The Oklahoma State and Education Employees Group Insurance Board
2010 HEALTHCHOICE MEDICARE SUPPLEMENT HANDBOOK
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Evidence of Coverage
HealthChoice Employer PDP High and Low Option Plans With Medicare Part D
HealthChoice High and Low Option Plans Without Medicare Part D
For Plan Year January 1, 2010 through December 31, 2010
Revised January 1, 2010
http://www.sib.ok.gov/ or http://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. All references to you and your are interchangeable as related to the member who is Medicare eligible or covered by Medicare. This handbook provides details about your health and prescription drug coverage and explains how to get the medical services and prescription drugs you need. Please use this handbook to get familiar with your Plan’s benefits and the rules you must follow to get covered services and prescriptions. The HealthChoice Medicare Supplement Plans are often referred to throughout this handbook as the “Plan” or “Plans”.
Contracting Statement for Part D
The Oklahoma State and Education Employees Group Insurance Board (OSEEGIB) contracts with the Centers for Medicare and Medicaid Services (CMS), a division of the federal government, to provide Part D coverage. OSEEGIB is a Medicare approved Part D plan sponsor. OSEEGIB’s contract is renewed annually and is not guaranteed beyond the 2010 contract year. OSEEGIB has the right to refuse to renew its contract with CMS or CMS may refuse to renew its contract with OSEEGIB. Termination or non-renewal of the contract will result in the termination of your enrollment in a HealthChoice Employer PDP Medicare Supplement Plan With Part D.
Visual Impairment
A searchable text version of this handbook/Evidence of Coverage is available on the OSEEGIB website at http://www.sib.ok.gov/ or http://www.healthchoiceok.com/. This handbook is also available in CD format at the Oklahoma Library for the Blind and Physically Handicapped (OLBPH). Contact OLBPH, Monday through Friday, 8:00 a.m. to 5:00 p.m. with the exception of state holidays, at 1-405-521-3514, toll-free 1-800-523-0288, or TDD 1-405-521-4672.
Please Review this Handbook Carefully
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. The information contained in this guide is only a brief summary of the listed options. All benefits and limitations of these plans are governed in all cases by the relevant plan documents, insurance contracts, handbooks, Rules of the Oklahoma State and Education Employees Group Insurance Board, and the regulations governing the Medicare Prescription Drug Benefit, Improvement, and Modernization Act. The Federal Regulation at 42 C.F.R. SS423 et seq. and the Rules of the Oklahoma Administrative Code, Title 360, are controlling in all aspects of Plan benefits. No oral statement of any person shall modify or otherwise affect the benefits, limitations, or exclusions of any plan.
TABLE OF CONTENTS
Plan Identification and Contact Information
Who to Contact About Complaints, Grievances, Appeals, or Coverage Determinations
How Your Plan Will Change for 2010 - Annual Notice of Change
Information About Your Premiums
Summary of HealthChoice High and Low Option Medicare Supplement Plans
Information and Rules for Using Your Prescription Drug Coverage
Medications Requiring Prior Authorization (PA)
Medications Subject to Step Therapy (ST)
Medications Subject to Quantity Limitations (QL)
Claim Procedures for Health and Pharmacy Services
Eligibility, Enrollment, and Disenrollment
Your Rights as a Member of the Plan
When Your Claim for Health Benefits is Denied (Plans with and without Part D)
When Your Claim for Pharmacy Benefits is Denied (Plans without Part D)
When Your Claim for Pharmacy Benefits is Denied (Plans with Part D)
Fraud, Waste, and Abuse Compliance
Health Education Lifestyle Planning
MONTHLY PREMIUMS* FOR HEALTHCHOICE MEDICARE SUPPLEMENT PLANS
For Plan Year January 1, 2010 through December 31, 2010
*The premium rates listed do not reflect contributions from any retirement system or any Medicare Part D late enrollment penalty that may apply. You must pay the full monthly premiums (unless you qualify for extra help from Medicare) and your Part A and/or Part B premium, if applicable.
MEDICARE SUPPLEMENT
HealthChoice Employer PDP High Option With Part D
$289.42 per enrolled person
HealthChoice Employer PDP Low Option With Part D
$236.10 per enrolled person
HealthChoice High Option Without Part D
$345.82 per enrolled person
HealthChoice Low Option Without Part D
$292.50 per enrolled person
COBRA - MEDICARE SUPPLEMENT PLANS
HealthChoice Employer PDP High Option With Part D
$289.42 per enrolled person
HealthChoice Employer PDP Low Option With Part D
$236.10 per enrolled person
HealthChoice High Option Without Part D
$352.74 per enrolled person
HealthChoice Low Option Without Part D
$298.35 per enrolled person
PLAN IDENTIFICATION AND CONTACT INFORMATION
Plan Administrator*
Oklahoma State and Education Employees Group Insurance Board (OSEEGIB)
Monday through Friday, 7:30 a.m. to 4:30 p.m. Central time
3545 NW 58th St, Ste 110, Oklahoma City, OK 73112
1-405-717-8701 or toll-free 1-800-543-6044
TDD 1-405-949-2281 or toll-free 1-866-447-0436
HealthChoice Medicare Supplement Plan*
Member Services / Monday through Friday, 7:30 a.m. to 4:30 p.m. Central time
With Part D Plans: 1-405-717-8699 or toll-free 1-800-865-5142
Without Part D Plans: 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: http://www.sib.ok.gov/ or http://www.healthchoiceok.com/
HealthChoice Health Claims Administrator
HP Administrative Services, LLC
Monday through Friday, 7:00 a.m. to 7:00 p.m. 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
HealthChoice Pharmacy Benefit Administrator
Medco Customer Service
24 hours a day / 7 days a week, except Thanksgiving and Christmas
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
HealthChoice Certification Administrator
APS Healthcare
Monday through Friday, 7:00 a.m. to 7:00 p.m. Central time
PO Box 700005, Oklahoma City, OK 73107-0005
Toll-free 1-800-848-8121 or toll-free TDD 1-877-267-6367
Medicare
Customer Service: 24 hours a day / 7 days a week
Toll-free 1-800-633-4227 or toll-free TTY 1-877-486-2048
Website: http://www.medicare.gov
Website for Questions and Answers: http://questions.medicare.gov
Social Security Administration
Customer Service: Monday through Friday, 7:00 a.m. to 7:00 p.m. Central time
Toll-free 1-800-772-1213 or toll-free TTY 1-800-325-0778
Website: http://www.socialsecurity.gov
*Calls to HealthChoice, received before or after hours, on weekends, or holidays, will be answered by an automated phone system. Leave a message, including your name and telephone number. A Member Service Representative will return your call the next business day.
WHO TO CONTACT ABOUT COMPLAINTS, APPEALS, GRIEVANCES, OR COVERAGE DETERMINATIONS
PLANS WITH PART D
Health Appeals
HP Administrative Services, LLC
Monday through Friday, 7:00 a.m. to 7:00 p.m. Central time
1-405-416-1800 or toll-free 1-800-782-5218
TDD 1-405-416-1525 or toll-free 1-800-941-2160
Pharmacy Coverage Determinations (Prior Authorization)
Medco
24 hours a day / 7 days a week
Toll-free 1-800-753-2851 or toll-free TDD 1-800-825-1230
Pharmacy Coverage Redeterminations
HealthChoice Member Services – Ask for the Pharmacy Unit
Monday through Friday, 7:30 a.m. to 4:30 p.m. Central time
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
Pharmacy Grievances
HealthChoice Member Services
Monday through Friday, 7:30 a.m. to 4:30 p.m. Central time
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
Quality Improvement Organization
Health Integrity, LLC
Monday through Friday, 8:00 a.m. to 7:00 p.m. Eastern time
Toll-free 1-877-772-3379 or TDD 1-800-855-2880
Email: MEDICinfo@healthintegrity.org
PLANS WITHOUT PART D
Health Appeals
HP Administrative Services, LLC
Monday through Friday, 7:00 a.m. to 7:00 p.m. Central time
1-405-416-1800 or toll-free 1-800-782-5218
TDD 1-405-416-1525 or toll-free 1-800-941-2160
Pharmacy Appeals
HealthChoice Member Services – Ask for the Pharmacy Unit
Monday through Friday, 7:30 a.m. to 4:30 p.m. Central time
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
HOW YOUR PLAN WILL CHANGE FOR 2010
Annual Notice of Change
Monthly Plan Premiums for 2010
HealthChoice Employer PDP High Option With Part D increased from $279.28 to $289.42
HealthChoice Employer PDP Low Option With Part D increased from $222.92 to $236.10
HealthChoice High Option Without Part D increased from $333.24 to $345.82
HealthChoice Low Option Without Part D increased from $276.88 to $292.50
Medicare Deductibles
Part A increased from $1,068.00 to $1,100.00
Part B increased from $135.00 to $155.00
Part D (Pharmacy) increased from $295.00 to $310.00
HealthChoice Pharmacy Network
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 http://www.healthchoiceok.com or you can contact Medco, 24 hours a day, 7 days a week except Thanksgiving and Christmas, at the toll-free numbers listed in the Plan Identification and Contact Information section.
HealthChoice Medicare Formulary
There have been some changes to the HealthChoice Medicare Formulary. Both the HealthChoice Medicare Abridged and Comprehensive Formularies are available on the web at http://www.sib.ok.gov/ or http://www.healthchoiceok.com. Click ‘Medicare Members’ to access either formulary, or you can contact Medco, 24 hours a day, 7 days a week except Thanksgiving and Christmas at the numbers listed in the Plan Identification and Contact Information section.
To request a printed copy of either formulary, contact HealthChoice Member Services, Monday through Friday, 7:30 a.m. to 4:30 p.m. Central time at the numbers listed in the Plan Identification and Contact Information section.
HealthChoice Pharmacy Benefits
Pharmacy copays are increasing for the high option Plans. Refer to the Pharmacy Benefit Information section for details.
Medicare members will no longer be charged the cost difference between a brand-name product and its generic version.
In accordance with CMS guidelines, the pharmacy deductible, initial coverage limit, and out-of-pocket amounts are changing. Refer to the Pharmacy Benefit Information section for details.
HealthChoice Health Benefits
As of January 1, OSEEGIB is required by CMS to designate its status as an Employer Prescription Drug Plan (PDP) in the names of its HealthChoice Medicare Supplement Plans With Part D. The new plan names are HealthChoice Employer PDP High Option Medicare Supplement With Part D and HealthChoice Employer PDP Low Option Medicare Supplement With Part D.
Based on CMS changes to Medigap plans, At-Home Recovery and Preventive Care Not Covered by Medicare (up to $120) will no long be covered by the HealthChoice Medicare Supplement Plans.
INFORMATION ABOUT YOUR PREMIUMS
Be aware that all costs for medical and pharmacy expenses are separate.
Medicare Premiums
If you currently pay a premium for Medicare Part A and/or Part B, you must continue to pay your premiums in order to keep your Medicare coverage.
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 disability provisions.
If you did not sign up for Part B when you first became eligible, you 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.
All HealthChoice benefits are paid as if you are enrolled in both Medicare Part A and Part B. The 2010 Medicare & You handbook explains these premiums in the section titled 2010 Medicare Costs.
Plan Premiums
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. You will receive a monthly premium statement. Please return your payment in the self-addressed envelope included with your monthly statement.
COBRA participants must pay premiums directly to OSEEGIB. Premium payment options are to have the payment withheld from your bank account or paid directly to OSEEGIB as stated previously.
Extra Help Paying for Prescription Costs (Plans with Part D)
(Medicare Low Income Subsidy Information)
If you have limited income and resources as determined by Social Security, you may be able to get Extra Help paying your monthly premiums, pharmacy deductibles, and pharmacy copays.
If you think you may qualify or you want more information, you may visit the Social Security website at http://www.socialsecurity.gov or you can call Social Security customer service, Monday through Friday, 7:00 a.m. to 7:00 p.m. Central time toll-free at 1-800-772-1213 or TTY/TDD 1-800-325-0778.
You can also visit http://www.medicare.gov, or call Medicare toll-free, 24 hours a day, 7 days a week, at 1-800-633-4227 or TTY/TDD 1-877-486-2048.
After you apply, you will get a letter in the mail letting you know whether or not you qualify 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 applies to your prescription drug costs.
If you qualify for extra help in 2010, the information immediately following lists the amount you will have to pay for your prescription drug benefits.
If you qualify for full help:
A premium reduction of $31.90
No pharmacy deductible
Continuous coverage (no coverage gap)
Maximum copays of $2.50 for generics and Preferred drugs and $6.30 for other drugs
If you qualify for partial help:
A premium reduction between $8.00 and $31.90
A pharmacy deductible of $63
Continuous coverage (no coverage gap)
Coinsurance of 15% (up to the out-of-pocket maximum)
If you qualify for extra help, Medicare will notify HealthChoice. HealthChoice will then notify you of the amount of the extra help you will receive.
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 pay the lowest premium. If you want to opt out of the Low Option Plan and elect the High Option Plan, please contact HealthChoice Member Services, Monday through Friday, 7:30 a.m. to 4:30 p.m. Central time at the number listed in the Plan Identification and Contact Information section.
If You Qualify for Extra Help but Think You Are Paying the Wrong Copay
If you have qualified for Extra Help but disagree with your pharmacy copay amount, HealthChoice will work with CMS to get verification of your proper copay level.
Once the Plan receives verification of your proper pharmacy copay level, we will update our system so that you pay the correct copay in the future. In the event you paid a higher copay than you should have, HealthChoice will reimburse you by sending you a check in the amount of your overpayment.
Note to members who live in a long-term care facility: If the pharmacy hasn’t collected copays from you and is carrying your copays as a debt you owe, HealthChoice can make payment directly to the pharmacy.
Changes in Your Monthly Premium
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 do not currently get extra help but you qualify for it during the plan year, your monthly premium will decrease.
If you currently get extra help but the amount of help you qualify for changes, your premium will be adjusted up or down.
If you add or drop dependents to or from your coverage sometime during the plan year, your premium will increase or decrease.
For more information, refer to the 2010 Medicare & You handbook, visit http://www.medicare.gov, or contact Medicare at the numbers listed in the Plan Identification and Contact Information section.
Late Enrollment Penalty
Medicare applies a late enrollment penalty to your Part D premium when:
You don’t join a Medicare Part D plan, or other plan that offers creditable prescription drug coverage, when you first become eligible (the Initial Enrollment Period).
You have a lapse in creditable prescription drug coverage that lasts longer than 63 continuous days.
The late enrollment penalty is applied once you enroll in 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 that applies to HealthChoice members; however, the penalty could be applied if you leave OSEEGIB and enroll with another insurance carrier.
In some situations, you do not have to pay a premium penalty even though your enrollment is late. The penalty is not applied if you:
Already have creditable prescription drug coverage through another group plan or government plan such as TRICARE, the Veterans Administration, or Indian Health Services.
Were without Creditable Coverage for less than 63 days.
Did not receive enough information to know whether or not your previous drug coverage was creditable.
Are receiving “Extra Help”.
Non-Payment of Premiums
If your monthly plan premiums are late, we will notify you in writing that if you don’t pay your monthly premium by a certain date, which includes a grace period, we will end your coverage. HealthChoice has a grace period of two months.
GENERAL INFORMATION
This handbook provides a 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 information about the Plans’ eligibility rules and benefits.
The HealthChoice Medicare Supplement Plans provide benefits to members who are eligible for Medicare. The Plans are designed to provide supplemental benefits to Medicare Part A and Part B, as well as Part D 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 fee schedules. To see if a particular procedure is covered, review your Medicare & You handbook, visit http://www.medicare.gov, or call Medicare at the numbers listed in the Plan Identification and Contact Information section.
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, your Plan will estimate Medicare’s benefits and provide supplemental coverage as if Medicare were your primary carrier. For complete information about Medicare enrollment, visit the Social Security Administration website at http://www.ssa.gov. You can also contact Social Security customer service at the numbers listed in the Plan Identification and Contact Information section.
Other websites that may be helpful are:
Centers for Medicare and Medicaid Services at http://www.cms.hhs.gov
Medicare Questions and Answers at http://questions.medicare.gov
Provider-Patient Relationship
You may choose any provider or other practitioner who is contracted with Medicare in the state in which he or she 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.
Federal Limiting Charge
Providers who do not accept Medicare assignment may not charge a Medicare beneficiary more than 115% of the Medicare approved amount.
Certification
Certification may be required if Medicare is not your primary carrier. If you have questions, contact the HealthChoice certification administrator, APS Healthcare, Monday through Friday, 7:00 a.m. to 7:00 p.m. Central time toll-free at 1-800-848-8121 or TDD 1-877-267-6367.
The HealthChoice Plans Supplement Medicare Part A (hospitalization) by:
Paying the inpatient hospitalization deductible and coinsurance in full
Paying for an additional 365 lifetime reserve days for hospitalization
Paying the Medicare Part A coinsurance for skilled nurse facility care for days 21 through 100
Paying for the first three pints of blood while hospitalized
Having no maximum lifetime benefit
The HealthChoice Plans Supplement Medicare Part B (medical) by:
Paying the 20% of medical expenses that are not paid by Medicare Part B
Paying the 20% of durable medical equipment expenses not paid by Medicare Part B
The HealthChoice Plans Provide Prescription Drug Coverage
To be eligible for a plan with Part D, you must be entitled to Part A and/or enrolled in Part B and permanently reside in the United States.
Pharmacy Deductible
High Option Pharmacy Benefit
Not Applicable
Low Option Pharmacy Benefit
$310.00
Cost Sharing / Copay
25% - Member’s share $630.00
75% - Plan’s share $1,890.00
High Option Pharmacy Benefit
Refer to High Option Pharmacy section
Low Option Pharmacy Benefit
$2,520.00
Coverage Gap
High Option Pharmacy Benefit
Not Applicable
Low Option Pharmacy Benefit
$3,610.00
Annual Out-of-Pocket Maximum
High Option Pharmacy Benefit
$4,550.00
Low Option Pharmacy Benefit
$4,550.00
Coverage After Annual Out-of-Pocket Maximum
High Option Pharmacy Benefit
100%
Low Option Pharmacy Benefit
100%
Plan ID Cards
HealthChoice members have two ID cards, one for health and dental benefits and another for pharmacy benefits. If you are currently a HealthChoice member, continue using your current ID cards. If you are new to HealthChoice, you will be issued new ID cards.
Health/Dental 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 present your red, white, and blue Medicare card to your provider.
To request a replacement health/dental ID card, contact HP Administrative Services, LLC at the numbers listed in the Plan Identification and Contact Information section.
Prescription ID Card
Please present your Prescription Drug ID card when you purchase your prescriptions. You only need to present your HealthChoice Prescription Drug ID card; you do not need to present your Medicare ID card.
If you don’t have your ID card with you when you fill a prescription, ask your pharmacy to contact the Plan to get the necessary information. If your pharmacy cannot get the needed information, 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 for Health and Pharmacy Services section.
To request a replacement Prescription Drug ID card, contact Medco at the numbers listed in the Plan Identification and Contact Information section.
Your Contact Information
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 changes in your name, address, or telephone number to your insurance plan. Changes may be faxed to 1-405-717-8939 or sent in writing to HealthChoice, 3545 NW 58th St, Ste 110, Oklahoma City, OK, 73112.
ALL HEALTHCHOICE HIGH AND LOW OPTION MEDICARE SUPPLEMENT PLANS
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 $155 Medicare Part B deductible will be credited toward the Plans’ $155 deductible upon receipt of Medicare’s Explanation of Benefits. Once you have been billed $155 of Medicare Part B approved amounts for covered services, your HealthChoice Medicare Supplement deductible will have been met for the calendar year.
SUMMARY OF HEALTH BENEFITS FOR HIGH AND LOW OPTION MEDICARE SUPPLEMENT PLANS
Supplemental Benefits for Medicare Part A (Hospitalization)
For both High and Low Options - Unless otherwise stated, the member copay is $0.
All benefits are based on Medicare Approved Amounts.
Hospitalization
Semiprivate room, meals, drugs as part of your inpatient treatment, and other hospital services and supplies
First 60 days
Medicare Part A Pays
All except $1,100, the Part A deductible
HealthChoice Pays
$1,100, the Part A deductible
61st through 90th day
Medicare Part A Pays
All except $275 per day
HealthChoice Pays
$275 per day
91st day and after while using 60 lifetime reserve days
Medicare Part A Pays
All except $550 per day
HealthChoice Pays
$550 per day
Once Medicare’s lifetime reserve days are used, HealthChoice provides additional lifetime reserve days, limited to 365 days
Medicare Part A Pays
0%
HealthChoice Pays
100% of Medicare eligible expenses; certification by HealthChoice is required
Beyond the additional 365 days
Medicare Part A Pays
0%
HealthChoice Pays
0%
Member Pays
100%
Skilled Nurse Facility Care
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. Limited to 100 days per calendar year.
First 20 days
Medicare Part A Pays
All approved amounts
HealthChoice Pays
0%
21st through 100th day
Medicare Part A Pays
All except $137.50 per day
HealthChoice Pays
$137.50 per day
101st day and after
Medicare Part A Pays
0%
HealthChoice Pays
0%
Member Pays
100%
Hospice Care
Available as long as your doctor certifies you are terminally ill and you elect to receive these services
Medicare Part A Pays
All but very limited coinsurance for outpatient drugs and inpatient respite care
HealthChoice Pays
0%
Member Pays
Balance
Blood
Limited to the first three pints unless you or someone else donates blood to replace what you use
Medicare Part A Pays
0%
HealthChoice Pays
100%
Supplemental Benefits for Medicare Part B (Medical) Based on Medicare Approved Amounts
For both High and Low Options - Unless otherwise stated, the member copay is $0.
All benefits are based on Medicare Approved Amounts.
Medical Expenses
Inpatient and outpatient hospital treatment, such as physician’s services, medical and surgical services and supplies, physical and speech therapy, and diagnostic tests (Medicare limits apply)
The first $155 of Medicare approved amounts, the Part B deductible
Medicare Part B Pays
0%
HealthChoice Pays
0%
Member Pays
$155, the Part B deductible
Remainder of Medicare approved amounts
Medicare Part B Pays
80%
HealthChoice Pays
20%
Part B charges above Medicare approved amounts
Medicare Part B Pays
0%
HealthChoice Pays
100%
Clinical Laboratory Services
Blood tests and urinalysis for diagnostic services
Medicare Part B Pays
100%
HealthChoice Pays
0%
Home Health Care
Medicare approved services
Medically necessary skilled care services and medical supplies
Medicare Part B Pays
100%
HealthChoice Pays
0%
Durable Medical Equipment
Items such as wheelchairs, walkers, and hospital beds
The first $155 of Medicare approved amounts, the Part B deductible
Medicare Part B Pays
0%
HealthChoice Pays
0%
Member Pays
$155, the Part B deductible
Remainder of Medicare approved amounts
Medicare Part B Pays
80%
HealthChoice Pays
20%
Blood
Amounts in addition to the coverage under Part A unless you or someone else donates blood to replace what you use
Medicare Part B Pays
80% after the Part B deductible
HealthChoice Pays
20% after the Part B deductible
Hospice Prescription
Covered for Medicare beneficiaries with a terminal illness
Medicare Part B Pays
80%
HealthChoice Pays
20%
One-time Initial Wellness Physical Exam
To be completed within 12 months of your enrollment in Medicare Part B
Covered for all Medicare beneficiaries
Medicare Part B Pays
80% with no Part B deductible
HealthChoice Pays
20% with no Part B deductible
Screening Mammogram
Limited to one every 12 months
Covered for all female Medicare beneficiaries age 40 and older
Medicare Part B Pays
80% with no Part B deductible
HealthChoice Pays
20% with no Part B deductible
Screening Blood Tests for Early Detection of Cardiovascular (Heart) Disease
Covered for all Medicare beneficiaries
Medicare Part B Pays
100%
HealthChoice Pays
0%
Pap Test and Pelvic Exam
Limited to one every 24 months; includes a clinical breast exam. Limited to one every 12 months if high risk/abnormal Pap Test in preceding 36 months.
Covered for all female Medicare beneficiaries
Medicare Part B Pays
Pap Test, 100% with no Part B deductible; All other exams, 80% with no Part B deductible
HealthChoice Pays
Pap Test, 0%; All other exams, 20% with no Part B deductible
Diabetes Screening Test
Covered for all Medicare beneficiaries at risk of diabetes
Medicare Part B Pays
100%
HealthChoice Pays
0%
Diabetes Self-Management Training
Covered for all Medicare beneficiaries with diabetes (insulin users and non-insulin users)
Medicare Part B Pays
80% after the Part B deductible
HealthChoice Pays
20% after the Part B deductible
Diabetes Monitoring Supplies
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
Medicare Part B Pays
80% after the Part B deductible
HealthChoice Pays
20% after the Part B deductible
Ostomy Supplies
Includes ostomy bags, wafers, and other ostomy supplies
Covered for all Medicare beneficiaries in need of ostomy supplies
Medicare Part B Pays
80% after the Part B deductible
HealthChoice Pays
20% after the Part B deductible
Colorectal Cancer Screening
Fecal Occult Blood Test; limited to one every 12 months
Flexible Sigmoidoscopy; limited to one every 48 months for age 50 or older; for those not at high risk, 10 years after a previous screening
Colonoscopy; limited to one 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.
Medicare Part B Pays
For the fecal occult blood test, 100% with no Part B deductible; For all other tests, 80% after the Part B deductible
HealthChoice Pays
For the fecal occult blood test, 0%; For all other tests, 20% after the Part B deductible
Prostate Cancer Screening
Digital Rectal Exam; limited to one every 12 months
Prostate Specific Antigen Test (PSA); limited to one every 12 months
Covered for all male Medicare beneficiaries age 50 and older
Medicare Part B Pays
For the digital rectal exam, 80% after the Part B deductible; For the PSA test, 100% with no Part B deductible
HealthChoice Pays
For the digital rectal exam, 20% after the Part B deductible; For the PSA test, 0%
Bone Mass Measurements
Limited to one every 24 months for qualified individuals
Covered for all Medicare beneficiaries at risk for losing bone mass
Medicare Part B Pays
80% after the Part B deductible
HealthChoice Pays
20% after the Part B deductible
Glaucoma Screening
Limited to one every 12 months; must be performed or supervised by an eye doctor who is authorized to do this within the scope of their practice
Covered for Medicare beneficiaries at high risk or having a family history of glaucoma
Medicare Part B Pays
80% after the Part B deductible
HealthChoice Pays
20% after the Part B deductible
Medicare Vaccinations
Some vaccinations are covered under Medicare Part B and others are covered under Medicare Part D. What you pay will depend on the type of vaccine, where you purchase the vaccine, and who administers the vaccination shot. The rules for coverage of vaccinations can be complicated. If you are not sure how your vaccination is covered, before you go for your vaccination, you may want to contact HealthChoice Member Services, Monday through Friday, 7:30 a.m. to 4:30 p.m. Central time at the following numbers.
Members with Part D call 1-405-717-8699 or toll-free 1-800-865-5142.
Members without Part D call 1-405-717-8780 or toll-free 1-800-752-9475.
TDD users call 1-405-949-2281 or toll-free 1-866-447-0436.
Flu Vaccination
Limited to 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
Pneumococcal Vaccination
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
Hepatitis B Vaccination
Limited to beneficiaries at medium to high risk for Hepatitis B
Covered for all Medicare beneficiaries with Part B, the vaccination and administration are covered at 100% if the provider accepts Medicare assignment
Shingles Vaccination
e.g., ZOSTAVAX (zoster vaccine live)
Neither the vaccine nor the administration fee is covered under Part B, refer to the Pharmacy Benefit Information section for coverage information
Tetanus Vaccination
e.g., TETANUS TOXOID
Covered only for those not immunized, following acute injury
Covered for all Medicare beneficiaries with Part B, the vaccination and administration are covered at 100% if the provider accepts Medicare assignment
Services Covered Only by HealthChoice
Foreign Travel
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
Medicare Part B Pays
0%
HealthChoice Pays
80% of billed charges after the first $250 of each calendar year; $50,000 lifetime maximum
Member Pays
First $250 of each calendar year, then 20% and all amounts over the $50,000 lifetime maximum; No Medicare deductible
Pharmacy Benefits for HealthChoice High Option Medicare Supplement Plans With and Without Part D
What You and HealthChoice Pay for Covered Prescription Drugs
HealthChoice Pays
100% of covered medications for the remainder of the calendar year once you reach the $4,550 pharmacy out-of-pocket maximum.
Member Pays
$4,550, the pharmacy out-of-pocket maximum, in prescription drug copays or coinsurance. Following is the copay/coinsurance information.
Copay/Coinsurance for the High Option Plans
Prescriptions Purchased at a Network Pharmacy
Generic (Tier 1) and Preferred (Tier 2) medications costing $100 or less
HealthChoice Pays
Allowed charges after your copay
Member Pays
Copay up to $30
Generic (Tier 1) and Preferred (Tier 2) medications costing more than $100
HealthChoice Pays
Allowed charges after your copay
Member Pays
Copay of 25% up to $60 maximum
Non-Preferred (Tier 3) medications costing $100 or less
HealthChoice Pays
Allowed charges after your copay
Member Pays
Copay up to $60
Non-Preferred (Tier 3) medications costing more than $100
HealthChoice Pays
Allowed charges after your copay
Member Pays
Copay of 50% up to $120 maximum
Preferred high-cost (Tier 4) medications have the same benefits/copays as the generic (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 medication. Specialty medications are only covered when purchased through Accredo Health.
Pharmacy Benefits for HealthChoice Low Option Medicare Supplement Plans With and Without Part D
What You and HealthChoice Pay for Covered Prescription Drugs
Member’s Deductible
You pay your deductible of $310
Initial Coverage Period (Cost Sharing)
You pay coinsurance of 25% ($630) and HealthChoice pays 75% ($1,890) of the next $2,520 of prescription drug costs
Coverage Gap
You pay 100% of the next $3,610 of prescription drug costs until you reach the out-of-pocket maximum of $4,550.
100% Benefit
Once you reach the $4,550 out-of-pocket, HealthChoice pays 100% of Allowed Charges for covered prescription drugs purchased at Network pharmacies for the rest of the calendar year.
Reaching the Out-of-Pocket Maximum for the Low Option Plans
Individual annual out-of-pocket maximum for covered drugs is $4,550. This amount includes the $310 deductible, the $630 (25% of the next $2,520), and the Coverage Gap of $3,610 (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 medication. Specialty medications are only covered when purchased through Accredo Health.
PHARMACY BENEFIT INFORMATION
Information and Rules for Using Your Prescription Drug Coverage
Unless specifically noted, the information provided in this section applies to all HealthChoice Medicare Supplement Plans.
Creditable Prescription Drug Coverage
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, it is available on the HealthChoice website at http://www.sib.ok.gov/ or http://www.healthchoiceok.com. Click Medicare Members to access the Notices of Creditable Coverage, or you can request one by contacting HealthChoice Member Services at the numbers listed in the Plan Identification and Contact Information section.
Pharmacy Coverage Gap (Low Option Plans)
After your $310 deductible is met and your total drug costs reach the initial coverage limit ($2,520), you pay 100% of the cost of your Part D covered drugs until you reach the out-of-pocket maximum ($4,550). This time period when you must pay for all your medications is known as the Coverage Gap.
The HealthChoice Medicare Formulary
HealthChoice has developed a list of covered medications, known as the HealthChoice Medicare Formulary. This drug list tells which drugs are covered by the Plan, which drug tier they are in, and if there are any restrictions that apply.
This formulary was designed with the help of a team of doctors and pharmacists and lists the categories of medications believed to be part of a good prescription drug program. Medicare has approved this formulary. The formulary is available in two versions, an abridged (condensed) and a comprehensive version. You were mailed the abridged version of the HealthChoice Medicare Formulary with your enrollment materials. Both versions of the formulary are available on our website at http://www.sib.ok.gov/ or http://www.healthchoiceok.com. To request a printed copy of either version, contact HealthChoice Member Services at the numbers listed in the Plan Identification and Contact Information section.
The abridged version of the formulary lists covered Preferred and generic drugs. The comprehensive version lists both Preferred and non-Preferred medications. While most generics are Preferred, some brand-name medications may also be Preferred.
Generic drugs have the same active-ingredient formulas as brand-name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand-name drugs. Generic drugs usually cost less than brand-name drugs.
Be aware that HealthChoice does not cover all prescription drugs. In some cases, the law does not allow Medicare to cover certain types of drugs, and in other cases, HealthChoice has decided not to include certain medications in our formulary
For questions about coverage of a specific medication, contact Medco at the numbers listed in the Plan Identification and Contact Information section.
Changes to the Formulary During the Year
Most formulary changes occur at the beginning of each plan year; however, some formulary changes may occur during the plan year. For example, HealthChoice may add or remove drugs from its Medicare formulary throughout the year. HealthChoice may
Move a drug to a higher or lower drug tier (cost group)
Add or remove a coverage restriction for a drug
Replace a brand-name drug with a generic alternative
Remove a drug from the formulary
HealthChoice is required to notify you of a formulary change at least 60 days before the change, or at the time you request a refill of your drug. If 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.
Be aware that if the Food and Drug Administration 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.
Using the HealthChoice Medicare Formulary
Medications are listed in the formulary guide by the general medical condition they treat and also alphabetically at the back of the formulary. 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 whether there are restrictions on the drug, such as Quantity Limitations (QL) or Prior Authorization (PA).
Drug Tiers
HealthChoice has a four-tier prescription drug formulary, and in general, each tier represents a different cost group. Tier 1 medications usually have the lowest out-of-pocket costs and Tier 4 medications have the highest cost. If a generic medication is not available, then a Tier 2 medication may be your next least expensive choice. Following is a description of the drug tiers or cost groups:
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
Tier Exception – Non-Preferred Prior Authorization (High Option Plans)
If you choose a non-Preferred medication when a Preferred alternative is available, you will pay the non-Preferred copay, unless you get a Tier Exception for a lower copay. Please note that specific medical criteria must be met and information must be supplied by your physician to justify your request for an exception.
To request a Tier Exception for a medication, have your physician contact Medco at the numbers listed in the Plan Identification and Contact Information section.
Non-Covered and Non-Formulary Medications
Your physician may prescribe a medication that is non-covered or non-formulary. If you receive a prescription for a non-covered or a non-formulary medication, your options are to:
1. Ask your physician for a prescription for a generic (Tier 1) or Preferred (Tier 2) medication that is on the HealthChoice Medicare Formulary.
2. Continue the non-covered medication and pay the full cost.
3. Request a prior authorization to receive the non-covered medication. For more information, contact HealthChoice Member Services at the numbers listed in the Plan Identification and Contact Information section.
Prior Authorization for Covered Medications
Prior authorization is always needed for certain drugs even though they are listed on the HealthChoice Medicare Formulary. Prior authorization is required 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
A request for prior authorization must be submitted by your physician. Your request must be approved before you fill your prescription. To apply:
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, your physician’s office will receive notice of the approval within 24 to 48 hours. You will also be notified in writing.
4. If your prior authorization is denied because it does not meet clinical criteria, your physician’s office will receive notice of denial within 24 to 48 hours. You will also be notified in writing.
Note: A prior authorization is valid for one year from the date it is issued and must be renewed when it expires. For a list of covered medications that require prior authorization, refer to the Medications Requiring Prior Authorization (PA) section.
Medication Quantities
HealthChoice pharmacy benefits generally cover up to a 34-day supply or 100 units (tablets or capsules), whichever is greater. Medication quantities cannot 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.
Quantity Limitations
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. For a list of medications subject to quantity limitations, refer to the Medications Subject to Quantity Limitations (QL) section.
Step Therapy
Step therapy requires you to first try a designated drug(s) to treat your medical condition before the Plan covers another drug for that same condition.
Specialty Medications (Plans with Part D)
Members enrolled in the Medicare Supplement Plan with Part D will access specialty medications through their usual pharmacy outlets.
Specialty Medications (Plans without Part D)
Certain specialty medications will be covered only if you order them from the HealthChoice specialized 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.
Vaccines Covered Under Your Pharmacy Benefits for Plans With and Without Part D
In the absence of injury or direct exposure, certain vaccines including Zostavax, tetanus, and Hepatitis A and B are covered under the Plan’s pharmacy benefits rather than under Medicare Part B. The appropriate copays apply to vaccines purchased at your pharmacy. Your pharmacist will electronically submit a claim for the vaccine to Medco.
Vaccine Administration Fees for Plans With Part D
The vaccine administration fee, if given by either your physician or a pharmacist certified to administer (inject) vaccines, will also be reimbursed under your pharmacy benefits.
If the vaccine is purchased through and administered by a certified pharmacist, the pharmacist will electronically submit a claim to Medco for both the vaccine and the administration fee.
If you purchase the vaccine from your pharmacy and take it to your physician’s office for administration, your pharmacy will electronically submit a claim to Medco for the vaccine; however, you will have to file a paper claim with Medco for reimbursement of the administration fee.
Vaccine Administration Fees for Plans Without Part D
You are responsible for the administration fee for vaccines covered under your pharmacy benefits.
When You are Hospitalized
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 through a coverage determination, exception, or appeal.
When You are Admitted to a Skilled Nursing Facility
Usually, a long-term care facility, such as a nursing home, has its own pharmacy or a pharmacy that supplies prescription drugs for its residents. 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 as long as they meet plan guidelines. The skilled nursing facility must be in the HealthChoice Pharmacy Network, and the drug cannot be covered under Medicare Part B. HealthChoice will also cover your prescription drugs if they are approved through a coverage determination, exception, or appeal.
Temporary Supply of Medication (Plans with Part D)
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 temporary supply, limited to a 34-day supply, is intended to give you time to transition to a formulary medication.
For information about a temporary supply of medication, contact Medco at the numbers listed in the Plan Identification and Contact Information section.
Medication Therapy Management (Plans with Part D)
Medication Therapy Management (MTM) is a free program designed to promote the proper use of medications. The program conducts drug reviews to make sure members are receiving safe and appropriate prescription therapies. These reviews can be very important to those who have more than one provider prescribing medications.
The MTM 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 $3,000 annually.
If you qualify, you will be automatically enrolled in the program and will receive a letter 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 do not wish to participate in the program, you will need to contact Medco.
If you choose to participate in the program, you can visit with Medco’s pharmacists who have been specially trained in patient counseling. Topics include 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 and Contact Information section.
HealthChoice Pharmacy Network
In most cases, your prescriptions are covered only if they are filled at a HealthChoice Network Pharmacy. They are called Network Pharmacies because they contract with our Plans to provide covered prescription drugs for HealthChoice members. Network Pharmacies provide electronic claims processing, so generally, there are no paper claims to file.
Sometimes a pharmacy may leave the HealthChoice Pharmacy Network. When this occurs, you will have to get your prescriptions filled at another Network Pharmacy. The HealthChoice Pharmacy Network includes more than 900 pharmacies across Oklahoma and nearly 60,000 pharmacies nationwide. To find a Network Pharmacy near you, contact Medco at the numbers listed in the Plan Identification and Contact Information section.
Non-Network Pharmacy Benefits
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:
Travel outside your Plan’s service area and run out of medications, or you become ill and need a covered medication and cannot access a Network Pharmacy
Cannot get a covered medication in a timely manner within your Plan’s pharmacy network
Fill a prescription for a covered medication that is not regularly stocked at a Network Pharmacy
Receive a prescription for a covered medication that is dispensed by a non-Network outpatient facility, such as an emergency room, clinic, or surgery center
If you must use a non-Network pharmacy, you will probably have to pay the full cost for your prescription and then ask HealthChoice to repay you for its share of the cost. Refer to the Claim Procedures for Health and Pharmacy Services section.
Before you fill a prescription under these circumstances, when possible, check to see if there is a Network Pharmacy in your area by visiting Medco’s website or calling them at the numbers listed in the Plan Identification and Contact Information section.
Pharmacy Lifetime Maximum Benefit
All HealthChoice Medicare Supplement Plans provide $2 million of prescription drug benefits to each enrolled member. Benefits began accumulating January 1, 2004.
Pharmacy Out-of-Pocket Maximum
All HealthChoice Medicare Supplement Plans have a pharmacy out-of-pocket maximum of $4,550. This total includes the amounts you spend on deductibles, copays, and coinsurance at Network Pharmacies. If you are a member of the Low Option Plan, this total also includes amount you spend during the Coverage Gap.
Once you reach the $4,550 out-of-pocket maximum, the Plan pays 100% for all covered medications purchased at Network Pharmacies for the remainder of the calendar year.
What Applies to Your Pharmacy Out-of-Pocket Maximum
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 Network Pharmacies for costs to apply to the out-of-pocket maximum. The following types of payments for covered prescription medications count toward your out-of-pocket maximum:
Your deductible
Your coinsurance and copays
Your costs during the Coverage Gap (Low Option Plans)
What Does Not Apply to Your Pharmacy Out-of-Pocket Maximum
Drugs purchased outside the United States and its territories
Medications not covered by the Plan
Medications purchased at non-Network pharmacies when non-Network requirements are not met
Drugs covered under Medicare Part A or Part B
Payments made by another group health plan or government plan such as TRICARE, the Veterans Administration, or Indian Health Services
Pharmacy Explanation of Benefits (EOB)
A pharmacy EOB tells you the total amount you have spent on your prescription drugs and the total amount the plan has paid for your prescription drugs. HealthChoice is not required to send you a Pharmacy EOB statement; however, you can request a Pharmacy EOB by contacting Medco at the numbers listed in the Plan Identification and Contact Information section.
Pharmacy Exclusions and Limitations
Impotency medications such as Levitra, Viagra, and Caverject are specifically excluded from coverage unless you have had radical retropubic prostatectomy surgery. Prior authorization is required.
Drugs covered under Medicare Part A or Part B
Fertility drugs
Cough and cold medications
Lost, stolen, or damaged medications
Over-the-counter medications
Prescription drugs purchased outside of the United States
Drugs used for cosmetic purposes or hair regrowth
Drugs used for the treatment of anorexia, weight loss, or weight gain
Most barbiturates and benzodiazepines
Drugs prescribed for “off-label” uses
All over-the-counter and legend (prescription) vitamins – except Prenatal Vitamins
Drugs not FDA approved
This list is not all-inclusive.
Medications Requiring Prior Authorization (PA)
This list, with brand-name in capital and generic in lower case, is not all-inclusive and is subject to change.
Note: Some medications listed in these categories are non-formulary. Refer to Non-Covered and Non-Formulary Medications in this section for more information.
Anabolic Steroids
Promote body mass or weight gain
ANADROL-50 (oxymetholone tablets), DECA-DURABOLIN, KABOLIN (nandrolone decanoate injection), OXANDRIN (oxandrolone tablets), WINSTROL (stanozolol tablets)
Androgens
Are similar to the male hormone, testosterone
ANDRODERM (testosterone transdermal system), ANDROGEL (testosterone gel), ANDROID (methyltestosterone tablets), FIRST-TESTOSTERONE (testosterone propionate ointment), HALOTESTIN (fluoxymesterone tablets), ORETON (methyltestosterone), METHITEST (methyltestosterone), METHYL, TESTIM (testosterone gel), TESTODERM PATCH (testosterone transdermal), TESTODERM TTS (testosterone transdermal), TESTRED (methyltestosterone), VIRILON (methyltestosterone capsules)
Androgens – Injectable
Are similar to the male hormone, testosterone
ANDRO-CYP (testosterone intramuscular), ANDRO LA (testosterone intramuscular), ANDROPOSITORY (testosterone intramuscular), DELATESTRYL (testosterone enanthate), DEPOANDRO, DEPOTEST (testosterone), DEPO-TESTOSTERONE (testosterone cypionate injection), DURATHATE (testosterone injection), EVERONE (testosterone injection), HISTERONE (testosterone injection), MALOGEN (testosterone propionate injection), TESAMONE (testosterone injection), TESTANDRO, TESTRO (testosterone aqueous injection), TESTRO-LA (testosterone enanthate injection), VIRILON (methyltestosterone injection), VIRILON IM (testosterone cypionate injection)
Antiemetics
Treat nausea or nausea side-effects of other drugs
ANZEMET (dolasetron), ATARAX (hydroxyzine hcl), COMPAZINE (prochlorperazine maleate), EMEND (aprepitant), KYTRIL (granisetron), MARINOL (dronabinol), PHENERGAN (promethazine hcl), THORAZINE (chlorpromazine hcl), TRILAFON (perphenazine), VISTARIL (hydroxyzine hcl), ZOFRAN (ondansetron)
Anti-Infective Inhalant Agents
Treat infections
TOBI (tobramycin solution for inhalation)
Antiviral Agents
Treat flu or flu-like symptoms
RELENZA (zanamir), TAMIFLU (oseltamivir)
CNS Stimulants
Stimulate the nervous system
ADDERALL, ADDERAL XR (amphetamine/destroamphetamine), CONCERTA (methylphenidate), DEXADRINE (dextroamphetamine sulfate), DEXEDRINE SPANSULES (dextroamphetamine), DEXTROSTAT (dextroamphetamine), DESOXYN (methamphetamine hydrochloride), DESOXYN GRADUATE (methamphetamine), FOCALIN (dexmethylphenidate), METADATE CD (methylphenidate), METHYLIN ER (methylphenidate), RITALIN (methylphenidate), RITALIN LA (methylphenidate), RITALIN SR (methylphenidate)
Colony Stimulating Factors
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)
COX2 Inhibitor (COX1 Sparing Agents)
Treat pain and/or inflammation of the joints
CELEBREX (celecoxib)
Erythroid Stimulants
Stimulate the production of red blood cells
ARANESP (darbepoetin alfa injection), EPOGEN, PROCRIT (epoetin alfa injection)
Erectile Dysfunction/Impotence Agents
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.
Gastrointestinal Agents
Treat rheumatoid arthritis, Crohn’s Disease, or ulcerative colitis
REMICADE (infliximab)
Growth Hormones
Stimulate physical growth or metabolism
DEPOT (somatrem), GEREF (sermorelin), GENOTROPIN (somatropin), GENOTROPIN MINIQUICK (somatropin), HUMATROPE (somatropin), NORDITROPIN (somatropin), NUTROPIN (somatropin), NUTROPIN AQ (somatropin), PROTROPIN (somatrem), SAIZEN (somatropin), ZORBTIVE (somatropin)
Growth Hormone Receptor Antagonists
Treat overgrowth due to hormone imbalances
SOMAVERT (pegvisomant)
Biological Response Modulator - Human Growth Factors
Increase blood platelet levels
NEUMEGA (oprelvekin)
Immunosuppressant Agents
Treat rejection response to a transplant
A-METHAPRED (methylprednisolone sodium succinate), CELLCEPT (mycophenolate), CYTOXAN (cyclophosphamide), DEPO-MEDROL (methylprednisolone acetate), GENGRAF (cyclosporine modified), IMURAN (azathioprine), MEDROL (methylprednisolone), MYFORTIC (mycophenolate), NEORAL (cyclophosphamide), ORAPRED ODT (prednisolone sodium phosphate), ORTHOCLONE OKT-3 (muromonab-CD3), PREDNISONE INTENSOL (prednisone concentrate sol), PROGRAF (tacrolius), PROTOPIC (tacrolimus), RAPAMUNE (sirolimus), prednisone, prednisolone, SANDIMMUNE (cyclosporine), SOLU-MEDROL (methylprednisolone sodium succinate), THYMOGLOBULIN (antithymocyte globulin), ZENAPAX (daclizumab)
Injectable Medications and Other Miscellaneous Treatments
ALDURAZYME (laronidase), AMBISOME (amphotericin B), BCG vaccine, CEREZYME (imiglucerase), CYTOVENE (ganciclovir), FABRAZYME (agalsidase beta), FASLODEX (fluvestrant), FOSCAVIR (foscarnet), LIORESAL (baclofen), NITROSTAT (nitroglycerin), NEBUPENT (pentamidine), PLATINOL (cisplatin), VITRASERT IMPLANT (ganciclovir), UROMITEXAN (mesna), ZOLADEX IMPLANT (goserelin)
Intravenous Immune Globulins
Treat antibody and/or autoimmune deficiencies
GAMIMUNE N, GAMMAGARD, GAMMAR-IV, IVEEGAM, SANDOGLOBULIN, VENOGLOBULIN
Nebulized Drugs
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 (acetylcysteine), MUCOMYST (acetylctsteine), MUCOMYST-10 (acetylcysteine), NEBUPENT (pentamidine isethionate), PULMICORT (budesonide), ROBINUL (glycopyrrolate), TORNALATE (bitolterol), XOPENEX (isoetharine, levosalbutamol hydrochloride)
Osteoporosis Therapies
Treat those at high risk of bone fracture or having had a bone fracture
FORTEO (teriparatide)
Respiratory Agents
Treat special bronchial-related disease states
PULMOZYME (recombinant dornase alfa inhalation solution), SYNAGIS (palivizumab), XOLAIR (omalizumab), XOPENEX (levalbuterol inhalation solution)
Medications Subject to Step Therapy (ST)
Gastrointestinal Agents
Treat ulcer, reflux conditions
KAPIDEX (dexlansoprazole)
Medications Subject to Quantity Limitations (QL)
This list, with brand-name in capital and generic in lower case, is not all-inclusive and is subject to change.
Note: 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.
Anti-rheumatic Agents
Treat rheumatoid arthritis
ARAVA (leflunomide), ENBREL (etanercept), HUMIRA (adalimumab), KINERET (anakinra)
Antiviral Agents
Treat flu or flu-like conditions
RELENZA (zanamivir), TAMIFLU (oseltamivir)
Erectile Dysfunction Agents
Treat male impotence
CAVERJECT (alpostadil), CIALIS (tadalafil), EDEX (alpostadil), LEVITRA (vardenafil), MUSE (alprostadil), VIAGRA (sildenafil)
Intranasal Corticosteroids
Spray dosage forms that treat asthma or allergic responses
BECONASE AQ (beclomethasone), FLONASE (fluticasone), NASACORT AQ (triamcinolone), NASAREL (flunisolide), NASONEX (mometasone), RHINOCORT AQUA (budesonide), VERAMYST (fluticasone), OMNARIS (ciclesonide)
Cancer Therapies
Treat cancer conditions
IRESSA (gefitinib)
Mast Cell Stabilizers
INTAL (cromolyn), NASALCROM (cromolyn), TILADE (nedocromil)
Migraine Therapies
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), TREXIMET (sumatriptan/naproxen), ZOMIG (zolmitriptan), ZOMIG NS (zolmitriptan), ZOMIG-ZMT (zolmitriptan – orally disintegrating tablets)
Multiple Sclerosis Therapies
Treat multiple sclerosis
AVONEX (interferon beta-la), BETASERON (interferon beta-lb), COPAXONE (glatiramer), REBIF (interferon beta-la)
Osteoporosis/Paget’s Disease Therapies
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)
Opthalmic Therapies
Treat special eye conditions
RESTASIS (cyclosporine ophthalmic emulsion) 0.05%
Sedative-Hypnotic Agents
Treat insomnia or sleeping disorders
AMBIEN (zolpidem), AMBIEN CR (zolpidem), BUTISOL (butabarbital), DORAL (quazepam), HALCION (triazolam), LUNESTA (eszopiclone), PROSOM (estazolam), RESTORIL (temazepam), ROZEREM (ramelteon), SONATA (zaleplon), Various (chloral hydrate)
Topical Estrogens
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 (estradiol), ESTRASORB (estradiol), MENOSTAR (estradiol), VIVELLE, VIVELLE-DOT (estradiol)
Transdermal Patches
Patches of medication that are absorbed through the skin
ANDRODERM (testosterone), ANDROGEL (testosterone), DAYTRANA (methylphenidate), DURAGESIC (fentanyl), EMSAM (selegiline), LIDODERM (lidocaine), (nitroglycerin), ORTHO-EVRA (norelgestromin/ethinyl estradiol), OXYTROL (oxybutynin), STRIANT (testosterone), TESTIM GEL (testosterone)
Insulin Syringes
All BD Insulin Syringes
Insulin
All Insulins (Novolin, Novolong, Humulin, Humalog, Lantus, Levemir)
CLAIM PROCEDURES FOR HEALTH AND PHARMACY SERVICES
Claims Filing Deadline
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, 2009, the claim will be accepted through December 31, 2010.
Health Claims Filing
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 HP Administrative Services, LLC at PO Box 24870, Oklahoma City, OK, 73124-0870.
HealthChoice will send you an Explanation of Benefits on all claims that are processed.
Coordination of Health Benefits
If you or your covered 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 HP Administrative Services, LLC at PO Box 24870, Oklahoma City, OK, 73124-0870.
If you have any questions regarding coordination of health benefits, please contact HP Administrative Services, LLC at the numbers listed in the Plan Identification and Contact Information section.
Medicare Beneficiaries with End-Stage Renal Disease
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, you can visit their website at http://www.medicare.gov or call Medicare toll-free at 1-800-633-4227. TTY/TDD users call toll-free 1-877-486-2048.
Pharmacy Claims Filing
In most cases, your pharmacy claim will be processed electronically at the pharmacy. If your pharmacy has questions, have your pharmacist contact the Medco Pharmacy Help Line toll-free, 24 hours a day, 7 days a week including holidays, at 1-800-922-1557 or TTY/TDD 1-800-825-1230.
In some cases, however, you may need to file a direct (paper) claim with us. To do so, send your pharmacy receipt and Direct Claim Form to:
Without Part D: Medco, PO Box 14711, Lexington, KY, 40512
With Part D: Medco, PO Box 14718, Lexington, KY, 40512
While you don’t have to use a Direct Claim Form, it is helpful. You can access a Direct Claim Form on our website at http://www.sib.ok.gov/ or http://www.healthchoiceok.com or by calling Medco at the numbers listed in the Plan Identification and Contact Information section.
If your claim involves other group health insurance, you will also need to include a copy of the Explanation of Benefits statement you received from your other carrier.
When your request for payment is received, Medco will let you know if any additional information is needed to process your claim.
If it is determined that your claim is for covered prescriptions and you followed all Plan guidelines, we will mail you reimbursement for the Plan’s share of the cost.
If it is determined that your claim is for non-covered prescriptions or you did not follow Plan guidelines, we will send you a letter letting you know our reasons for not sending reimbursement and letting you know what your rights are to appeal the decision. Refer to the Grievance and Appeals section.
Coordination of Pharmacy Benefits
If you or a covered 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 the pharmacist your HealthChoice Prescription Drug ID card, along with your primary insurance ID card. If the pharmacy cannot file your secondary HealthChoice claims electronically, have your pharmacy contact the Medco Pharmacy Help Line toll-free, 24 hours a day, 7 days a week, at 1-800-922-1557 or TTY/TDD 1-800-825-1230. 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 and Contact Information section.
Claims for Services Outside the United States
When traveling outside the U.S., you must pay for services up front and then submit the itemized bill for reimbursement. 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 HP Administrative Services, LLC at PO Box 24870, Oklahoma City, OK, 73124-0870.
For questions regarding claim filing, call HP Administrative Services, LLC at the numbers listed in the Plan Identification and Contact Information section.
Private Contracts with Physicians and Practitioners Who Opt Out of Medicare
A Private Contract is a written agreement between a Medicare beneficiary and a doctor or 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
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.
Once all necessary 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 and Contact Information section.
Do not contact the claims office, HP Administrative Services, LLC, regarding subrogation as this will only delay any response.
ELIGIBILITY, ENROLLMENT, AND DISENROLLMENT
Medicare Eligibility
Medicare is the federal health insurance program for people 65 years of age and older, some people under age 65 with disabilities, and people with End-Stage Renal Disease. Medicare is managed by the Centers for Medicare and Medicaid Services (CMS). The Social Security Administration is responsible for determining eligibility and enrolling people in Medicare and for collecting Medicare premiums. For more information regarding Medicare, please visit the CMS website at http://www.cms.hhs.gov or the Social Security Administration website at http://www.ssa.gov. You can also contact Social Security customer service at the numbers listed in the Plan Identification and Contact Information section.
Medicare is divided into several parts. The parts that apply to your Plan are:
Part A – Hospital insurance
Part B – Medical insurance for doctors’ services and other outpatient care
Part D – Prescription drug benefits
Enrollment in Medicare
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 Social Security or Railroad Retirement Board benefits, you must apply for Medicare by contacting the Social Security Administration, or if appropriate, the Railroad Retirement Board.
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, rather than age.
Plan Eligibility
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 St, 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.
Eligibility Requirements
To participate in the Plans described in this handbook, you must be:
Entitled to benefits under Medicare Part A or enrolled in Medicare Part B.
Enrolled in only one Part D plan. If you have Part D coverage through another plan and wish to continue that coverage, you must select the HealthChoice Medicare Supplement High or Low Option Plan Without Part D. Enrolling in another Medicare Supplement Plan With Part D will end your current Part D coverage.
Enrollment Periods
There are three time periods when you may enroll or disenroll from the HealthChoice Medicare Supplement Plans.
The Initial Enrollment Period
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, 2010. She is eligible for Medicare Part A and her Part B and Part D initial enrollment period begins on January 1, 2010, (three months prior to the birthday month) and ends on July 31, 2010 (three months after her birthday month).
The Annual Enrollment Period/Option Period
The HealthChoice annual Option Period (Annual Enrollment 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, you have exhausted your annual enrollment period and plan changes cannot be made until the next annual Option Period.
Special Enrollment Periods
Special Enrollment Periods are allowed under certain situations, such as when:
You enter or leave a skilled nursing facility.
You move outside the United States – the HealthChoice service area.
CMS or HealthChoice terminates the Plans’ participation in the Part D program.
You lose Creditable Coverage for reasons other than failure to pay premiums.
You meet other exception rules as set out by CMS.
You gain or lose Extra Help paying for your prescription drug coverage.
For information on Special Enrollment Periods, contact HealthChoice Member Services at the numbers listed in the Plan Identification and Contact Information section.
Effective Date of Coverage
Initial Enrollment Period
Effective date is the first of the month you become Medicare eligible, or the first of the month following the election, whichever is later.
Annual Election Period or Option Period
Effective date is January 1.
Special Enrollment Periods
Effective date is dependent on the individual circumstances. The effective date of coverage always follows the processing of your completed enrollment request and can never be before that date.
Confirmation Statements
Anytime a change is made to your coverage, you will be mailed a Confirmation Statement (CS). Your CS lists the coverage you are enrolled in, the effective date of your coverage, and the premium amounts for your coverage. The CS is provided so that you can review changes, and any errors can be identified and corrected as soon as possible.
Dependent Coverage
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 dependents. 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 dependents.
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 dependent children are eligible for coverage until:
Age 25
They marry
Over-age, disabled, dependent children are eligible to continue coverage as long as they continue to meet the Plan’s definition of a disabled dependent.
COBRA continuation of coverage is available for dependents who lose eligibility. Refer to Consolidated Omnibus Budget Reconciliation Act (COBRA) in this section.
Eligible Dependents Include
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 due to 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 your 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 other 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.
To Request Coverage Changes
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 St, Ste 110, Oklahoma City, OK, 73112.
Education Retirees
If you were a career tech employee or a common school employee who 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 entity other than a common school (e.g., higher education, charter school, etc.) you may continue coverage through the Plan as long as the education entity 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.
Local Government Retirees
If you were a local government employee who 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 employer terminates coverage with the Plan, you must follow your former employer to its new insurance carrier.
New Employer Retirees
All retirees with former employers that join the Plan after the grandfathered dates specified previously must follow their former employer to its new insurance carrier.
Following Your Employer to a New Plan
When you terminate employment, your benefits are tied to your most recent employer. If your most recent employer discontinues participation with OSEEGIB, some or all of the employer’s retirees and their dependents (depending on the type of employer) must follow the employer to its new insurance carrier. This is true regardless of the amount of time you were employed with any participating employer.
If you retire and then return to work for another employer and enroll in benefits through your new employer, your benefits will be tied to your new employer.
If You Return to Work
If you return to work and 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 carrier.*
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 carrier.*
If you are a retired or vested member returning to work and you did not continue health coverage at the time you retired or vested, 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 cannot provide a Medicare supplement plan, or pay for any premiums related to a Medicare supplement plan.
Ending Your Coverage With HealthChoice
Ending your coverage 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 coverage.
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 your Plan, he/she cannot be re-enrolled unless he/she loses other group coverage.
All Plan members have the option to leave the Plan during the Annual Enrollment Period (Option Period); however, in certain situations, you may leave the Plan at other times of the year which are known as Special Enrollment Periods.
If HealthChoice ends your coverage, we will send you a letter explaining our reasons. Instructions about how you can file a complaint against HealthChoice, if you choose to do so, will be included.
As a retiree, if your health, dental, or life coverage is canceled, it cannot be reinstated at a later date unless you return to work as an employee of a participating employer. You will forfeit any retirement system contribution paid toward your health insurance premium. Vision coverage is not affected by the cancellation rule and can be elected during the annual Option Period.
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.
In the Event of Your Death
Your surviving dependents are eligible to continue any coverage that was in effect at the time of your death, as long as all premiums are paid. Surviving dependents have 60 days to notify HealthChoice they wish to continue coverage under the Plan. If your dependents are on a plan With Part D, their coverage will automatically continue, and they will have the option to cancel coverage. Coverage is 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 after your survivors are enrolled and premiums are received
Notification of your death should be directed to the appropriate retirement system and to HealthChoice.
Consolidated Omnibus Budget Reconciliation Act (COBRA)
COBRA is federal legislation which gives members and their covered dependents who lose health benefits, the right to choose to continue group health benefits for limited periods of time under certain circumstances.
You and your covered dependents are eligible for limited continuation of coverage (up to 18 months) if you lose coverage due to:
A reduction in your hours of employment
Termination of your employment for reasons other than gross misconduct
Your covered spouse and dependent children are eligible for limited continuation of coverage (up to 36 months) if coverage is lost for reasons such as:
A divorce or legal separation*
Your dependent loses dependent status
Your death – Refer to In the Event of Your Death in this section
As a former employee, you must notify OSEEGIB in writing within 30 days of a divorce*, legal separation*, or your child’s loss of dependent status under this Plan.
You or your eligible dependents must elect continuation of coverage within 60 days after the later of the following events occur:
The date the qualifying event would cause you or your dependent to lose coverage
The date your employer notifies you or your dependents of continuation of coverage rights
All COBRA premiums must be paid. It is the policy of OSEEGIB that for any benefit continued under COBRA, one person must always pay the primary member premium. In cases where a spouse, child, or children are insured under a particular benefit and the member did not retain coverage, one person will always be billed at the primary member rate.
If you have questions regarding COBRA, contact OSEEGIB Member Services at the numbers listed in the Plan Identification and Contact Information section.
*Oklahoma law prohibits dropping your spouse/dependents in anticipation of a divorce or legal separation. If you are in the process of a divorce or legal separation, it is important you contact your legal counsel for advice before making changes to your benefits coverage.
YOUR RIGHTS AS A MEMBER OF THE PLAN
Your Medicare prescription drug benefit and your rights and responsibilities are governed by Oklahoma and federal laws. The primary federal law that applies to this document is Title XVIII of the Social Security Act by the Centers for Medicare and Medicaid Services (CMS). In addition, other federal and state laws apply.
For more information about your rights, you can visit http://www.medicare.gov to read or print the publication Your Medicare Rights and Protections. You can also call Medicare, 24 hours a day, 7 days a week toll-free at 1-800-633-4227 or TTY/TDD 1-877-486-2048.
Non-Discrimination
OSEEGIB does not discriminate based on a person’s race, disability, religion, sex, sexual orientation, health, ethnicity, creed, age or national origin when it provides benefits. Federal laws that prohibit discrimination include Title VI of the Civil Rights Act of 1964, the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, the Americans with Disabilities Act, and all other laws that apply to organizations that receive federal funding.
If you want more information or have concerns about discrimination or unfair treatment, please call the federal Office for Civil Rights toll-free at 1-800-368-1019 or TDD 1-800-537-7697.
Timely Access to Covered Drugs
You have the right to get your prescriptions filled or refilled at any Network Pharmacy without long delays. If you don’t think you are getting your Part D drugs in a reasonable amount of time, refer to the Grievances and Appeals section which explains how you can file a grievance.
Protecting the Privacy of Your Personal Health Information
The laws that protect your privacy give you certain rights related to getting information and controlling how your health information is used. The HIPAA Notice that follows describes how medical information about you may be used and disclosed and how you can get access to this information.
Health Insurance Portability and Accountability Act (HIPAA)
The Oklahoma State and Education Employees Group Insurance Board (OSEEGIB) is a State of Oklahoma governmental agency created and governed by Oklahoma law for the purpose of administering health, life, disability, and dental benefits to state, local government, and education employees, and other groups designated by statute, including each of the preceding groups’ respective retirees. Oklahoma privacy laws and the federal Health Insurance Portability and Accountability Act (HIPAA) govern privacy matters between OSEEGIB and its participants concerning the privacy of identifiable health information. Information contained in an OSEEGIB member’s file is confidential by law and we at OSEEGIB are committed to protecting this information.
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 benefits, case management, approval for supplemental life insurance, grievance matters, premium rate setting, required disease management programs, law enforcement, public health threats, workers’ compensation/disability, national security, and as required by law. OSEEGIB will ask for your written permission before it uses or discloses your health information for purposes that are not described in this Notice.
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 http://www.sib.ok.gov/ or http://www.healthchoiceok.com
If you believe your privacy rights have been violated, call or send a written complaint to the OSEEGIB HIPAA Information Officer, Monday through Friday, 7:30 to 4:30 Central time, at 3545 NW 58th St, 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
Information the Plan Must Provide to You
You have the right to get several kinds of information from the Plan. This handbook/Evidence of Coverage provides much of the information you need concerning your health and pharmacy benefits, eligibility, premiums, and grievances and appeals processes. It also provides information about the rules you must follow when you use your prescription drug benefits, as well as, why some drugs are not covered by the Plan.
More information about the HealthChoice Pharmacy Network and coverage of specific medications is available on our website at http://www.sib.ok.gov/ or http://www.healthchoiceok.com. You can also contact Medco at the numbers listed in the Plan Identification and Contact Information section.
GRIEVANCE AND APPEAL PROCESSES
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. You cannot be disenrolled from the Plan or penalized in any way for making a complaint, grievance, or appeal.
When Your Claim for Health Benefits is Denied (Plans with and without Part D)
If your health claim was denied in whole or in part for any reason, you have the right to have that claim reviewed. A request for review of your denied claim, along with any additional information you wish to provide, must be submitted in writing to Medical Claims Review, PO Box 24870, Oklahoma City, OK 73124-0870, or call Monday through Friday, 7:00 a.m. to 7:00 p.m. Central time at 1-405-416-1800 or toll-free 1-800-782-5218. TDD users call 1-405-416-1525 or toll-free 1-800-941-2160.
If your claim is reviewed and 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, 3545 NW 58th St, Ste 110, Oklahoma City, OK, 73112, or call 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.
When Your Claim for Pharmacy Benefits is Denied (Plans without Part D)
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 at the numbers listed in the Plan Identification and Contact Information section.
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 OSEEGIB Pharmacy Unit, 3545 NW 58th St, Ste 110, Oklahoma City, OK, 73112, or Fax to 1-405-717-8925.
If your appeal is denied, you have the right to file a grievance with OSEEGIB following the same procedures for appealing a denied health claim.
When Your Claim for Pharmacy Benefits is Denied (Plans with Part D)
The following is a summary of the guidelines for filing a Medicare Part D prescription drug grievance or appeal. A complete Grievance and Appeal Guide is available on our website at http://www.sib.ok.gov/ or http://www.healthchoiceok.com or by calling HealthChoice at the numbers listed in the Plan Identification and Contact Information 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 About Complaints, Appeals, Grievances, or Coverage Determination section.
Making a Complaint – Filing a Grievance (Plans with Part D)
The complaint process is used when you have problems related to the quality of your care, waiting time, or the customer service you receive. The Medicare program has 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.
Complaints about the quality of care you receive under Medicare will be handled by Medco, HealthChoice, and/or by an independent organization known as the Quality Improvement Organization (QIO). A complaint (grievance) does not involve coverage or payment.
There is a QIO in each state. In Oklahoma, the QIO is called Health Integrity, LLC. Health Integrity has a group of doctors and other health professionals who are paid by Medicare to review and help improve the quality of care for people with Medicare.
Following are a few examples of quality of care issues:
You are unhappy about the quality of care you have received; i.e., you think your pharmacist provided you with the wrong prescription or the wrong dosage.
You believe someone did not respect your privacy, or was rude or disrespectful.
You believe a pharmacist or customer service representative has kept you waiting too long.
You think your hospital stay is ending too soon.
You think your home health care, skilled nursing facility care, or your outpatient rehabilitation care is ending too soon.
Following are some problems that might lead you to file a complaint:
You feel you are being encouraged to disenroll from HealthChoice.
You believe HealthChoice informational materials are difficult to understand.
HealthChoice doesn’t make a decision about your claim in the required time frame.
You disagree with a HealthChoice decision not to fast track your request for a determination or redetermination.
HealthChoice fails to forward your case to a certified Independent Review Organization (IRO) when a decision is not made within the required time frame.
If you wish to make a complaint regarding quality issues involving the Part D prescription drug program, you or your physician may contact Medco at the numbers listed in the Plan Identification and Contact Information section.
Coverage Determinations (Plans with Part D)
Whenever you ask for coverage of a medication under Medicare Part D, it is called a coverage determination or decision. An example might be when you take your prescription to be filled at the pharmacy and coverage for your prescription is approved or denied.
If your request is denied, you may request an exception. You might ask HealthChoice for an exception if:
You want to receive a non-Preferred drug at the Preferred copay.
You want HealthChoice to pay for a non-covered medication.
You disagree with the quantity limitation set for a medication.
You want HealthChoice 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 HealthChoice 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 want HealthChoice to pay you back for a medication purchased at a non-Network Pharmacy.
If your request for an exception is denied, you have the right to file an appeal. You can contact Medco toll-free at 1-800-753-2851 or TDD 1-800-825-1230.
Appeals
An appeal refers to any of the procedures that deal with the review of an unfavorable decision. 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.
The Appeals Process
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 this option 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 in the Who to Contact for Complaints, Grievances, Appeals, or Coverage Determinations section.
Appeal Levels
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 complaint (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.
Appeal Level 1
The first step in the appeals process is requesting a coverage redetermination. You should ask for a coverage redetermination if you are unhappy with a coverage determination. In general, this process consists of the review of the 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 decision or the amount you will have to pay for a drug, you may appeal to the next level.
Appeal Level 2
If HealthChoice denies your request for a coverage redetermination, you may request, in writing, a review by a federal government-contracted Independent Review Organization (IRO). For a standard appeal, the IRO 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 IRO must notify you in writing about its decision.
Appeal Level 3
If the IRO 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.
Appeal Level 4
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.
Appeal Level 5
If the amount in question is more than $1,260 and you want to continue your appeal, 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.
For more information about the grievances and appeals process, download a copy of the Grievance and Appeals Guide for Pharmacy Benefits available on our website at http://www.sib.ok.gov/ or http://www.healthchoiceok.com. You can also request one by calling HealthChoice Member Services at the numbers listed in the Plan Identification and Contact Information section.
Grievance and Appeals Data
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 Plan Identification and Contact Information section.
FRAUD, WASTE, AND ABUSE COMPLIANCE
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 St, 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.
HEALTH EDUCATION LIFESTYLE PLANNING (H.E.L.P.)
H.E.L.P. offers wellness opportunities for Plan participants who are choosing to become and stay well. Wellness opportunities include:
HealthVoice Newsletter
You may find health and wellness information in the HealthVoice newsletter.
Online Health and Wellness Information
The website home page of the HealthChoice website has ‘featured articles’ on health and wellness.
Walking Club
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, Monday through Friday, 8:00 a.m. to 5:00 p.m. Central time 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.
Fitness Center Discounts
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 the numbers listed previously.
NOTIFICATIONS
Certificate of Coverage
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. This certificate may be required by your next health plan, as proof of your previous group health coverage. This certificate will be required in order to waive preexisting condition limitations.
Women’s Health Cancer Rights Act of 1998 Notice*
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.
Coverage of Side Effects Associated With Prostate Related Conditions*
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 HP Administrative Services, LLC at the numbers listed in the Plan Identification and Contact Information section.
Wigs and Scalp Prostheses
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.
PLAN DEFINITIONS
Appeal
A special kind of complaint you make if you disagree with the Plan’s decision to deny your request for prescription drug benefits. There is a specific process that HealthChoice must use when you ask for an appeal.
Assignment
An arrangement with a physician or medical supplier who agrees to accept the Medicare approved amount as full payment for services and supplies covered under Medicare Part B.
Brand-Name Drug
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.
Centers for Medicare & Medicaid Services (CMS)
The federal agency that runs the Medicare program.
Certification
A review process performed by either the certification administrator or the HealthChoice Health Care Management Division depending on the type of medical services to be reviewed.
Coinsurance
The percentage of the cost of a covered service or medication that you pay as your share of the expense.
Copay
The set amount you pay as your share of the costs for covered services or medications.
Cosmetic Procedure
A procedure that primarily serves to improve appearance.
Coverage Determination
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.
Covered Drugs
The term we use to refer to all the prescription drugs covered by the Plans.
Coverage Gap (Low Option 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
Creditable coverage is coverage that is at least as good as the standard Medicare prescription drug coverage.
Deductible
The initial out-of-pocket expense you pay on Allowed Charges before a benefit is paid by the Plan.
Dependent
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 age 25.
Disenrollment
The process of ending your coverage with our Plan. Disenrollment can be voluntary (your own choice) or involuntary (not your own choice).
Eligible Participating Former Employee
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.
Evidence of Coverage (handbook)
This document explains your coverage, your rights, and what you have to do as a member of our Plan.
Exception
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).
Federal Limiting Charge
The highest dollar amount 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.
Grievance - Health
A health benefit grievance is an appeal you file with the Plan when, after a review, your request for health care coverage remains denied.
Grievance - Pharmacy
A pharmacy benefit grievance is a complaint such as 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.
Generic Drug
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.
HealthChoice Medicare Formulary
A list of medications covered by the Plans.
Initial Coverage Limit (Low Option Plans)
After you meet your deductible, the next $2,520 of prescription drug costs is known as the initial coverage limit. You pay 25% ($630) and HealthChoice pays 75% ($1,890) of this amount for covered prescription drugs.
Late Enrollment Penalty
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 longer. You pay this higher amount as long as you have a Medicare drug plan. There are some exceptions.
Medically Necessary
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.
Medicare
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.
Medicare Eligible Expenses
Expenses recognized as reasonable and medically necessary by Medicare.
Medicare Approved Amount
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.
Member (member of HealthChoice)
A person with Medicare who is eligible to get covered services and has enrolled in HealthChoice.
Network Pharmacy
Network Pharmacies contract with our Plan. In most cases, your prescriptions are covered at the maximum benefit only if they are filled at a HealthChoice Network Pharmacy.
Non-Covered Service
Any service, procedure, or supply excluded from coverage.
Non-Network Pharmacy
A pharmacy that doesn’t have a contract with our Plans. Most services you get from non-Network pharmacies are not covered by the Plans except under certain conditions.
Option Period
The annual time period, established by OSEEGIB, when changes may be made to coverage.
Out-of-Pocket Maximum
The maximum amount you pay before the Plan pays 100% for covered services or medications.
Part D
The Medicare Prescription Drug Benefit Program.
Part D Drugs
Drugs that Congress permits HealthChoice to offer as part of a standard Medicare prescription drug benefit. We may or may not offer all Part D drugs.
Participating Employer
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.
Pharmacy Prior Authorization
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.
Quantity Limitations
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.
Step Therapy
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.
Last Modified on 07/22/2010