The
Oklahoma State and Education Employees Group Insurance Board
For Plan Year January 1, 2009 through December 31, 2009
Revised
January 1, 2009
www.sib.ok.gov or www.healthchoiceok.com
This
HealthChoice Medicare Supplement Handbook, also known as an Evidence of
Coverage, together with your enrollment form, Confirmation of Benefits
Statement, Annual Notice of Change, and HealthChoice Medicare Formulary,
represent our responsibilities to you, the member. This handbook provides
details about your health and prescription drug coverage from January 1 through
December 31, 2009, and explains how to get the services and prescription drugs
you need. The HealthChoice Medicare Supplement Plans are offered by OSEEGIB and
are often referred to throughout this handbook as the “Plan” or “Plans”.
The
Oklahoma State and Education Employees Group Insurance Board (OSEEGIB)
contracts with the Centers for Medicare and Medicaid Services to provide
Medicare Supplement Plans With Part D benefits. OSEEGIB’s contract is renewed
annually and is not guaranteed beyond the 2009 contract year.
Audio
CDs and CD versions for PC of the HealthChoice Medicare Supplement
Handbook/Evidence of Coverage have been prepared and are available at the
Oklahoma Library for the Blind and Physically Handicapped (OLBPH). Contact the
OLBPH at 1-405-521-3514, toll-free 1-800-523-0288, and TDD 1-405-521-4672. You
may also access a searchable text version of this document on the OSEEGIB
website at www.sib.ok.gov or www.healthchoiceok.com.
A
dispute concerning information contained within any OSEEGIB written or
electronic materials or oral communications, regardless of the source, shall be
resolved by a strict application of OSEEGIB Rules or benefit administration
procedures and guidelines as adopted by the Plan. Incorrect, misleading, or
obsolete language contained within any written or electronic document, or oral
communication, regardless of the source, is of no effect under any
circumstance.
Plan Identification
and Contact Information
Who to Contact for Complaints, Grievances,
Appeals, or Coverage Determinations
How Your Plan Will Change for 2009 - Annual
Notice of Change
Your Costs for Health and Prescription Drug
Coverage
Outline of
HealthChoice Plan Benefits
Summary of Benefits for High and Low Option Medicare
Supplement Plans
Part D – Pharmacy
Important Information
About Your Prescription Drug Coverage
Medications Requiring
Prior Authorization
Medications Subject
to Quantity Limitations
Claim Procedures for Health and
Pharmacy Services
Health Education
Lifestyle Planning
Eligibility and
Effective Dates
Grievance and Appeals Processes
Health Plans (Plans With and Without Part D)
Pharmacy (Plans
Without Part D)
Fraud, Waste, and Abuse Compliance
For Plan Year January 1, 2009 through December 31, 2009
Rates do not reflect any contribution from your retirement system or any
Medicare Part D late enrollment penalty that may apply. You must pay the full
monthly premium (unless you qualify for extra help from Medicare) and your Part
B premium, if applicable.
Member $279.28
Spouse $279.28
Child or Children $279.28
Member $222.92
Spouse $222.92
Child or Children $222.92
Member $333.24
Spouse $333.24
Child or Children $333.24
Member $276.88
Spouse $276.88
Child or Children $276.88
Member $279.28
Spouse $279.28
Child or Children $279.28
Member $222.92
Spouse $222.92
Child or Children $222.92
Member $339.90
Spouse $339.90
Child or Children $339.90
Member $282.42
Spouse $282.42
Child or Children $282.42
Oklahoma
State and Education Employees Group Insurance Board (OSEEGIB)
3545
NW 58th Street, Suite 110, Oklahoma City, OK 73112
1-405-717-8701
or toll-free 1-800-752-9475
TDD
1-405-949-2281 or toll-free 1-866-447-0436
Monday
through Friday, 7:30am to 4:30 pm Central time
With
Part D call 1-405-717-8699 or toll-free 1-800-865-5142
Without
Part D call 1-405-717-8780 or toll-free 1-800-752-9475
All
Members – TDD 1-405-949-2281 or toll-free 1-866-447-0436
Fax
1-405-717-8942
Website:
www.sib.ok.gov/ or www.healthchoiceok.com
EDS
Administrative Services, LLC
Monday
through Friday, 7:00am to 7:00pm Central time
PO
Box 24870, Oklahoma City, OK 73124-0870
1-405-416-1800
or toll-free 1-800-782-5218
TDD
1-405-416-1525 or toll-free 1-800-941-2160
Medco
Customer Service
7
days a week / 24 hours a day
With
Part D Plans; Toll-free 1-800-590-6828 or toll-free TDD 1-800-716-3231
Without
Part D Plans: Toll-free 1-800-903-8113 or toll-free TDD 1-800-825-1230
Website:
http://www.medco.com
APS
Healthcare
Monday
through Friday, 7:00am to 7:00pm Central time
PO
Box 700005, Oklahoma City, OK 73107-0005
Toll-free
1-800-848-8121 or toll-free TDD 1-877-267-6367
Customer
Service: 7 days a week / 24 hours a day
Toll-free
1-800-633-4227 or toll-free TTY 1-866-486-2048
Website:
http://www.medicare.gov
Website
Questions and Answers: http://questions.medicare.gov
Customer
Service: Monday through Friday, 7:00am to 7:00pm Central time
Toll-free
1-800-772-1213 or toll-free TTY 1-800-325-0778
Website:
http://www.socialsecurity.gov
HealthChoice
Member Service Representatives are available Monday through Friday, from 7:30
a.m. to 4:30 p.m. Central time. If you call before or after hours, on weekends,
or holidays, your call will be answered by our automated phone system. Please
follow the instructions to leave a message, including your name and telephone
number, and a Member Service Representative will return your call the next
business day.
Medical Claim Review
PO Box 24870
Oklahoma City, OK
73124-0870
1-405-416-1800
or toll-free 1-800-782-5218
TDD
1-405-416-1525 or toll-free 1-800-941-2160
3545 NW 58th St, Ste 110
Oklahoma City, OK
73112
1-405-717-8701 or toll-free 1-800-543-6044
TDD users call 1-405-949-2281 or toll-free 1-866-447-0436
Toll-free
1-800-753-2851 or toll-free TDD 1-800-825-1230
1-405-717-8699
or toll-free 1-800-865-5142
TDD
1-405-949-2281 or toll-free 1-866-447-0436
Fax
1-405-717-8925
Mail
or bring your appeal to the HealthChoice Pharmacy Unit at:
OSEEGIB,
3545 NW 58th St, Ste 110, Oklahoma City, OK 73112
1-405-717-8699
or toll-free 1-800-865-5142
TDD
1-405-949-2281 or toll-free 1-866-447-0436
Fax
1-405-717-8942
Monday
through Friday, 8:00am to 7:00pm Eastern time
Toll-free
1-877-772-3379
Website:
MEDICinfo@healthintegrity.org
Medical Claim Review
PO Box 24870
Oklahoma City, OK
73124-0870
1-405-416-1800
or toll-free 1-800-782-5218
TDD
1-405-416-1525 or toll-free 1-800-941-2160
3545 NW 58th St, Ste 110
Oklahoma City, OK
73112
1-405-717-8701 or toll-free 1-800-543-6044
TDD users call 1-405-949-2281 or toll-free 1-866-447-0436
1-405-717-8780 or toll-free 1-800-752-9475
TDD 1-405-949-2281 or toll-free 1-866-447-0436
Fax 1-405-717-8925
Mail
or bring your appeal to the HealthChoice Pharmacy Unit at:
OSEEGIB,
3545 NW 58th St, Ste 110, Oklahoma City, OK, 73112
Annual Notice of Change
HealthChoice High Option With Part D increased from $245.80 to $279.28
HealthChoice Low Option With Part D increased from $197.32 to $222.92
HealthChoice High Option Without Part D increased from $304.24 to $333.24
HealthChoice Low Option Without Part D increased from $255.76 to $276.88
Part A increased from $1,024 to $1,068
Part B remained the same at $135
Pharmacy increased from $275 to $295
The HealthChoice Pharmacy Network continues to grow and includes
participating network Pharmacies across Oklahoma and throughout the nation. To
locate a HealthChoice Network Pharmacy near you, go to the HealthChoice website
at http://www.sib.ok.gov/ or www.healthchoiceok.com or contact Medco
toll-free at the numbers listed in the Plan Identification section.
HealthChoice members will have two ID cards, one card will be used for
health and/or dental benefits, and the other card will be used for pharmacy
benefits. HealthChoice will issue a new ID card for your health and/or dental
coverage. If you are currently a HealthChoice member, you should continue using
your current prescription drug ID card. If you are new to HealthChoice, you
will also be issued a prescription drug ID card.
There have been some changes to the HealthChoice Medicare formulary. To
find out how your medications are covered, please contact Medco toll-free at
the numbers listed in the Plan Identification section.
The HealthChoice Medicare Formulary is also available on the web at http://www.sib.ok.gov/ or http://www.healthchoiceok.com. Click Medicare
Members to access the formulary. To request a printed copy of the HealthChoice
Abridged or comprehensive Medicare Formulary, contact HealthChoice Member
Services at the numbers listed in the Plan Identification section.
Specialty Pharmacy Medications (applies to Medicare Supplement Plans
Without Part D)
Members enrolled in the HealthChoice Medicare Supplement Plans Without
Part D will now pay the applicable copay for each 30-day fill of a specialty
medication. Specialty medications are only
covered when purchased through Accredo Health Group.
The health, dental, and life
claims administrator for HealthChoice is changing to EDS Administrative
Services, LLC. A new health/dental identification card is being sent to all
HealthChoice members.
APS Healthcare will be the new
certification administrator.
Medicare approved At-Home
Recovery Services are now covered under Medicare Part B at 100%.
Be aware that all costs for medical and pharmacy expenses are separate.
If you currently pay a premium for Medicare Part A or Part B, you must
continue paying your premium in order to keep your Medicare coverage. All
HealthChoice benefits will be paid as if you are enrolled in both Medicare Part
A and Part B.
As a member of a HealthChoice Medicare Supplement Plan, you must pay the
full monthly premium unless you qualify for extra help from Medicare. Payment
of your premium is handled in one of three ways:
Withheld from your retirement
check.
Withheld automatically from your
bank account through an automatic draft.
Paid directly to OSEEGIB through
direct billing. Please return your payment in the self-addressed envelope
included in your monthly premium statement.
COBRA participants, you must pay premiums directly to OSEEGIB. Please
return your payment in the self-addressed envelope included in your monthly
statement
The set amount you pay for a specific covered service or prescription
drug.
The initial out-of-pocket expense you must pay on allowed services or
covered prescription medications before a benefit is paid by the Plan.
The percentage of the cost of a covered service or medication that you
pay as your share of the expense.
After your deductible is met and your total drug costs reach the initial
coverage limit ($2,405), you pay 100% of the cost of your Part D covered drugs
until you reach the out-of-pocket maximum ($4,350). This time period when you
must pay for all your medications is known as the coverage gap.
All HealthChoice Medicare Supplement Plans have a pharmacy out-of-pocket
maximum of $4,350. This total includes the amounts you spend on deductibles,
copays, and coinsurance. If you are a member of the Low Option Plan, the total
also includes amounts you spend during the coverage gap.
Once you have reached the $4,350 out-of-pocket maximum, the Plan pays
100% of the cost of all covered medications purchased at a Network Pharmacy for
the remainder of the calendar year.
Medications must be covered Part D drugs and listed on the HealthChoice
Medicare Formulary (or covered through one of the appeals or exceptions
processes). Medications must also be purchased at a Network Pharmacy for costs
to apply to the out-of-pocket maximum. The following types of payments for
prescription medications may count toward your out-of-pocket maximum:
Your deductible
Your coinsurance or copays
Your costs after you reach the
initial coverage limit (Only Low Option Plans)
Prescription medications not
covered by the Plan
Prescription medications purchased
at non-Network pharmacies when non-Network requirements have not been met
Cost differences between generic
and brand-name medications
Prescription medications covered
under Medicare Part A or Part B
If you have limited income and resources as determined by Social
Security, you may be able to get help paying your monthly premiums, pharmacy,
deductibles, and pharmacy copays.
If you think you may qualify or you want more information, please contact
Social Security by calling toll-free 1-800-772-1213. TTY/TDD users call
toll-free 1-800-325-0778.
You may also visit the Social Security website at http://www.socialsecurity.gov.
After you apply, you will get a letter in the mail letting you know if
you qualify or not, and what you need to do next. You may receive full or
partial help depending on your income, family size, and resources.
For the prescription drug portion of your coverage, you pay $0 or a
reduced monthly premium if you qualify for extra help. Extra help also assists
you in paying for your prescription drugs. If you qualify for extra help in
2009, the information below shows the amount you will have to pay for your
prescription drug benefits.
Beneficiaries who qualify for full help will receive:
A premium reduction of $29.40
No pharmacy deductible
Continuous coverage (no coverage
gap)
Maximum copays of $2.40 for
generics and Preferred drugs and $6.00 for other drugs
Beneficiaries receiving partial help will receive:
A premium reduction between
$7.40 and $29.40
A pharmacy deductible of $60
Continuous coverage (no coverage
gap)
Coinsurance of 15% (up to the
out-of-pocket maximum)
If you qualify for extra help, you will first be enrolled in the plan you
select. Within a few days, HealthChoice will receive notice from Medicare that
you qualify for extra help. You will then receive a letter from HealthChoice
notifying you of the amount of your extra help.
NOTE: The extra help applies to either the High or Low Option Plans with
Part D. If you qualify for extra help, HealthChoice will automatically move you
to the Low Option Plan so that you will receive the lowest premium. If you wish
to opt out of the Low Option Plan and elect the High Option Plan, please
contact HealthChoice Member Services at the number listed in the front of this
handbook.
Generally, your premium will not change during the calendar year;
however, in certain cases, a premium change can occur. Following are some
examples of instances that might change your premium:
If you are not currently getting
extra help but you qualify for it during the plan year, your monthly premium
amount will decrease.
If you are currently getting
extra help but the amount of help you qualify for changes, your premium will be
adjusted up or down.
If you marry sometime during the
plan year and add your spouse or dependents to coverage, your premium will
increase.
For more information, refer to the Medicare
and You 2009 Handbook, visit the Medicare website,
or call Medicare toll-free.
Medicare applies a penalty to you if you don’t join a Medicare Part D
plan, or other plan offering Creditable Coverage, when you first become
eligible (the Initial Enrollment Period). Additionally, any time there is a
lapse in creditable prescription drug coverage that lasts longer than 63
continuous days, a late enrollment penalty will be applied when you get
creditable prescription drug coverage. Once a penalty is applied, it will
follow you as long as you have Part D prescription drug coverage.
Currently, OSEEGIB pays the late enrollment penalty on behalf of any
member to whom this applies; however, the penalty could be applied if you leave
OSEEGIB and enroll with another insurance carrier.
This handbook provides a quick guide to the features of the Plans. It is
not a complete description of the plans. Please review the other sections of
this handbook carefully for an explanation of eligibility rules and plan
benefits.
The HealthChoice Medicare Supplement Plans provide benefits for
participants who are eligible for Medicare. The Plans are designed to provide
supplemental benefits to Medicare Part A and Part B, as well as prescription
drug benefits.
The Plans provide benefits for services covered by Medicare. Except as
specifically noted otherwise in this handbook, services not covered by Medicare
are not covered under the Plans. Medical benefits provided under the Plans are
based on Medicare’s approved schedules and amounts. Please review your Medicare & You handbook or contact
your local Medicare office to see if a particular procedure is covered.
As specifically described in this handbook, certain additional benefits
such as coverage for foreign travel and preventive medical care are included in
the Plans, even though Medicare does not cover such services.
All medical benefits under the Plans are paid as if you are enrolled in
both Medicare Part A and Part B. If you are not enrolled in Medicare, the Plan
will estimate Medicare’s benefits and provide supplemental coverage as if
Medicare were your primary carrier. Please contact your local Social Security
office for complete information about Medicare enrollment.
Paying the inpatient
hospitalization deductible and coinsurance in full; skilled nurse facilities
and hospice care have different limits
Providing payment for an
additional 365 lifetime reserve days for hospitalization
Providing payment of the
Medicare Part A coinsurance on skilled nurse facility care for days 21 through
100
Paying for the first three pints
of blood while hospitalized
Having no maximum lifetime
benefit
Paying the 20% of medical
expenses that are not paid by Medicare
Providing a home recovery
benefit during recovery from illness, surgery, or injury
Providing limited coverage for
emergency medical care received in a foreign country
High Option Pharmacy
Benefit
Not Applicable
Low Option Pharmacy
Benefit
$295.00
High Option Pharmacy
Benefit
Refer to High Option Pharmacy Section
Low Option Pharmacy
Benefit
$2,405.00
High Option Pharmacy
Benefit
Not Applicable
Low Option Pharmacy
Benefit
$3,453.75
High Option Pharmacy
Benefit
$4,350.00
Low Option Pharmacy
Benefit
$4,350.00
High Option Pharmacy
Benefit
100%
Low Option Pharmacy
Benefit
100%
Contact Medicare and the Social Security Administration at the toll-free
number listed earlier in this handbook, or visit thefollowing websites:
Social Security Administration
at www.ssa.gov
Centers for Medicare and
Medicaid Services at www.cms.hhs.gov
Medicare at www.medicare.gov
Medicare Questions and answers
at http://questions.medicare.gov
HealthChoice members will have two ID cards, one card will be used for
health and/or dental benefits, and the other card will be used for pharmacy
benefits. HealthChoice will issue a new ID card for your health and/or dental
coverage. If you are currently a HealthChoice member, you should continue using
your current pharmacy ID card. If you are new to HealthChoice, you will also be
issued a pharmacy ID card.
Please present your health/dental ID card when you receive these types of
services. When you receive health services, you will also need to provide your
Medicare number to your provider.
To request a replacement health and/or dental ID card, contact EDS
Administrative Services at the numbers listed in the Plan Identification section.
Please present your Prescription Drug ID card with you when you fill a
prescription, you may have to pay the full cost for your medication, and then
ask HealthChoice to pay you back. You can ask for reimbursement by filing a
paper pharmacy claim. Refer to the Claims Procedures section later in this
document.
To request a replacement prescription ID card, contact Medco at the
numbers listed in the Plan Identification section.
It is important that you keep your member information up-to-date. You run
the risk of delaying claims processing or missing important communications when
there is incorrect information in our files. Additionally, Medicare requires
that you report any change in residence to your insurance plan. Address changes
may be faxed to 1-405-717-8939 or sent in writing to HealthChoice at 3545 NW 58th,
Ste 110, Oklahoma City, OK, 73112.
For both High and Low
Options - Unless otherwise stated, the member copay is $0.
Federal Limiting
Charge - Providers who do not accept Medicare assignment may not charge a
Medicare beneficiary more than 115% of the Medicare allowed amount.
The $135 Medicare
Part B deductible will be credited toward the Plans’ $135 deductible upon
receipt of Medicare’s Explanation of Benefits. Once you have been billed $135
of Medicare Part B approved amounts for covered services, your HealthChoice
Medicare Supplement deductible will have been met for the calendar year.
For both High and Low
Options - Unless otherwise stated, the member copay is $0.
Semiprivate
room and board, general nursing, and miscellaneous services and supplies per
benefit period
All
except $1,068, the Part A deductible
$1,068,
the Part A deductible
All
except $267 per day
$267
per day
All
except $534 per day
$534
per day
0%
100%
of Medicare eligible expenses; certification by HealthChoice is required
0%
0%
100%
Must
meet Medicare requirements, including: inpatient hospitalization for at least
three days and entering a Medicare approved facility within 30 days after
leaving the hospital. Only 100 days are allowed per calendar year.
All
approved amounts
0%
All
except $133.50 per day
$133.50
per day
0%
0%
100%
All
but very limited coinsurance for outpatient drugs and inpatient respite care
0%
Balance
0%
100%
For both High and Low
Options - Unless otherwise stated, the member copay is $0.
Inpatient
and outpatient hospital treatment, such as physician’s services, inpatient and
outpatient medical and surgical services and supplies, physical and speech
therapy, diagnostic tests (Medicare limits apply)
0%
0%
$135,
the Part B deductible
80%
20%
0%
100%
100%
0%
Medicare
approved services
100%
0%
Items
such as wheelchairs, walkers, and hospital beds
0%
0%
$135,
the Part B deductible
80%
20%
0%
100%
80%
20%
Home
care certified by your doctor, for personal care during recovery from an injury
or illness for which Medicare approves a Home Care Treatment Plan
100%
0%
0%
0%
100%
80%
20%
To
be completed within 12 months of your enrollment in Medicare Part B
Covered
for all Medicare beneficiaries
80%
of the Medicare approved amount with no Part B deductible
20%
of the Medicare approved amount with no Part B deductible
Once
every 12 months
Covered
for all female Medicare beneficiaries age 40 and older
80%
of the Medicare approved amount with no Part B deductible
20%
of the Medicare approved amount with no Part B deductible
Covered
for all Medicare beneficiaries
100%
0%
Includes
a clinical breast exam once every 24 months. Once every 12 months if high
risk/abnormal Pap Test in preceding 36 months.
Covered
for all female Medicare beneficiaries
Pap
Test, 100% of the Medicare approved amount with no Part B deductible; All other
exams, 80% of the Medicare approved amount with no Part B deductible
Pap
Test, 0%; All other exams, 20% of the Medicare approved amount with no Part B
deductible
Covered
for all Medicare beneficiaries at risk of diabetes
100%
0%
Covered
for all Medicare beneficiaries with diabetes (insulin users and non-insulin
users)
80%
of the Medicare approved amount after the Part B deductible
20%
of the Medicare approved amount after the Part B deductible
Includes
coverage for glucose monitors, test strips, and lancets without regard to the
use of insulin
Covered
for all Medicare beneficiaries with diabetes – must be requested by your doctor
80%
of the Medicare approved amount after the Part B deductible
20%
of the Medicare approved amount after the Part B deductible
Includes
ostomy bags, wafers, and other ostomy supplies
Covered
for all Medicare beneficiaries in need of ostomy supplies
80%
of the Medicare approved amount after the Part B deductible
20%
of the Medicare approved amount after the Part B deductible
Fecal
Occult Blood Test once every 12 months
Flexible
Sigmoidoscopy once every 48 months for age 50 or older; for those not at high
risk, 10 years after a previous screening
Colonoscopy
once every 24 months if you are at high risk for colon cancer; if not, once
every 10 years, but not within 48 months of a screening flexible sigmoidoscopy
Barium
Enema, doctor can substitute for sigmoidoscopy or colonoscopy
Covered
for all Medicare beneficiaries age 50 and older. There is no minimum age for
having a colonoscopy.
Note:
For a flexible sigmoidoscopy or screening colonoscopy in an outpatient hospital
setting or an ambulatory surgical center, you pay 25% of the Medicare approved
amount.
For
the fecal occult blood test, 100% of the Medicare approved amount with no Part
B deductible; For all other tests, 80% of the Medicare approved amount after
the Part B deductible
For
the fecal occult blood test, 0%; For all other tests, 20% of the Medicare
approved amount after the Part B deductible
Digital
Rectal Exam once every 12 months
Prostate
Specific Antigen Test (PSA) once every 12 months
Covered
for all male Medicare beneficiaries age 50 and older
For
the digital rectal exam, 80% of the Medicare approved amount after the Part B
deductible; For the PSA test, 100% of the Medicare approved amount with no Part
B deductible
For
the digital rectal exam, 20% of the Medicare approved amount after the Part B
deductible; For the PSA test, 0%
Once
every 24 months for qualified individuals
Covered
for all Medicare beneficiaries at risk for losing bone mass
80%
of the Medicare approved amount after the Part B deductible
20%
of the Medicare approved amount after the Part B deductible
One
every 12 months; must be performed or supervised by an eye doctor who is
authorized to do this within the scope of his practice
Covered
for Medicare beneficiaries at high risk or having a family history of glaucoma
80%
after the Part B deductible
20%
after the Part B deductible
One
per flu season
Covered
for all Medicare beneficiaries with Part B
The
vaccination and administration are covered at 100% if the provider accepts
Medicare assignment
One-time
vaccination
Covered
for all Medicare beneficiaries with Part B
The
vaccination and administration are covered at 100% if the provider accepts
Medicare assignment
Covered
for Medicare beneficiaries at medium to high risk for Hepatitis B
For
members with Part D, the vaccine and administration are covered under the
HealthChoice pharmacy benefit
For
members without Part D, the vaccine and administration are covered under the
Medicare Part B benefit
e.g.,
ZOSTAVAX (zoster vaccine live)
For
members with Part D, the vaccine and administration are covered under the
HealthChoice pharmacy benefit
For
members without Part D, the vaccine and administration are covered under the
Medicare Part B benefit
e.g.,
TETANUS TOXOID
For
members with Part D, the vaccine and administration are covered under the
HealthChoice pharmacy benefit
For
members without Part D, the vaccine and administration are covered under the
Medicare Part B benefit
Medically
necessary emergency care services beginning during the first 60 days of each
trip outside the U.S.A.
Contact
Medicare for foreign travel exceptions that are covered by Medicare
0%
80%
of billed charges after the first $250 of each calendar year; $50,000 lifetime
maximum
First
$250 of each calendar year, then 20%; All amounts over the $50,000 lifetime
max; No Medicare deductible
Annual
physical and preventive tests and services such as digital rectal exam, hearing
screening, dipstick urinalysis, thyroid function test, tetanus and diphtheria
booster, and education, administered or ordered by your doctor when not covered
by Medicare.
First
$120 of each calendar year
0%
$120
Balance;
No Medicare deductible
100%
of covered medications after the member reaches the $4,350 pharmacy
out-of-pocket maximum
$4,350,
the pharmacy out-of-pocket maximum, in prescription benefit copays. The copay
information follows.
Allowed
charges after your copay
Copay
up to $25
Allowed
charges after your copay
Copay
of 25% up to $50 maximum
Allowed
charges after your copay
Copay
up to $50
Allowed
charges after your copay
Copay
of 50% up to $100 maximum
Preferred
high-cost (Tier 4) medications have the same benefits/copays as the generics
(Tier 1) and Preferred (Tier 2) medications. Some medications may require Prior
Authorization.
Pharmacy
benefits may cover up to a 34-day supply or 100 units, whichever is greater,
not to exceed the FDA approved ‘usual’ dosing for a 100-day supply and subject
to specific quantity limits.
Specialty
Medication Copays – Members enrolled in the HealthChoice Medicare Supplement
Plans Without Part D must pay the applicable copay for each 30-day fill of a
specialty medications. Specialty medications are only covered when purchased
through Accredo Health.
You
pay your deductible of $295
You
pay 25% ($601.25) and HealthChoice pays 75% ($1,803.75) of the next $2,405 of
prescription drug costs
You pay 100%
of the next $3,453.75 of prescription drug costs until you reach the
out-of-pocket maximum of $4,350.
Once
you reach the $4,350 out-of-pocket, HealthChoice pays 100% of allowed amounts
for covered prescription drugs purchased at Network pharmacies for the rest of
the calendar year.
Individual
annual out-of-pocket maximum for covered drugs is $4,350. This amount includes
the $295 deductible, the $601.25 (25% of the next $2,405), and the Coverage Gap
of $3,453.75 (member pays 100%).
Pharmacy
benefits may cover up to a 34-day supply or 100 units, whichever is greater,
not to exceed the FDA approved ‘usual’ dosing for a 100-day supply and subject
to specific quantity limits.
Specialty
Medication Copays – Members enrolled in the HealthChoice Medicare Supplement
Plans Without Part D must pay the applicable copay for each 30-day fill of a
specialty medications. Specialty medications are only covered when purchased
through Accredo Health.
HealthChoice Medicare Supplement Plans With and Without Part D provide
Creditable Coverage. Prescription drug coverage is called creditable if the
plan meets or exceeds Medicare’s prescription drug coverage guidelines. The
HealthChoice plans provide coverage that is equal to (the Low Option Plans) or
better than (the High Option Plans) the standard benefits set by Medicare.
HealthChoice is a qualified prescription drug plan and is not required to
send Creditable Coverage letters. However, if you need a letter of Creditable
Coverage, you can request one by contacting HealthChoice at the numbers listed
in the Plan Identification
section.
All HealthChoice Medicare Supplement Plans provide $2,000,000 of
prescription drug benefits to each enrolled member. Benefits are cumulative as
of January 1, 2004.
In most cases, you must use Network Pharmacies to get your prescription
drugs covered. They are called HealthChoice Network Pharmacies because they
contract with our Plans. Network Pharmacies provide electronic claims
processing, so generally, there are no paper claims to file.
The HealthChoice Pharmacy Network includes more than 900 pharmacies
across Oklahoma and nearly 60,000 pharmacies nationwide. To find a HealthChoice
Network Pharmacy near you, contact Medco, the HealthChoice pharmacy benefit
administrator at the numbers listed in the Plan Identification section.
You can also locate a HealthChoice Network Pharmacy by visiting the
HealthChoice website at http://www.sib.ok.gov/ or http://www.healthchoiceok.com.
Sometimes a pharmacy may leave the HealthChoice Pharmacy Network. When
this occurs, you will have to get your prescriptions filled at another Network
Pharmacy.
Although HealthChoice may pay for your covered prescriptions if they are
purchased at a non-Network pharmacy, a reduced, non-Network benefit may apply.
An exception may be made in the event of an emergency.
It is considered an emergency when you are:
Traveling outside the Plan’s
service area and run out of medications, or you become ill and need covered
medications and cannot access a network Pharmacy
Unable to obtain a covered
medication in a timely manner within the Plan’s pharmacy network
Filling a prescription for a
covered medication that is not regularly stocked at an accessible Network
Pharmacy
Prescribed a covered medication
that has been dispensed by a non-Network outpatient facility, such as an emergency
room, clinic, or outpatient surgery setting
Before you fill a prescription under these circumstances, when possible,
contact Medco to see if there is a Network Pharmacy in your area.
HealthChoice has developed a list of medications, known as the
HealthChoice Medicare Formulary. This list incorporates the categories of
prescription medications believed to be part of a good prescription drug
program. The formulary is available in two versions, an Abridged Formulary (condensed)
and a Comprehensive Formulary. You were mailed the abridged version of the
HealthChoice Medicare Formulary with your enrollment materials, and both
versions of the formularies are available on our website at http://www.sib.ok.gov/ or http://www.healthchoiceok.com. To request a copy
of the comprehensive version, contact HealthChoice Member Services at the
numbers listed in the Plan Identification section.
The abridged version of the formulary lists covered Preferred brand-name
and generic drugs. The comprehensive version of the formulary list contains
both Preferred and non-Preferred medications. While some generics are always Preferred,
some brand-name medications may also be Preferred. Generic drugs have the same
active-ingredient formula as a brand-name drug. Generic drugs usually cost less
than brand-name drugs are rated by the Food and Drug Administration (FDA) to be
as safe and effective as brand-name drugs.
For questions about coverage of a specific medication, contact Medco at
the numbers listed in the Plan Identification section.
HealthChoice may add or remove drugs from the formulary throughout the
year. HealthChoice is required to notify you of a formulary change at least 60
days prior to the change, or at the time you request a refill of the drug. Once
you receive a 60-day notice, you should work with your physician to switch your
prescription to a covered drug or request a prior authorization for a medical
necessity exception. However, if the FDA finds that a drug on the formulary is
unsafe or if the drug’s manufacturer removes the drug from the market,
HealthChoice will immediately remove the drug from our formulary and then
notify you of the change.
Medications are listed in the formulary guide by the general medical
condition they treat and in the alphabetical listing at the back of the
booklet. Brand-name and generic medications are listed in the formulary.
Brand-name medications appear in all capital letters, i.e., NEXIUM, and generic
medications are listed in lower-case italics, i.e., omeprazole. Listed by each
drug name is the drug tier, and a code indicating any restrictions on the drug,
i.e., Quantity Limitations (QL) or Prior Authorization (PA).
HealthChoice has a four-tier prescription drug formulary, and in general,
each tier represents a different cost category. By using generic (Tier 1)
medications whenever possible, you can maximize your pharmacy benefits because
they usually have the lowest out-of-pocket costs. If a generic medication is
not available, then a Preferred (Tier 2) medication may be your next least
expensive choice. The drug tiers are:
Tier 1 – Generic medications
Tier 2 – Preferred, brand-name
medications
Tier 3 – Non-Preferred,
brand-name medications
Tier 4 – Preferred, very high
cost, and unique formulary drugs
HealthChoice pharmacy benefits generally cover up to a 34-day supply or
100 units (tablets or capsules), whichever is greater, not to exceed the FDA
approved ‘usual’ dosing for a 100-day supply. Some medications and/or dosage
forms may have more restrictive quantity, and or length of therapy limits. All
prescriptions are subject to your doctor’s written orders. Refer to the
Medications Subject to Quantity Limitations section of this handbook.
This section does not apply to members of the Medicare Supplement Low
Option Plans because the Low Option Plans follow the prescription drug coverage
guidelines set by Medicare. While the Low Option Plans offer members a
selection of medications within each drug treatment category, the brand-name
exception and non-Preferred prior authorization processes do not apply.
If you choose a brand-name medication when a generic is available, you
will pay your copay plus the cost difference between the brand-name and generic
medication. You may apply for a brand-name exception. If approved, you will
receive the brand-name medication at the applicable copay, and you will not be
responsible for the cost difference between the brand-name and generic
medication. Please note that specific criteria must be met and information
supplied by your physician must justify the request for an exception.
If you choose a non-Preferred medication when a Preferred alternative is
available, you will pay the non-Preferred copay, unless you obtain a Tier
Exception for a lower copay. Please note that specific criteria must be met and
information supplied by your physician must justify the request for an
exception.
HIGH OPTION MEMBERS ONLY – To request a Brand-Name Exception or a
non-Preferred Medication Prior Authorization, please have your physician call
Medco toll-free at 1-800-841-5409. TDD users call toll-free 1-800-871-7138.
Your physician may prescribe a medication that is a non-covered or
non-formulary medication. If you receive a prescription for a non-covered or
non-formulary medication, your options will be to:
1. Ask your physician for a prescription for a generic (Tier 1) or a
Preferred (Tier 2) medication that is on the HealthChoice Medicare Formulary.
2. Continue with your non-covered medication and pay the full cost.
3. Request a prior authorization to receive the non-covered medication.
If a prior authorization is granted, the medication will be covered as a
non-Preferred drug. You will pay the higher copay unless you also request a prior
authorization for a Preferred copay. For more information, contact HealthChoice
Member Services at the numbers listed earlier in this handbook. Please ask for
the Pharmacy Resolution Unit.
*There are certain drugs that are never covered under the Plans.
Prior authorization is needed for certain drugs even though they are
listed on the HealthChoice Medicare Formulary. Prior authorization is required
for a variety of reasons, for instance if the drug:
Has a very high cost
Has specific prescribing
guidelines
Might be covered under Medicare
Part B
Is generally used for cosmetic
purposes
Requests must be submitted by your physician and approved before you fill
your prescription.
1. Have your physician’s office contact Medco toll-free at
1-800-753-2851. Your physician’s office will need to have your Member ID and
medication name available.
2. Medco will fax a Prior Authorization Form to your physician’s office
and request that it be completed and faxed back.
3. If your prior authorization is approved, it will be loaded in Medco’s
system within 24 to 48 hours and notification of the approval will be sent to
your physician’s office. You will also be notified in writing.
4. If your prior authorization does not meet clinical criteria, your
physician’s office will be sent a notification of denial within 24 to 48 hours.
You will also be notified in writing.
Note: A prior authorization is valid for one year for the date it is
issued and must be renewed when it expires. A list of
covered medications that require prior authorization is found later in
this handbook.
Due to approved therapy guidelines, certain medications have set maximum
quantity limits. Quantity limitations may also apply if the medication form is
other than a tablet or capsule. A list of medications
subject to quantity limitations is found later in this handbook.
Step therapy requires you to first try one drug to treat your medical
condition before another drug will be covered for that same condition.
Members enrolled in the Medicare Supplement Plan with Part D will continue
to have access to specialty medications through their usual pharmacy outlets.
Certain specialty medications will be covered only if you order them from
the HealthChoice specialty pharmacy, Accredo Health. Specialty medications are
usually high-cost medications that are injected or require special handling.
Members enrolled in the HealthChoice Medicare Supplement Plans Without Part D
must pay the applicable copay for each 30-day fill of a specialty medication.
Be aware that if you don’t order your specialty medications through
Accredo, you will be responsible for the full cost. Accredo also provides free
supplies, such as needles and syringes, free shipping, refill reminder calls, and
personal counseling with a team of registered nurses and pharmacists.
For more information, contact Accredo toll-free at 1-800-501-7260. TDD
users call 1-800-759-1089.
This category of medications, such as Levitra, Viagra, and Caverject is
specifically excluded from coverage unless you have had radical retropubic
prostatectomy surgery. Prior authorization is required.
Your enrollment in HealthChoice doesn’t affect Medicare’s payment for
medications covered under Part A or Part B. Some medications will be covered
under Medicare Part A or Part B, and others will be covered by HealthChoice.
Your provider or pharmacist will determine who to bill for your medication.
If you are admitted to a hospital for a Medicare-covered stay, Medicare
Part A should cover the cost of your prescription drugs while you are
hospitalized. Once you are released from the hospital, HealthChoice will cover
your prescription drugs as long as they are not covered by Medicare Part A or
Part B. HealthChoice will also cover your prescription drugs if they are
approved under the coverage determination, exception, or appeals processes.
If you are admitted to a skilled nursing facility for a Medicare-covered
stay, after Medicare Part A stops paying for your prescription drug costs,
HealthChoice will cover your prescriptions. The skilled nursing facility must
be in the HealthChoice Pharmacy Network, and the drug must not be covered under
Medicare Part B. HealthChoice will also cover your prescription drugs if they
are approved under the coverage determination, exceptions, or appeals
processes.
Upon enrollment, during transition to a HealthChoice Part D plan, or when
a physician prescribes a new drug that is non-formulary, you can be authorized
to receive a one-time supply of a non-covered medication. This transition supply,
limited to a 34-day supply, is intended to help you make a successful
transition to a formulary medication.
This temporary supply will be provided, when necessary, prior to
beginning or completing the process for prior authorization for a non-formulary
medication. For information contact Medco at the numbers listed in the Plan Identification section.
Medication Therapy Management (MTM) is a free program designed to help
improve the results of medication therapies and promote the proper use of
medications. The program is directed toward members who suffer from multiple,
chronic health conditions who are being treated with multiple medications.
Additionally, eligible members must incur prescription drug costs that exceed
$4,000 annually.
If you qualify for the program, you will receive a letter of invitation
from Medco. The letter will include information about the MTM program and a
toll-free number you can call to speak with a Medco pharmacist.
If you choose to participate in the program, you will have access to Medco’s
pharmacists who have been specially trained in patient counseling. The
pharmacists will touch on such topics as medication use and compliance, drug
education, health and safety, and when appropriate, cost saving measures.
Although the MTM program is voluntary, HealthChoice encourages all
eligible members to participate in this program. For more information contact
Medco at the numbers listed in the Plan Identification Section.
HealthChoice is not required to send you a Pharmacy EOB statement;
however, you can request a Pharmacy EOB from Medco by calling the numbers
listed in the Plan Identification Section.
Lost, stolen, or damaged
medications
Over-the-counter medications
including over-the-counter vitamins
Prescription drugs purchased
outside of the United States
This list is not all-inclusive.
Note: Some medications listed in these categories are non-formulary.
Additional information regarding non-formulary
medications is listed earlier in this handbook.
This
list, with brand-name in capital and generic in lower case, is not all-inclusive
and is subject to change.
Promote
body mass or weight gain
ANADROL-50
(oxymetholone tablets), DECA-DURABOLIN, KABOLIN (nandrolone decanoate
injection), OXANDRIN (oxandrolone tablets), WINSTROL (stanozolol tablets)
Are
similar to the male hormone, testosterone
ANDRODERM
(testosterone transdermal system), ANDROGEL, ANDROID (methyltestosterone
tablets), FIRST-TESTOSTERONE (testosterone propionate ointment), HALOTESTIN
(fluoxymesterone tablets), ORETON, METHITEST, METHYL, TESTIM (testosterone
gel), TESTODERM PATCH, TESTODERM TTS, TESTRED, VIRILON (methyltestosterone
capsules)
Refer
to previous
ANDRO-CYP,
ANDRO LA, ANDROPOSITORY, DELATESTRYL, DEPOANDRO, DEPOTEST, DEPO-TESTOSTERONE,
DURATHATE, EVERONE, HISTERONE, MALOGEN (testosterone propionate injection),
TESAMONE, TESTANDRO, TESTRO (testosterone aqueous injection), TESTRO-LA
(testosterone enanthate injection), VIRILON (methyltestosterone injection),
VIRILON IM (testosterone cypionate injection)
Treat
nausea or nausea side-effects of other drugs
ANZEMET
(dolasetron), EMEND (aprepitant), KYTRIL (granisetron), ZOFRAN (ondansetron)
Treat
infections
VFEND
(voriconazole), ZYVOX (linezolid)
Refer
to previous
TOBI
(obramycin solution for inhalation)
Treat
flu or flu-like symptoms
RELENZA
(zanamir), TAMIFLU (oseltamivir)
Stimulate
the nervous system
ADDERALL,
ADDERAL XR (amphetamine/destroamphetamine), CONCERTA (methylphenidate),
DEXADRINE, DEXEDRINE SPANSULES, DEXTROSTAT (dextroamphetamine), DESOXYN,
DESOXYN GRADUATE (methamphetamine), FOCALIN (dexmethylphenidate), METADATE CD
(methylphenidate), METHYLIN ER (methylphenidate), RITALIN, RITALIN LA (methylphenidate),
RITALIN SR
Stimulate
the production of white blood cells
G-CSF
(granulocyte colony-stimulating factor), GM-CSF (granulocyte-macrophage
colony-stimulating factor), LEUKINE (sargramostim), NEULASTA (pegfilgrastim),
NEUPOGEN (filgrastim)
Treat
pain and/or inflammation of the joints
CELEBREX
(celecoxib)
Stimulate
the production of red blood cells
ARANESP
(darbepoetin alfa injection), EPOGEN, PROCRIT (epoetin alfa injection)
Treat
male impotence
CIALIS
(tadalafil), CAVERJECT, EDEX (alprostadil inj), LEVITRA (vardenafil), MUSE
(alprostadil uretral inserts), VIAGRA (sildenafil tablets) – These medications
are specifically excluded unless you have had radical retropubic prostatectomy
surgery.
Treat
rheumatoid arthritis, Crohn’s Disease, or ulcerative colitis
REMICADE
(infliximab)
Stimulate
physical growth or metabolism
DEPOT
(somatrem), GEREF (sermorelin), GENOTROPIN, GENOTROPIN MINIQUICK, HUMATROPE,
NORDITROPIN, NUTROPIN, NUTROPIN AQ, PROTROPIN, SAIZEN, somatrem, ZORBTIVE
(somatropin)
Treat
overgrowth due to hormone imbalances
SOMAVERT
(pegvisomant)
Increase
blood platelet levels
NEUMEGA
(oprelvekin)
Reduce
rejection response to a transplant
CELLCEPT
(mycophenolate), CYTOXAN (cyclophosphamide), IMURAN (azathioprine), MYFORTIC
(mycophenolate), NEORAL (azathioprine, cyclophosphamide cyclosporine),
ORTHOCLONE OKT3 (muromonab-CD3), PROGRAF (tacrolius), PROTOPIC (tacrolimus),
RAPAMUNE (sirolimus), prednisone, prednisolone, SANDIMMUNE (cyclosporine),
THYMOGLOBULIN (antithymocyte globulin), ZENAPAX (daclizumab)
ALDURAZYME
(laronidase), AMBISOME (amphotericin B), ANXEMET (dolasetron), AVELOX
(moxifloxacin), BCG vaccine, CAMPTOSAR (irinotecan), CEREZYME (imiglucerase),
CIPRO (ciprofloxacin), CYTOVENE (ganciclovir), DOBUTREX (dobutamine), dopamine,
ELIGARD (leuprolide), FABRAZYME (agalsidase beta), FASLODEX (fluvestrant),
FLAGYL (metronidazole), FLOXIN (ofloxacin), FLUDARA (fludarabine), FOSCAVIR (foscarnet),
GANITE (gallium nitrate), GEODON (ziprasidone), HALDOL (haloperidol decanoate),
KEMSTRO (baclofen), KYTRIL (granisetron), LEUSTAT (cladribine), NEXIUM
(esomeprazole), NITROSTAT (nitroglycerin), NEBUPENT (pentamidine), PLATINOL
(cisplatin), PRIMACOR (milrinone), PROLASTIN (alpha-1 proteinase inhibitor),
PROLEUKIN (aldesleukin), PROTONIX (pantoprazole), RISPERDAL CONSTA
(risperidone), TRILAFON (perphenazine), TRISENOX (arsenic), VFEND
(voriconazole), VIBRAMYCIN (doxycycline), VITRASERT IMPLANT (ganciclovir),
UROMITEXAN (mesna), ZITHROMAX (asithromycin), ZOFRAN (ondasetron), ZOLADEX
IMPLANT (goserelin), ZOVIRAX (acyclovir)
Treat
antibody and/or autoimmune deficiencies
GAMIMUNE
N, GAMMAGARD, GAMMAR-IV, IVEEGAM, SANDOGLOBULIN, VENOGLOBULIN
Medications
available in a mist dosage form
ACCUNEB
(albuterol sulfate), ALUPENT (metaproterenol), ATROVENT (ipratropium bromide),
BRETHINE (terbutaline sulfate), CROLOM (cromolyn sodium), DECADRON
(dexamethasone), DUONEB (albuterol sulfate/ipratropium bromide), MAXIDEX
(dexamethasone), MUCOSIL, MUCOMYST, MUCOMYST-10 (acetylcysteine), NEBUPENT
(pentamidine isethionate), PULMICORT (budesonide), ROBINUL (glycopyrrolate),
TORNALATE (bitolterol), XOPENEX (isoetharine, levosalbutamol hydrochloride)
Treat
those at high risk of bone fracture or having had a bone fracture
FORTEO
(teriparatide)
Treat
special bronchial-related disease states
PULMOZYME
(recombinant dornase alfa inhalation solution), SYNAGIS (palivizumab), XOLAIR (omalizumab),
XOPENEX (levalbuterol inhalation solution)
Treat
skin conditions
TAZORAC
(tazarotene)
New medications that
become available in the drug categories listed will automatically have quantity
limits per copay. New drug categories may be added throughout the year. If
generic equivalents are available or become available, they will also be
limited in quantity. Some medications listed in these categories are
non-formulary. Additional information
regarding non-formulary medications is listed
earlier in this handbook.
This
list, with brand-name in capital and generic in lower case, is not
all-inclusive and is subject to change.
Treat
rheumatoid arthritis
ARAVA
(leflunomide), ENBREL (etanercept), HUMIRA (adalimumab), KINERET (anakinra)
Treat
male impotence
CAVERJECT
(alpostadil), CIALIS (tadalafil), EDEX (alpostadil), LEVITRA (vardenafil), MUSE
(alprostadil), VIAGRA (sildenafil)
Spray
dosage forms that treat asthma or allergic responses
BECONASE
AQ (beclomethasone), FLONASE (fluticasone), fluticasone, NASACORT AQ
(triamcinolone), NASACORT HFA (triamcinolone), NASAREL (flunisolide), NASONEX
(mometasone), RHINOCORT (budesonide), RHINOCORT AQUA (budesonide), VANCENASE
POCKETHALER (beclomethasone)
Treat
cancer conditions
IRESSA
(gefitinib)
INTAL
(cromolyn), NASALCROM (cromolyn), TILADE (nedocromil)
Treat
headaches
AMERGE
(naratriptin), AXERT (almotriptan), FROVA (frovatriptan), IMITREX
(sumatriptan), IMITREX INJ (sumatriptan), IMITREX NS (sumatriptan), MAXALT
(rizatriptan), MAXALT-MLT (rizatriptan), MIGRANAL NS (dihydroergotamine
mesylate), RELPAX (eletriptan), STADOL NS (butorphanol nasal spray), ZOMIG
(zolmitriptan), ZOMIG NS (zolmitriptan), ZOMIG-ZMT (zolmitriptan – orally
disintegrating tablets)
Treat
multiple sclerosis
AVONEX
(interferon beta-la), BETASERON (interferon beta-lb), COPAXONE (glatiramer),
REBIF (interferon beta-la)
Treat
those at high risk of bone fracture or having had a bone fracture
ACTONEL
(risedronate) 35mg & 75mg, BONIVA (ibandronate) 150mg, FORTEO
(teriparatide), FOSAMAX (alendronate) 35mg & 70mg, FOSAMAX-D
(alendronate/vitamin D) 70mg/2800IU & 70mg/5600IU, FOSAMAX SOLUTION
(alendronate) 70mg/Btl, MIACALCIN (calcitonin-salmon)
Treat
special eye conditions
RESTASIS
(cyclosporine ophthalmic emulsion) 0.05%
Treat
insomnia or sleeping disorders
AMBIEN
(zolpidem), BUTISOL (butabarbital), DORAL (quazepam), HALCION (triazolam),
LUNESTA (eszopiclone), PROSOM (estazolam), RESTORIL (temazepam), RESEREM
(ramelteon), SONATA (zaleplon), VARIOUS (chloral hydrate)
Medications
that are absorbed through the skin to replenish estrogen levels
ALORA
(estradiol), CLIMARA (estradiol), CLIMARA PRO (estradiol/levonorgestrel),
COMBIPATCH (estradiol/morethindrone), ESCLIM (estradiol), ESTRADERM
(estradiol), ESTROGEL (estrodiol), ESTRASORB (estrodiol), MENOSTAR (estradiol),
VIVELLE, VIVELLE-DOT (estradiol)
Patches
of medication that are absorbed through the skin
ANDRODERM
(testosterone), ANDROGEL (testosterone), CATAPRESS TTS (clonidine), DAYTRANA
(methylphenidate), DURAGESIC (fentanyl), EMSAM (selegiline), LIDODERM
(lidocaine), nitroglycerin, ORTHO-EVRA (norelgestromin/ethinyl estradiol),
OXYTROL (oxybutynin), STRIANT (testosterone), TESTIM GEL (testosterone), TRANSDERM-SCOPE
(scopolamine)
Claims
must be received no later than December 31st of the year following
the year claims were incurred. For example, if the date of service was July 1,
2008, the claim will be accepted through December 31, 2009.
Most
providers will file your claims for you. Once your provider has filed a claim
with Medicare, he/she will automatically file your claim with HealthChoice. In
order to process your claim electronically, HealthChoice must have your and
your covered dependents’ Medicare numbers on file.
If
you must file your claims with HealthChoice personally, you will need to wait
until Medicare has processed your claim and sends you an Explanation of
Benefits statement for Part A and Part B services. You can then file your claim
with HealthChoice by sending a copy of the Explanation of Benefits statement to
EDS Administrative Services at PO Box 24870, Oklahoma City, OK, 73124-0870.
HealthChoice
will send you an Explanation of Benefits on all claims that are processed.
If
you or your enrolled dependents incur charges that are covered by another group
health plan, your HealthChoice benefits will be coordinated with your other
health plan so that the total benefits received are not greater than the amount
billed or greater than your liability. If you have other group coverage that is
primary over your HealthChoice coverage, you must file your claim through your
primary plan first.
If
your other group coverage terminates, please send written notice to EDS
Administrative Services at PO Box 24870, Oklahoma City, OK, 73124-0870.
If
you have any questions regarding coordination of health benefits, please
contact EDS Administrative Services Customer Service at the numbers listed in
the Plan Identification Section.
If
you have End-Stage Renal Disease, Medicare is the secondary payer to your
employer’s group health plan for 30 months. This requirement applies regardless
of whether you have your own coverage under a group health plan or are covered
as a dependent under a group health plan. During this time period, group health
plans are the primary payers without regard to the size of the plan, or whether
you or a family member works.
If
you have questions regarding Medicare coverage of End-Stage Renal Disease,
please call Medicare toll-free at 1-800-633-4227. TTY/TDD users call toll-free
1-877-486-2048. You can also visit their website at http://www.medicare.gov.
In
most cases your pharmacy claim will be processed electronically at the
pharmacy. If your pharmacy has questions, please have your pharmacy call
toll-free
Medco Pharmacy Help Line: 1-800-922-1557
Medco TDD Line: 1-800-825-1230
In
rare cases, however, you may need to file a direct (paper) claim with us. To do
so, send your pharmacy receipt and Statement of Claim form to:
With Part D: Medco, PO Box 14718, Lexington,
KY, 40512
Without Part D: Medco, PO Box 14711, Lexington,
KY, 40512
You
can get a Statement of Claim form by calling Medco at the numbers listed in the
Plan Identification Section.
If
your claim involves other group health insurance, you will also need to include
a copy of the Explanation of Benefits Form (EOB) you received from your other
carrier.
If
you or a dependent have other group pharmacy coverage that is primary over
HealthChoice, your pharmacy can still process your prescription drug claims
electronically at the time of purchase.
If
your pharmacy is equipped for electronic claims submission, you will need to
show that pharmacist your HealthChoice Prescription Drug ID card, along with
your primary insurance coverage card. If the pharmacy cannot file your
secondary claims electronically, have your pharmacy contact the Medco Pharmacy
Help Line toll-free at 1-800-922-1557. It may be necessary for you to file a
direct (paper) claim. Refer to the Pharmacy Claims
Filing Section.
If
you have questions about how your pharmacy benefits will be affected by
coordination of benefits, please contact Medco at the numbers listed in the Plan Identification Section.
When
traveling outside the U.S., you must pay for services up front and then submit
the itemized bill. The bill must be translated to English and converted to U.S.
dollars using the exchange rates applicable for the date(s) of service. Claims
should be submitted to EDS Administrative Services at PO Box 24870, Oklahoma
City, OK, 73124-0870.
For
questions regarding claim filing, call EDS Administrative Services at the
numbers listed in the Plan Identification
Section.
A
Private Contract is a written agreement between a Medicare beneficiary and a
doctor or other practitioner who has decided not to provide services through
the Medicare program.
A
provider who opts out of Medicare will ask you to sign a Private Contract
before he or she provides care. If you sign a Private Contract and receive
services:
You will have to pay whatever the doctor or
practitioner charges. Medicare’s limiting charges will not apply.
Claims for Private Contract services will
not be accepted by Medicare or HealthChoice, and neither Medicare nor
HealthChoice will pay anything for these services.
Subrogation applies when you are sick or injured as a result of the
negligent act or omission of another person or party. Subrogation means the
HealthChoice plans have a right to recover any benefit payments made to you or
your dependents by a third party’s insurer, because of an injury or illness
caused by the third party. Third party means another person or organization.
If you or your covered dependents receive HealthChoice benefits and have
a right to recover damages from a third party, this plan has the right to
recover any benefits paid on your behalf. All payments from a third party,
whether by lawsuit, settlement, or otherwise, must be used to repay
HealthChoice.
You must promptly notify HealthChoice if you make a claim against a third
party regarding any illness or injury for which HealthChoice benefits have been
or will be paid. You, or your dependent, must provide information requested by
HealthChoice. HealthChoice benefits may be withheld until information is
received.
After any requested information is received, HealthChoice will process
your covered claims, regardless of whether any third party may eventually be
found liable for the expenses arising from the injury.
If you need more information about subrogation, please contact OSEEGIB at
the numbers listed in the Plan Identification Section.
Do not contact the claims office, EDS Administrative Services, regarding
subrogation as this will only delay any response.
You may choose any provider or other practitioner who is contracted with
Medicare in the state in which the provider practices and who is recognized by
the Plans. Your provider is responsible to you for medical advice, treatment,
or any liability resulting from that advice or treatment. Although a provider
may recommend or prescribe a service or supply, this does not of itself,
establish coverage by the Plans.
Certification may be required if Medicare is not paying as the primary
carrier. If you have questions, contact the HealthChoice certification
administrator, APS Healthcare, toll-free at 1-800-848-8121 or TDD
1-877-267-6367.
Ending your membership with HealthChoice can be voluntary (your choice)
or involuntary (not your choice). You might choose to leave the Plan or
HealthChoice may be required to end your membership.
If HealthChoice ends your membership, we will send you a letter
explaining our reasons and how you can file a complaint against HealthChoice,
if you choose to do so.
If you end your membership with HealthChoice and enroll in another plan
offered through OSEEGIB, you may do so during the annual Option Period. If you
drop coverage through OSEEGIB, you will not be able to re-enroll later, and you
may forfeit the retirement system contribution paid toward your health
insurance.
If you are enrolled in a plan with Part D, remember that if you drop your
HealthChoice coverage at any time, you must enroll in another qualified Part D
plan within 63 days to avoid a late enrollment penalty.
Anytime a change is made to your coverage, you will be mailed a
Confirmation Statement (CS). The CS identifies the coverage changes, the
effective date of the changes, and the premium amounts. The CS is provided so
that you can review changes, and any errors can be identified and corrected as
soon as possible.
If your monthly plan premiums are late, we will tell you in writing that
if you don’t pay your monthly plan premium by a certain date, which includes a
grace period, we will end your membership in our Plan. The HealthChoice Plans’
grace period is two months.
H.E.L.P. offers wellness opportunities for Plan participants who are
choosing to become and stay well. Wellness opportunities include:
You may find health and wellness information in the HealthVoice
newsletter.
The website home page of the HealthChoice website has ‘featured articles’
on health and wellness.
HealthChoice encourages you and your covered dependents to join the
HealthChoice Walking Club. Walking is one of the easiest types of exercise to
do and one of the most beneficial for your overall health and well-being.
Walking Club members will receive log sheets to record dates and distances
walked, walking tips, warm-up and cool down exercises, and shoe care
instructions. We also offer incentives for walking every 100 miles up to 1,000
miles. This requires you to send us your completed log sheets (or copies) to be
recorded. If you want to join this program, you may enroll online at http://www.sib.ok.gov/ or http://www.healthchoiceok.com or call the
H.E.L.P. Line 1-405-717-8991 or toll-free 1-800-318-2365. TDD users call
1-405-949-2281 or toll-free 1-866-447-0436.
HealthChoice contacted fitness centers throughout the State of Oklahoma
to ask them to provide a special discount to HealthChoice members and
dependents. All you have to do is present your HealthChoice ID card at any of
the participating fitness centers to receive your special discounted rate. The
listing of participating fitness centers is available on our website at http://www.sib.ok.gov/ or http://www.healthchoiceok.com. If your favorite
fitness center is not on the list contact the H.E.L.P. Line at 1-405-717-8991
or toll-free 1-800-318-2365. TDD users call 1-405-949-2281 or toll-free 1-866-447-0436.
Medicare is a national health insurance program for people 65 years of
age and older, certain younger disabled people, and people with permanent
kidney failure. Medicare is managed by the Centers for Medicare and Medicaid
Services (CMS). The Social Security Administration helps CMS by enrolling
people in Medicare and by collecting Medicare premiums. For more information
regarding Medicare, please contact the Social Security Administration at the
numbers and websites listed in the Plan Identification section.
Medicare is divided into several parts. The parts that apply to this plan
are:
Part A – Hospital insurance
Part B – Medical insurance for
doctors’ services and other outpatient care
Part D – Prescription drug
benefits
Helps pay for hospital and skilled nursing facility care as well as some
home health care and hospice care. If you do not qualify for premium-free Part
A, you may buy it. You must be at least 65 years old and meet certain other
requirements. You may also buy Part A if you are under age 65 and were once
entitled to Medicare under the disability provisions.
Pays fees for physicians and other outpatient service providers that are
not covered under Part A, such as physical or occupational therapists and some
home health care. If you did not sign up for Part B when you first became
eligible, your premiums for Part B may be higher than if you enrolled when you
were first eligible; however, you may delay enrollment in Part B if you are
still working and are eligible for insurance through your employer.
Helps pay for prescription drug benefits. HealthChoice has contracted
with Medicare to provide Part D benefits to members enrolled in the plans with
Part D. To be eligible for Part D, you must be entitled to Part A and/or
enrolled in Part B and permanently residing in the Plan’s service area.
Enrollment in Medicare is handled in two ways – either you are
automatically enrolled or you must apply. If you are already receiving Social
Security or Railroad Retirement Board benefits prior to turning age 65, you are
automatically enrolled and your Medicare ID card will be mailed to you about
three months before your 65th birthday. If you are not already
receiving retirement benefits, you must apply for Medicare by contacting the
Social Security Administration, or if appropriate, the Railroad Retirement
Board. You should apply three months before your 65th birthday to
avoid a possible delay in the start of your coverage.
If you have been a disabled beneficiary under Social Security or Railroad
Retirement for 24 months, you will automatically get a Medicare card in the
mail. Please notify OSEEGIB when you become Medicare eligible due to a
disability.
When you become Medicare eligible because you turned 65, you will
automatically be enrolled in the corresponding HealthChoice Medicare Supplement
Plan With Part D. For example, if you are a HealthChoice High Option Plan
member, you will be moved to the High Option Medicare Supplement Plan With Part
D. HealthChoice must have your and any covered dependents’ Medicare numbers on
file. To easily provide this information, please send a copy of your and your
dependents’ Medicare cards to HealthChoice at 3545 NW 58th, Ste 110,
Oklahoma City, OK, 73112.
If you become eligible for Medicare before age 65 due to a disability,
you must complete and return an Application for HealthChoice Medicare
Supplement With Part D to enroll in the Part D plan. You will be enrolled in
the Plan the first day of the month following receipt of your application or on
the effective date of Medicare coverage, whichever is later. You must be
enrolled in Medicare Part A and Part B.
There are three time periods when you may enroll or disenroll from the
HealthChoice Medicare Supplement Plans.
The Initial Enrollment Period refers to the time period when you first
become eligible for enrollment in Medicare. This seven month period begins
three months prior to the month you actually become eligible and extends three
months beyond the month of eligibility.
Example – Mrs. Smiths 65th birthday is April 20, 2009. She is
eligible for Medicare Part A and her Part B and Part D initial enrollment
period begins on January 1, 2009, (three months prior to the birthday month)
and ends on July 31, 2009 (three months after her birthday month).
The HealthChoice Annual Enrollment Period, also called Option Period,
occurs in the fall of each year. You may change a plan election up until the
effective date of coverage, which is January 1. Once your enrollment becomes
effective, no plan changes can be made until the next Option Period.
Special Enrollment Periods are allowed under certain situations, such as
when:
You move outside the United
States – the HealthChoice service area.
You lose Creditable Coverage for
reasons other than failure to pay premiums.
You gain or lose Extra Help
paying for your prescription drug coverage.
You enter or leave a skilled
nursing facility.
You meet other exception rules
as set out by CMS.
CMS or HealthChoice terminates
the Plans’ participation in the Part D program.
For information on Special Enrollment Periods, contact HealthChoice
Member Services at the numbers listed in the Plan Identification Section.
Effective date is the first of the month you become Medicare eligible, or
the first of the month following the election, whichever is later.
Effective date is January 1.
Effective date is dependent on the individual circumstances. The
effective date of coverage always follows the processing of the completed
enrollment request and can never be before the date of the completed enrollment
request.
Dependents may be added to your coverage only if one of the following
conditions is met:
Your dependent was insured under
other group health insurance and lost his/her coverage under that plan.
Application for enrollment and proof of the termination of other group health
coverage must be made within 30 days of the loss.
If you marry, and want your new
spouse and any dependent children added to your coverage, you must add them
within 30 days of your marriage. This 30-day window will be the only chance you
will have to enroll your new spouse or dependent children. Once the 30 days has
passed, there will not be another chance to add dependents to your coverage,
unless they lose other group coverage. A copy of your marriage certificate must
be presented at the time you enroll a new spouse and/or dependent.
You must enroll new dependent
children within 30 days of birth, adoption, or legal guardianship.
Documentation must be presented at the time of application.
Your legal spouse (including
common-law)
Your unmarried children up to
age 25 provided you are primarily responsible for their support
Your dependent, regardless of
age, who is incapable of self-support and who has a disability that was
diagnosed before the age of 25, subject to medical review and approval
Your stepchildren provided they
are living with you and you are primarily responsible for their support, or
regardless of residence if you spouse has been court ordered to provide
coverage and your spouse is also being covered
Other dependent children – in
the absence of a federal income tax return listing the children as dependents,
you will be required to provide and have approved a Declaration of Dependency
form
Newborns will be covered the first 48 hours following a vaginal birth or
the first 96 hours following a cesarean section without enrollment. To continue
coverage on your newborn, you must add him/her within 30 days of the birth. If
you do not enroll your newborn during this 30-day time period, you will not be
able to do so in the future. The newborn’s Social Security number is not
required at the time of initial enrollment, but must be provided once it is
received from the Social Security Administration. If enrolled, insurance
premiums must be paid for the full month of the child’s birth.
Eligible dependents can be excluded from coverage if they have group
health coverage or are eligible for Indian or military health benefits.
A dependent who is no longer eligible may elect continuation of coverage
under COBRA for a maximum of 36 months.
All requests for changes in coverage must be made in writing. Verbal
requests for changes in coverage will not be accepted. Please send all requests
for changes to HealthChoice at 3545 NW 58th, Ste 110, Oklahoma City,
OK, 73112.
If you terminate coverage in retirement or as a vested member, you cannot
re-enroll in the Plans offered through OSEEGIB. If your dependent is dropped
from the Plan, your dependent cannot be re-enrolled unless he/she loses other
group coverage.
As a retiree, if any portion of your coverage is canceled, i.e., health,
dental, or life, it cannot be reinstated at a later date unless you return to
work as an employee of a participating employer. The exception is vision
coverage which can be elected during the annual Option Period.
If you enroll in the group health plan offered through your employer,
that plan will be your primary insurance carrier; however, you may be eligible
to continue your HealthChoice Medicare Supplement Plan as your secondary
coverage*.
If you are able to opt out of your employer’s group health plan, Medicare
will be your primary insurance carrier, and you may be eligible to continue
your HealthChoice Medicare Supplement Plan as your secondary coverage*
If you are a retired or vested member returning to work, and you did not
continue health coverage at retirement or vesting, you must meet all the
eligibility requirements of a new employee. You must work for an additional
three years to be able to continue your health coverage into your second
retirement.
*Be aware that your employer can’t provide a Medicare supplement plan, or
pay for any premiums related to a Medicare supplement plan.
Your surviving dependents have 60 days to notify HealthChoice that they
wish to continue coverage under the Plan. If your dependents are on a With Part
D plan, their coverage will automatically continue as survivors with the option
to cancel coverage. Coverage will be made retroactive to the first day of the
month following your death. Surviving dependents will receive a bill for all
past months’ premiums. Claims for medical treatment and pharmacy purchases must
be filed for reimbursement after your survivors are enrolled and premiums are
received.
Your surviving dependents are eligible to continue any coverage that was
in effect at the time of your death, as long as all required premiums are paid.
Your surviving dependent children are eligible for coverage until:
Age 25
They marry
Over-age, disabled, dependent children are eligible to continue coverage
as a survivor as long as they continue to meet the Plan’s definition of a
disabled dependent.
COBRA continuation of coverage is available for dependents who lost
eligibility. Refer to the COBRA (Consolidated Omnibus
Budget Reconciliation Act) section.
Notification of death should be directed to the appropriate retirement
system and to HealthChoice.
If you were a career tech employee or a common school employee and
terminated active employment on or after May 1, 1993, you may continue coverage
through the Plan as long as the school system from which you retired or vested
continues to participate in the Plan. If your school system terminates coverage
with the Plan, you must follow your former employer to its new insurance
carrier.
If you were an employee of an education employer other than a common
school (e.g., Higher Education, Charter School, etc.) you may continue coverage
through the Plan as long as the education employer from which you retired or
vested continues to participate in the Plan. If your employer terminates
coverage with the Plan, you must follow your former employer to its new
insurance carrier regardless of the date you terminated active employment.
If you were a local government employee and terminated active employment
on or after January 1, 2002, you may continue coverage through the Plan as long
as the employer from which you retired or vested continues to participate in
the Plan. If your local government employer terminates coverage with the Plan,
you must follow your former employer to its new insurance carrier.
All group retirees that join the Plan after the grandfathered dates
specified above must follow the group to the new insurance carrier.
You dependents may have the right to COBRA continuation of coverage when:
Your spouse’s coverage under the
Plans ends due to divorce or legal separation
Your covered dependent children
become ineligible through age or marriage
Your eligible dependents must elect COBRA continuation of coverage within
60 days of the date they become ineligible for coverage under this Plan. All
required COBRA premiums must be paid.
What to do if you have a complaint, a denied claim, or you disagree with
a decision that has been made about your health or pharmacy benefits.
If your health claim was denied in whole or in part for any reason, you
have the right to have that claim reviewed. Requests for review of your denied
claim, along with any additional information you wish to provide, must be
submitted in writing to the address listed in the Who to Contact for Complaints, Grievances, Appeals,
or Coverage Determinations section.
If after a claim review, your claim remains denied, you may appeal that
decision to the Grievance Panel. You may submit a request for a Grievance Panel
hearing and represent yourself in these proceedings. If you are unable to
submit a request for a Grievance Panel hearing yourself, only attorneys
licensed to practice in Oklahoma are permitted to submit your hearing request
for you, or to represent you through the hearing process [75 O.S. Section
310(5)].
All requests for hearings must be filed within one year of the date you
are notified of the denial of a claim, benefit, or coverage. All medical claim
reviews and final decisions of the Grievance Panel are made as quickly as
possible. After exhausting the claim review and grievance procedures, an appeal
may be pursued in Oklahoma District Court.
The Grievance Panel is an independent review group as established by
Statute 74 O.S. Section 1306(6). For more information contact The Legal
Grievance Department, Contact information can be found in the Who to Contact for Complaints, Grievances, Appeals,
or Coverage Determinations section.
The following is an outline of the guidelines for filing and tracing a
Medicare Part D Prescription drug grievance or appeal. A complete guide is
available upon request by calling HealthChoice Member Services at the numbers
listed in the Plan Identification section.
Please let us know if you have questions, concerns, or problems related to
your Part D coverage. The contact information for each of the processes can be
found in the Who to Contact for
Complaints, Grievances, Appeals, or Coverage Determinations section.
Federal law guarantees your right to make complaints if you have concerns
or problems with care or services. The appeals process for Part D prescription
drug benefits required by the Medicare Modernization Act of 2003, is the
process you follow if you disagree with the policies or decisions regarding
quantity limits, non-formulary and tier exceptions, prior authorizations, and
exceptions to step therapy policies. The Medicare program has helped to set the
rules about what you need to do to make a complaint and what HealthChoice is required
to do when a complaint is received. You cannot be disenrolled from HealthChoice
or penalized in any way for lodging a grievance or appealing a claim.
Complaints concerning the quality of care received under Medicare may be
acted upon by Medco, by HealthChoice under the grievance process, by an
independent organization called the Quality Improvement Organization (QIO), or
by all parties. For example, if you believe your pharmacist provided the
incorrect dose of a prescription, you may file a complaint with the QIO in
addition to or instead of filing a complaint under the HealthChoice grievance
process. A complaint about a quality of care issue must be made in writing and
can be filed at any time.
A grievance concerns a complaint about a problem you have getting
accurate and timely information from HealthChoice Member Services or from
Customer Service at our pharmacy benefits manager, Medco. A grievance issue
does not involve coverage or payment. Following are some problems that might
lead you to file a grievance:
You feel you are being
encouraged to disenroll from HealthChoice
Problems with customer service
Problems with the behavior of a
network pharmacist
Waiting too long for
prescriptions to be filled
You believe informational materials
are difficult to understand
HealthChoice doesn’t make a
decision about your claim in the required time frame
You disagree with our decision
not to expedite (fast track) your request for a determination or
redetermination
HealthChoice fails to forward
your case to a certified Independent Review Entity (IRE) when a decision is not
made within the required time frame
If you wish to make a complaint regarding any quality issues involving
the Part D prescription drug program, you or your physician may call Medco at
the numbers found in the Who to Contact for Complaints, Grievances, Appeals, or Coverage
Determinations section.
Whenever you ask for coverage of a medication under Medicare Part D, it
is called a Coverage Determination. An example might be when you take your
prescription to be filled at the pharmacy and coverage for your prescription is
approved or denied. This decision is known as a Coverage Determination.
If your request is denied (also called an Adverse Coverage
Determination), you may request an exception. You might ask HealthChoice for an
exception if:
You want to receive a brand-name
medication when a generic is available
You want to receive a brand-name
or non-Preferred drug at the Preferred copay
You want us to pay for a
non-covered medication
You disagree with the quantity
limitation set for a medication
You want us to pay you back for
a medication you have already received
You are not getting a
prescription medication that you believe is covered by the Plan
You want us to pay for a drug
that is not on the HealthChoice Medicare Formulary
You disagree with the Plans’
requirement that you try another drug (step therapy) before HealthChoice will
pay for the drug your doctor prescribed
You bought a medication at a
non-Network Pharmacy and want HealthChoice to pay you back
If your request for an exception is denied, you have the right to file an
appeal by contacting Medco at the numbers listed in the Who to Contact for Complaints, Grievances, Appeals,
or Coverage Determinations section.
An appeal, also known as a Coverage Redetermination, is any of the
procedures that deal with the review of an unfavorable decision (coverage
determination). You can file an appeal if you want HealthChoice to reconsider
and change a decision that was made about prescription drug benefits. If you
are unhappy with a decision made at any level of the appeals process, you will
have 60 calendar days to file an appeal at the next level.
You must first decide if you want a standard or a fast coverage
determination. A standard determination is usually responded to within 72
hours. A fast determination is handled within 24 hours, but it is only
available if you or your doctor believe that waiting any longer could seriously
harm your health or your ability to function. Fast determinations are not
available if you have already received your medication. To make either kind of
request, you, your appointed representative, or your physician should call the
appropriate phone number listed in the Who to Contact for Complaints, Grievances, Appeals, or Coverage
Determinations section.
Federal regulations require five levels of appeal. At each level, your
request is considered and a decision is made. If you are unhappy with a
decision, you may be able to request an appeal at the next level. Whether you
are able to take the next step may depend on the dollar value of the medication
in question.
A grievance and/or appeal may be submitted by you, your appointed
representative, or your prescribing physician. Following is a description of
the levels of appeal.
The first step in the appeals process is requesting a Coverage
Redetermination. You should ask for a Coverage Redetermination if you are not
satisfied with the decision of a Coverage Determination. In general, this
process consists of a review of prescribing and therapeutic guidelines of your
medication. You will receive a written decision from Medco concerning your
drug. If you are not happy with the Coverage Redetermination, or the amount you
will have to pay for a drug, then this denial (Adverse Coverage Determination)
may be appealed to the next level.
If HealthChoice denied your request for a Coverage Redetermination, you
may request, in writing, a review by a federal government-contracted
Independent Review Entity (IRE). For a standard appeal, the IRE has up to seven
calendar days from the date your request is received to make a decision. A fast
decision about a Part D drug that you have not received should be handled
within 72 hours. The IRE must notify you in writing about its decision.
If the Independent Review Entity denies your Level 2 appeal, you may ask
for a review by an Administrative Law Judge (ALJ). You must request a Level 3
appeal in writing.
If the ALJ rules in your favor regarding a payment issue, HealthChoice
must send payment to you within 30 calendar days of the date we receive notice.
For a standard decision about a drug you have not received, HealthChoice must
authorize or provide you with that drug within 72 hours of the date we receive
notice. For a fast decision about a drug you have not received, HealthChoice
must authorize or provide you with that drug within 24 hours from the date we
receive notice.
At this level, you have the right to request that your case be reviewed
by a Medicare Appeals Council (MAC). The MAC may or may not decide to review
your appeal. If the MAC reviews your appeal and makes a decision in your favor,
HealthChoice will provide payment or authorization within the same time frames
stated in Level 3. In the event of a denial, the written notice you receive
from the MAC will explain what you need to do if you choose to take your appeal
to federal court.
If you choose to continue your appeal and request judicial review of your
case, you must file a civil action in a United States District Court. The
letter you receive from the Medicare Appeals Council in Level 4 will tell you
how to request this review. The decision whether or not to review your case
will be made by a federal court judge. The judge’s decision is final and you
may not take your appeal any further.
Complete instructions for filing an appeal at Levels 2 through 5 will be
sent to you directly from the source that is handling the appeal.
We encourage you to contact us as soon as possible if you have questions,
concerns, or problems related to your prescription drug coverage. If your
pharmacy claim is denied and you have questions concerning the denial, please
contact Medco’s Member Services toll-free at 1-800-903-8113 or TDD
1-800-825-1230.
If you wish to appeal a denied pharmacy claim based on clinical criteria
provided by your physician, you may mail or fax your written appeal to the OSEEGIB
Pharmacy Unit. Contact information can be found in the Who to Contact for Complaints, Grievances, Appeals,
or Coverage Determinations section.
If your appeal is denied, you have the right to file a grievance with OSEEGIB.
Members without Part D will follow the same appeals procedures used when
appealing a denied health claim.
To find out the number of grievances, appeals, and exceptions that
Medicare Part D members have filed with the Plans, please contact HealthChoice
Member Services at the numbers listed in the Plan Identification section.
OSEEGIB is committed to conducting its business activities with integrity
and in full compliance with the federal, state, and local laws governing its
business. This commitment applies to relationships with members, providers,
auditors, and all public and governmental bodies. Most importantly, it applies
to employees, subcontractors, and representatives of OSEEGIB. This commitment
includes the policy that all such individuals have an obligation to report
problems or concerns involving ethical or compliance violations related to its
business.
If you suspect that OSEEGIB and/or Medicare have been defrauded, are
being defrauded, or that resources have been wasted or abused, report the
matter to the OSEEGIB Compliance Officer immediately. You can report suspicious
acts or claims by:
Visiting the Compliance Officer
in person
Sending a report in writing to
OSEEGIB Compliance Officer, 3545 NW 58th, Ste 110, Oklahoma City,
OK, 73112
Emailing a message to antifraud@sib.ok.gov
Leaving a report in the secure drop box outside the OSEEGIB 5th
Floor Board Room
Calling the OSEEGIB toll-free
hotline at 1-866-381-3815
Submitting an online report
You are encouraged to provide adequate information in order to assist
with further investigation of fraud. All investigations will be handled
confidentially. Every attempt will be made to ensure the confidentiality of any
report, but please remember that confidentiality may not be guaranteed if law
enforcement becomes involved. There will be no retaliation against anyone who
reports conduct that a reasonable person acting in good faith would have
believed to be fraudulent or abusive. Any employee who violates the
non-retaliation policy will be subject to disciplinary action up to and including
termination.
You may also submit such reports anonymously. If you choose to submit
information anonymously and want to receive updates on the status of the
investigation, you will be required to supply to Compliance Officer with an
alias and a password as a means of obtaining secure updates. It will be the
reporting individual’s responsibility to remember both the alias and password
he or she provides, since the Compliance Officer will not be able to divulge or
reconfirm these if they are forgotten.
This notice describes how medical information about you may be used and
disclosed and how you can get access to this information. Please review it
carefully.
OSEEGIB is a State of
Oklahoma governmental agency created and governed by Oklahoma law for the
purpose of administering health, life, disability, and dental
This notice describes
and gives you examples of the permitted ways your health information may be used
and disclosed.
OSEEGIB uses and
discloses your protected health information for your treatment, payment for
services, and OSEEGIB business operations in the administration of health
plans. The health claims you submit, or health claims submitted by providers
for your treatment, contain protected health information and are processed for
payment and data collection by claims administrators according to Oklahoma law
and contractual terms of confidentiality with OSEEGIB. Your health information
is used and disclosed by OSEEGIB employees and other entities under contract
with OSEEGIB according to the ‘minimum necessary’ standard. OSEEGIB or its
claims administrators may use and disclose health information, to determine
medical necessity for pre-certification of hospital and medical
You have the right
to: a) inspect and copy your health information, (generally EOBs) with the
exception of psychotherapy notes and/or information that requires a court
order; b) amend and restrict the health information that OSEEGIB discloses
about you; however, OSEEGIB is not required to agree to a requested
restriction; c) request your communications remain confidential with OSEEGIB;
d) receive a copy of this Notice; e) file a complaint if you believe OSEEGIB
has improperly used or disclosed your information; f) request a listing of
disclosures, except for treatment, payment, business operations, and per your
authorization after April 14, 2003; and g) receive a paper copy of this Notice
upon request if you have received this Notice electronically.
OSEEGIB reserves the
right to change the terms of this Privacy Notice and will provide all
interested persons a revised notice either by U.S. Postal Service delivered to
the individual’s mailing address on file with OSEEGIB or electronic
communication by posting the revised Privacy Notice on the OSEEGIB website at www.healthchoiceok.com and www.sib.ok.gov
If you believe your
privacy rights have been violated, call or send a written complaint to the
OSEEGIB HIPAA Information Officer at 3545 NW 58th, Suite 110, Oklahoma City,
Oklahoma, 73112, 1-405-717-8701, toll-free 1-800-543-6044, TDD 1-405-949-2281,
or toll-free TDD 1-866-447-0436; the Secretary of the U.S. Department of Health
and Human Services (HHS) at the Office of Civil Rights, 1301 Young Street, Ste
1169, Dallas, Texas, 75202, 1-214-767-4056, or submit an electronic complaint
according to directions located on the HHS Office of Civil Rights website.
Complaints to HHS must be filed within 180 days after the date on which you
became aware, or should have been aware, of the violation. No retaliation is
allowed against the individual filing a complaint.
Revised Notice
effective August 5, 2005
When health insurance terminates, a Certificate of coverage will be sent
to your last known address. OSEEGIB will mail certificates for education and
local government employees, former members, surviving dependents, and COBRA
participants. The Employees Benefits Council (EBC) will mail Certificates of
Coverage to state employees. A Certificate of Coverage may be required, as
proof of previous group health coverage, by your next health plan for a waiver
of preexisting condition limitations.
Under the Oklahoma Breast Cancer Patient Protection Act, group health
plans, insurers, and HMOs that provide medical and surgical benefits in
connection with a mastectomy must provide benefits for certain reconstructive
surgeries effective for the first plan year beginning on or after January 1,
1998. In the case of a participant or beneficiary who is receiving benefits
under a plan in connection with a mastectomy and who elects breast
reconstruction, federal law requires coverage in a manner determined in
consultation with the attending physician and the patient for:
Reconstruction of the breast on
which the mastectomy was performed
Surgery and reconstruction on
the other breast to produce a symmetrical appearance
Prostheses and treatment of
physical complications at all stages of the mastectomy, including lymphedemas
This coverage is subject to a plan’s annual deductibles and coinsurance
provision. These provisions are generally described in the plan’s benefit
handbook.
The Health Insurance Portability and Accountability Act provides that the
plan sponsor a self-funded, non-federal, governmental plan may exempt the plan
from the requirement; however, HealthChoice plans currently have comparable
benefits for our members.
HealthChoice provides coverage for side effects that are commonly
associated with radical retropubic prostatectomy surgery, including but not
limited to impotence and incontinence, and for other prostate related
conditions.
*If you have questions about the HealthChoice coverage of mastectomies
and reconstructive surgery or prostate related conditions, contact EDS
Administrative Services at the numbers listed in the Plan
Identification section.
HealthChoice provides a benefit for wigs or other scalp prostheses for
individuals who are experiencing hair loss due to radiation or chemotherapy
treatment resulting from a covered medical condition. Coverage is subject to
annual deductibles and coinsurance, not to exceed $150 annually. The wig or
scalp prosthesis must be obtained from a licensed cosmetologist or DME
provider.
The
set dollar amount allowed in determining the benefit under the Plan for a
covered service or supply.
Also
called a Coverage Redetermination, is a special kind of complaint you make if
you disagree with a decision to deny a request for your prescription drug
benefits. There is a specific process that HealthChoice must use when you ask
for an appeal.
An
arrangement when a physician or medical supplier agrees to accept the Medicare
approved amount as full payment for services and supplies covered under
Medicare Part B.
A
prescription drug that is manufactured and sold by the pharmaceutical company
that developed the drug. A brand-name drug has the same active-ingredient
formulas as the generic versions of the drug.
The
federal agency that runs the Medicare program.
A
review process to determine the medical necessity for inpatient
hospitalization.
The
percentage of the cost of a covered service or medication that you pay as your
share of the expense.
A
procedure that primarily serves to improve appearance.
A
decision about whether a medication prescribed for you is covered by the Plan
and the amount, if any, you are required to pay for the prescription.
The
term we use to refer to all the prescription drugs covered by the Plans.
This
term refers to the period, following the initial coverage limit, when you are
responsible for the entire cost of your medications.
Creditable
coverage is coverage that is at least as good as the standard Medicare
prescription drug coverage.
The
initial out-of-pocket expense you pay on Allowed Charges before a benefit is
paid by the Plan.
An
employee’s spouse or any unmarried child under the age of 25 years, regardless
of residence, provided that the employee is primarily responsible for their
support, including an adopted child, stepchild, or child who lives with the
employee in a regular parent-child relationship. Additionally, dependents can
include children, regardless of age, who are incapable of self-support because
of mental or physical incapacity that existed prior to reaching the age of 25
years.
The
process of ending your membership in our Plan. Disenrollment can be voluntary
(your own choice) or involuntary (not your own choice).
An
eligible employee who is participating in any of the Plans authorized by or
through the State and Education Employees Group Insurance Act who retires, or
has a vesting right with a state funded retirement plan, or has the requisite
years of service with an employer participating in the Plan.
This
document explains your coverage, your rights, and what you have to do as a
member of our Plan.
A
type of coverage determination that, if approved, allows you to get a drug that
is not on the HealthChoice Medicare Formulary (a formulary exception), or get a
non-Preferred drug at the Preferred cost-sharing level (a tier exception). You
may also request an exception if you are required to try another drug before
receiving the drug you are requesting, or there are limits on the quantity or
dosage of the drug you are requesting (a formulary exception).
The
highest amount of money you can be charged for a covered service by doctors and
other health care providers who don’t accept Medicare assignment. The limit is
15% over Medicare’s approved amount. The limiting charge only applies to
certain services. It does not apply to supplies or equipment.
A
pharmacy benefit grievance is a complaint about a problem you may have getting
accurate and timely information from HealthChoice Member Services or from
Customer Service at our pharmacy benefits manager, Medco. A grievance issue
does not involve coverage or payment. A health benefit grievance is an appeal
you file with the Plan when, after a review, your request for health care
coverage remains denied.
A
prescription drug that has the same active-ingredient formula as a brand-name
drug. Generic drugs usually cost less than brand-name drugs and are rated by
the FDA to be as safe and effective as brand-name drugs.
A
list of medications covered by the Plans.
On
the Low Option Plan after you meet your deductible, the next $2,405 of coverage
is known as the initial coverage limit. You pay 25% ($601.25) and HealthChoice
pays 75% ($1,803.75) of this amount for allowed prescription drug costs.
An
amount added to your monthly premium for Medicare drug coverage if you go
without creditable coverage for a continuous period of 63 days or more. You pay
this higher amount as long as you have a Medicare drug plan. There are some
exceptions.
Direct
care and treatment within standards of good medical practice within the
community that are appropriate and necessary for the symptoms, diagnosis, and
treatment of the condition. Services or supplies must be the most appropriate
supply or level of service which can safely be provided. For hospital stays,
inpatient acute care is necessary due to the intensity of services the member
is receiving or the severity of the member’s condition, or when safe and
adequate care cannot be received as an outpatient or in a less intense medical
setting. Services or supplies cannot be primarily for the convenience of the
member, caregiver, or provider. The fact that services or supplies are
medically necessary does not, in itself, assure that the services or supplies
are covered by the Plans.
The
federal health insurance program for people 65 years of age or older, some
people under age 65 with disabilities, and people with End-Stage Renal Disease.
Expenses
recognized as reasonable and medically necessary by Medicare.
The
fee Medicare sets as reasonable for a covered medical service. This is the
amount a doctor or supplier is paid by you and Medicare for a service or
supply. The approved amount is sometimes called the approved charge.
A
person with Medicare who is eligible to get covered services and has enrolled in
HealthChoice.
A
Network Pharmacy contracts with our Plans. In most cases, your prescriptions
are covered at the maximum benefit only if they are filled at a HealthChoice
Network Pharmacy.
Any
service, procedure, or supply excluded from coverage.
A
pharmacy that doesn’t have a contract with our Plans. As explained in this
handbook, most services you get from non-Network pharmacies are not covered by
the Plans unless certain conditions apply.
The
annual time period, established by OSEEGIB, when changes may be made to
coverage.
The
maximum amount that is your responsibility.
The
Medicare Prescription Drug Benefit Program.
Drugs
that Congress permitted HealthChoice to offer as part of a standard Medicare
prescription drug benefit. We may or may not offer all Part D drugs.
Any
municipality, county, education employer, or other state agency whose employees
or members are eligible to participate in any plan authorized by the State and
Education Employees Group Insurance Act.
A
medical review process that is required for coverage of certain medications.
Some medications that require prior authorization are listed in this handbook
and in the HealthChoice Medicare Formulary.
Benefit
restrictions on the amount of medication you can receive. Some of the
medications that have quantity limits are listed in this handbook and in the
HealthChoice Medicare Formulary.
A
requirement that you may need to first try a specific, cost-effective
medication before moving to another medication which may be more costly or less
cost-effective.
This
is the term Medicare uses to describe out-of-pocket costs. HealthChoice uses
the term out-of-pocket maximum. Refer to the definition for out-of-pocket
maximum.