Where do I mail in my claims?
If you are an active member and using Blue Cross Blue Shield PPO network providers, the providers will submit claims for you. All other claims, including all Medicare and dental claims, should be mailed directly to the Fund Office. If you have received a second notice from your provider of service, please contact the Fund Office.
How do I find a network doctor or hospital? How do I know if my doctor or hospital is in the network?
Contact your network at the number listed on your medical I.D. card or visit the Blue Cross Blue Shield of Illinois Web site at www.bcbsil.com.
What is a deductible?
Each year, before the Plan begins to pay for most covered expenses, you pay the first dollars of eligible expenses. This is the deductible. There is a calendar year deductible per person ($300), with a family limit ($600). The deductible is payable to the doctor or hospital where the charges applied to the deductible were incurred. The Explanation of Benefits (EOB) you receive on the charges you submit will show the amount you owe.
How do the individual and family deductibles work?
Here’s an example: Sam is the first in his family to have covered medical expenses and he reaches his deductible. All of Sam’s covered medical expenses for the rest of the year will be paid at the 80% or 60% level, depending on whether Sam goes to a network or non-network provider. Let’s say Sam’s wife, Liz, meets her deductible as well. Because two family members have met their deductibles, the rest of the family’s covered medical expenses will be paid at the 80% or 60% from the first dollar. In other words, Sam’s children do not have any deductibles to meet for the year.
What is a copayment and how do I pay it?
After satisfying the deductible, you and the Plan will share responsibility for eligible medical expenses. The Plan pays 80% for PPO network expenses or 60% for non-PPO network expenses. You pay the remaining 20% for PPO network or 40% for non-PPO network expenses, which are within the Fund’s reasonable and customary guidelines, to the doctor or hospital where the services were performed. Your Explanation of Benefits (EOB) will indicate the amount you owe to the provider.
What is the difference between network and non-network?
A Preferred Provider Organization (PPO) is a network of providers (known as network providers) that have been contracted to provide services at discounted rates. The discounted rates and the associated savings are the biggest difference between network and non-network providers and benefits. The Fund shares this savings with you by reducing the amount that you owe for the services performed. With a PPO network provider, you owe the 20% of the discounted amount. With a non-PPO network provider, you will be responsible for 40% of the charged amount, as long as the charge is within the reasonable and customary guidelines; any amounts over the reasonable and customary guidelines are your responsibility.
Are my expenses limited?
Once your payments toward the deductible and copayment for eligible medical charges reach the annual out-of-pocket maximum for the individual ($5,000) or family ($10,000), the Plan will usually pay 100% of most eligible expenses for the rest of the calendar year. Expenses not covered under the Plan do not apply toward the out-of-pocket maximum. In addition, some expenses are never paid at 100%.
What is the annual maximum?
The annual maximum medical benefit payable for an eligible person under the Plan is $1,000,000 in a calendar year.
What types of covered medical expenses require pre-certification?
You will need to call Medical Cost Management at 800-367-9938 to pre-certify the following:
How much is the Copayment for my prescription?
Your Copayment depends on where the medication is dispensed (participating retail pharmacy or mail order program) and the type of medication it is (generic, preferred brand, non-preferred brand). Prescriptions filled at a non-participating retail pharmacy are not covered. To find a participating retail pharmacy, call Medco at 1-866-312-9068 or go online to www.express-scripts.com.
Prescription Copayments
Participating Retail Pharmacy (up to 34-day supply) |
Mail Order Program (up to a 90-day supply) |
|
| Generic | $7.50 |
$15.00 |
| Preferred Brand | 20% of TUF* up to $50 |
20% of TUF* up to $100 |
| Non-Preferred Brand | 30% of TUF* up to $75 |
30% of TUF* up to $150 |
* Total Undiscounted Fee (TUF)
Note: if you have a prescription filled for a brand name drug that has a generic equivalent, you will need to pay the difference between the brand name and generic drug as well as the brand name copayment.
What is the difference between generic, preferred, and non-preferred drugs?
The Plan pays benefits for prescription drugs based on three categories: generic, preferred, and non-preferred. Since there are different types of medications that can be used to treat the same condition, it’s important for you to know the difference by category. Being an educated prescription drug consumer can help you use the Plan most cost effectively.
By law, a generic drug must be equivalent to its brand name counterpart. When the patent runs out on a brand name drug (in 17 years), other Food and Drug Administration (FDA) manufacturers are allowed to produce the generic versions. The FDA approves all medications including generics.
Preferred drugs are brand name drugs that are listed on the Plan’s Preferred Drug List because they are either more effective than others in their class (group of drugs used to treat particular conditions) or as effective as and less costly than similar medications. Non-preferred drugs are brand name drugs that are not on the Plan’s Preferred Drug List. Ask your doctor if he or she can prescribe a generic or preferred brand name drug when you need a prescription.
What if only one of us, my wife or I, complete the requirements for getting the $200?
You and your spouse complete the requirements independently so if only one of you completes the requirements for a $200 contribution, only $200 will go into your HFA account.
If I complete the Health Risk Assessment (HRA) and nothing else will I still get $100?
Yes. Contributions into your HRA are made independently for each of the requirements you complete.
Can I use the money in my HFA account to pay for eligible expenses for my kids?
Yes. You can use your account to reimburse eligible expenses for anyone in the family who is eligible for benefits under the Plan.
When can I use the money in my HFA account?
You can use the money as soon as it is deposited in your account. When you or your family has covered healthcare expenses, the Plan will automatically use your HFA to pay expenses you would otherwise have to pay, up to your HFA balance.
What if I don’t use the money in my HFA account this year?
If you have a balance in your HFA account at the end of the calendar year, the money will stay in your account so that you can use it in the future.
What if I keep accumulating the money in my HFA account until I retire; can I cash it out?
You can only use your account for reimbursement of eligible healthcare expenses for your family. At retirement you can continue to use your account for reimbursement of eligible healthcare expenses, including your retiree self payment for coverage.
Am I eligible for the Healthy Foundations Program if I’m retired and eligible for Medicare?
Once you are in the Medicare Supplement Plan, you are no longer eligible for benefits under the Plan. However, if you have a balance in your HFA account, then you will be able to use the balance in your account, but you will not be eligible to participate in the Wellness or Disease Management Programs, and you will not be eligible for additional contributions into your HFA account. You may use your account to pay your self-payment for coverage.
I’m in the Disease Management Program, Optimal Health, what happens if I don’t contact my coach in a quarter?
You receive contributions of $25 into your HFA account for each quarter that you participate in the program. If you stop participation for one quarter and then start again in the next quarter, you will begin receiving the $25 contribution per quarter again. If your participation lapsed in one quarter, be sure to start again in the next quarter for your health and the $25 contribution.
My wife and I are healthy, why should we participate in the program?
For most of us, remaining healthy is an active process. We need to eat healthy, get exercise, get check-ups, and continue to learn about health. The Optimal Health program provides you with the resources to learn about and maintain your health. As a bonus, the program provides you with the opportunity to receive up to $200 contribution into your HFA account for each of you ($400 total) each year.
I’m already working with my physician to manage my chronic disease. Why do I need a coach?
The Optimal Health program provides you with resources and support to learn more about your condition and how to live with it. The Optimal Health coach provides you with detailed information, education, goal setting, and the ongoing support necessary to make lifestyle changes that are so important in managing chronic conditions. Many physicians do not have time to provide that level of support. You and your coach will determine your own, convenient schedule!