out of network provider.
- Are dependent children still covered up to the age of
25 regardless of student status? Yes
- Can dependents be enrolled in dental or vision if they
are not covered on the BCBSOK medical plan? Yes
- Will I have to file my own claims for medical services?
No, providers
that are in-network will file the claims with BCBSOK. If a provider is
out-of-network, they may require you to file the claim yourself. Claim
forms can be found at www.bcbsok.com and should be mailed to: Blue
Cross and Blue Shield of Oklahoma, PO Box 3282, Tulsa,
OK 74102-3282.
- When will I receive my ID card? You will receive new ID cards
on or before January 1, 2010. For single coverage you will receive one
card; for family coverage you will receive two cards. Additional cards can
be ordered online or by calling customer service. ID cards will list the
employee’s name only. Spouse and dependent information will not be on the
card.
- If I don’t sign-up for coverage when first eligible and
later want to enroll, will there be any restrictions? Yes, if you don’t enroll during
the upcoming/initial enrollment period (January 1, 2010), you cannot
sign-up until the next annual open enrollment which occurs each year,
unless you have a qualified status change during the plan year.
In
addition, if you do not enroll during this time (January 1, 2010), you may also
be subject to pre-existing conditions. Blue Cross and Blue Shield has waived
pre-existing conditions for all employees and
eligible dependents that enroll for January 1, 2010.
Here is more information on
pre-existing conditions:
A
condition (whether physical or mental), regardless of the cause of the
condition, for which medical advice, diagnosis, care or treatment was
recommended or received within the six-month period ending on the enrollment
date. In order to be taken into account, the medical advice, diagnosis, care,
or treatment must have been recommended by or received from an individual
licensed or similarly authorized to provide such services under state law and
operating within the scope of practice authorized by the state law. A pre-existing
condition does not include pregnancy, nor can it be applied to a newborn or
adopted child under age 18, as long as the child became covered under the
certificate within 31 days of birth or adoption.
Pre-existing Condition Exclusion
A
12-month or 18-month period during which no benefits will be provided for a
condition for which medical advice, diagnosis, care or treatment was
recommended or received within the six-month period before the enrollment date.
Your
benefits under this certificate are subject to a pre-existing condition
exclusion period. However, the pre-existing condition exclusion will only apply
to you and/or a dependent if the following conditions are met:
§
Six-month Look-back Rule
o
The
pre-existing condition exclusion must relate to a condition (whether physical
or mental, and regardless of the cause of the condition) for which medical
advice, diagnosis, care, or treatment was recommended or received within the
six-month period ending on the subscriber's enrollment date.
o
In
order to be taken into account, the medical advice, diagnosis, care, or
treatment must have been recommended or received from an individual licensed or
similarly authorized to provide such services under state law and operating
within the scope of practice authorized by state law.
o
The
six-month look-back period is based on the six-month "anniversary
date" of the enrollment date.
§
Length of Pre-existing Condition
Exclusion Period
o
The
exclusion period cannot extend for more than 12 months (18 months for late
enrollees) after the enrollment date. The 12-month or 18-month "look
forward" period is also based on the anniversary date of the enrollment
date.
§
Reduction of Pre-existing Condition
Exclusion Period by Prior Coverage
o
In
general, the pre-existing condition exclusion period must be reduced by the
individual's days of "creditable coverage" as of the enrollment date.
Creditable coverage includes coverage from a wide range of specified sources,
including group health plans, most individual health insurance coverage, Medicare, and Medicaid.
However, days of creditable coverage that occurs before a significant break in
coverage (63 or more consecutive days) will not be counted in reducing the pre-existing
condition exclusion period.
o
In
addition, the pre-existing condition exclusion period will be waived for an
individual with prior creditable coverage through a health maintenance
organization, and who enrolls under this certificate without a significant
break in coverage.
§
Elimination of Pre-existing
Condition Exclusion for Pregnancy and for Certain Children
o
A
pre-existing condition exclusion cannot apply to pregnancy. In addition, a pre-existing
condition exclusion period cannot be applied to a newborn, an adopted child
under age 18, or a child placed for adoption under age 18, if the child becomes
covered within 31 days of birth, adoption, or placement for adoption.
Notice to Subscribers
The plan may only impose a pre-existing
condition exclusion with respect to a subscriber by notifying the subscriber,
in writing, of the existence and terms of any pre-existing condition exclusion
under the plan and of the rights of the subscriber to demonstrate creditable
coverage. The plan will assist the subscriber in obtaining a certificate of
coverage from any prior health plan or issuer, if necessary.
The plan may, without waiving the
above provisions, elect to provide benefits for care and services while
awaiting the decision of whether or not the care and services fall within the
above pre-existing condition limitations. If it is later determined that the
care and services are excluded from the subscriber's coverage, the plan will be
entitled to recover the amount it has allowed for benefits under this
certificate. The subscriber must provide the plan with all documents it needs
to enforce its rights under this provision.
MEDICAL
/ DENTAL BENEFIT QUESTIONS (Answers are based on use of in-network providers)
- What will the doctor’s office co-pay be? $25
- What will the annual deductible
become? Deductible amounts will remain the same as what they
were on HealthChoice
in 2009.
- Do doctor’s office visits and pharmacy co-pays apply to
the deductible or out-of-pocket maximum? No, they do not apply and will remain separate.
- Will Blue Cross pay less of
the allowed charges than HealthChoice (co-insurance levels)? No, Blue Cross also pays 80% of allowed
charges after the annual deductible has been met.
- What are the mental health benefits for 2010? Mental health will be paid as any other illness.
- Is smoking cessation covered? Yes, two full
90 day courses of any FDA approved tobacco cessation drug are covered.
Over the counter drugs
and other smoking cessation related services are not covered.
- What is covered for family planning? Some services related to the
diagnosis and treatment of infertility
are covered, as well as prescription drugs for treatment of infertility.
Family planning services provided in a
physician’s office, including surgical procedures for sterilization,
injections, IUDs, and internally time-released implants are also covered.
Prescription drugs for birth control are covered under the pharmacy
benefit.
Artificial
insemination, embryo transplant, invitro fertilization, surrogate parenting,
ovum transplant, donor semen, gamete intrafallopian transfer (gift), zygote
intrafallopian transfer (zift), and reversal of voluntary sterilization are all
excluded.
- Are benefits under
therapeutic/chiropractic services – mechanical traction CPT code 97012 and
electric muscle stimulation CPT code 97014 covered by BCBSOK? No,
they are not a covered benefit. For more information regarding medical
policy for these procedures you can visit www.bcbsok.com and
go to “providers” then “medical policy”.
- Do I have to select/designate a primary care physician (PCP)? No, this is not a managed care or HMO
plan, so you can select your provider at the time of service.
- Are referrals required to specialists
or can I self-refer? BCBSOK does not require a primary care physician referral to see
a specialist; however, the specialist may require a referral from your
primary physician before seeing you.
- If my child has met part of the waiting
period for orthodontia, will I have to start over with Blue Cross? BCBSOK will waive
the waiting period for orthodontia for those who enroll on January 1, 2010. For
those that enroll after 1/1/10, there will be a 12 month waiting period
for orthodontia.
- If I have specific questions on whether specific medical treatment
will be covered under our plan, who
should I contact? Once you are enrolled in the
plan (after January 1, 2010) you may contact BCBSOK directly using the
customer service phone number listed on the back of your ID card. They
will ask for your name and member id in order to reference your plan’s
coverage information.
- What insurance carrier administers the Rx plan? The prescription drug plan is
administered by Prime Therapeutics. If you elect BCBSOK medical coverage,
you automatically are covered under the prescription drug plan.
- Will my prescription co-pays change for 2010? No, they will remain the same;
however BCBSOK’s formulary (drug list) does differ from HealthChoice so
your co-pay amount may change due to how your
specific prescription drug is
classified.
- How are mail-order prescriptions covered? Members will pay one co-pay
for a 90-day supply of maintenance medications purchased through mail
order.
- What medications are excluded from the Blue Cross plan? BCBS does not have a specific
exclusion list for just medications. Any medication used to treat
conditions listed on our standard exclusion and limitations list would not
be a covered benefit.
- Does our plan have a
prescription drug formulary? Yes, the Prime Therapeutics plan utilizes a formulary.
A formulary is a list of brand-name prescription drugs that are available
through Prime Therapeutics at the “preferred brand” copayment. If you fill
a brand-name prescription drug that is not on the formulary, you pay the
“non-preferred brand” copayment. To see if your prescription is on the
formulary or if there is a generic available, access
our website at www.bcbsok.com, click on “Members” then “Prescription Drug Information” to find the
BCBSOK drug formulary.
- If my doctor
says I cannot take a drug that is Generic or Preferred, can I get the Non
Preferred drug at the Generic or Preferred co-pay? No, you would pay the applicable co-pay for a
non-preferred prescription drug.
- If a drug is not listed on the
formulary, is it covered? Yes, as
long as the prescription is FDA approved for your covered medical
condition. Due to the numerous
drugs on the market today, the formulary (drug list) only includes all of
Tier 2 drugs and a partial listing of Tier 1 and 3 drugs.
- What card do I need to show at the Pharmacy? Is it the
same as my medical insurance card? You will receive an ID card from BCBSOK which is for
both your medical
and prescription drug coverage.
- How can I find a participating
retail pharmacy in my area? Prescriptions can be filled at
any participating retail pharmacy and through
the Prime Therapeutics mail order program. To find a participating
pharmacy, visit www.bcbsok.com.
- What is the process for step therapy
and preauthorization? BCBSOK requires pre-authorization or step-therapy on some
medications. After January 1, 2010 when your BCBSOK benefits become
effective, there will be a 90-day grace period when you will not be
required to obtain pre-authorization or undergo step therapy. After the
90-day grace period, approximately April 1, 2010, pre-authorization and
step therapy will be required for certain drugs. Example: If you are
currently taking Prevacid, or will start taking Prevacid between January
1, 2010 and March 31, 2010, you will not be required to obtain
pre-authorization or undergo step therapy for this medication. However, if
after the first 90 days of the BCBSOK plan (beginning April 1, 2010) you
begin taking Prevacid, or if you wait until that time to get an existing
prescription refilled for the first time in the year, you will be required
to start the pre-authorization and/or step therapy process.
- What is step therapy? Step therapy helps ensure your safety while
managing the cost of specific medications. Step therapy typically targets
high-cost drugs and drug classes of drugs, which should have careful
assessment of patient selection or prior treatment before providing the
drug. Drugs included in this program require that a prerequisite drug be
tried before the step therapy drug will be approved for coverage. If the
member meets the initial step therapy criteria, then the requested
medication will be covered automatically under the member’s current
prescription benefit. To see a list of drugs and drug groups subject to
step therapy, review BCBSOK’s drug formulary.
Visit www.bcbsok.com, click on
“Members”, then “Prescription Drug Information”.
- On the drug formulary, what does
“SP” stand for? On the BCBSOK drug formulary, “SP” stands for
“Specialty Pharmacy”. Specialty pharmacy medications are used
to treat chronic and/or complex medical conditions such as multiple
sclerosis, hepatitis C, and rheumatoid arthritis. BCBSOK’s specialty
pharmacy provider is Triessent.
Specialty drugs can be obtained for a maximum of a 30 day supply
and they are sent directly from Triessant to your home or to your health
care provider.