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Frequently Asked Questions

Eligibility

Managed Care

Basic Option - Pre-7/1/04 Non-Medicare Eligible Retirees

Prescription Drug Plan

Medicare

Miscellaneous


Eligibility


Q:
My wife and I just had a baby. Is my child automatically covered for health insurance?

A:

Your newborn is automatically covered for 31 days after birth. Coverage will not continue if you do not enroll your child within 60 days of birth.  Active members:  Contact the HR Service Center or your local HR Office if your agency is not serviced by the HR Service Center to complete a PEBTF-2 form to add the child.  Retiree members:  Contact the State Employees Retirement System (SERS).

Q:
My daughter is attending college. Does she still have coverage through the PEBTF?

A:

Dependents may continue coverage to age 26.

Q:
My spouse and I are getting divorced. How do I remove my spouse from coverage?

A:

It is your responsibility to notify the HR Service Center or your local HR Office if your agency is not serviced by the HR Service Center (Active members) or SERS (Retiree members) within 60 days of the date of the divorce. Your spouse must be removed from PEBTF benefits effective the date of divorce. Any claims incurred after the date of divorce are your responsibility. Your ex-spouse's right to COBRA coverage depends on the PEBTF being timely notified of the divorce.  COBRA coverage will continue for 36 months as long as the monthly premium is paid timely and as long as your ex-spouse does not become covered under another group health plan or Medicare.

Q:
My wife passed away. How do I report her death and remove her from benefits?

A:

If such an unfortunate event should occur, Active members should contact the HR Service Center or their local HR Office if their agency is not serviced by the HR Service Center.  Retiree members may contact the State Employees' Retirement System (SERS) at 800-633-5461.  Once you provide the necessary documentation, this information will be transmitted to the PEBTF.

Managed Care


Q:
If I'm enrolled in an HMO or Medicare HMO , how do I change my Primary Care Physician (PCP)?

A:

Once you are enrolled in the plan, you may contact the plan's member services department to change PCPs.  The plan telephone number appears on the back of your medical ID card.

Q:
What if my Primary Care Physician (PCP) terminates affiliation with the HMO or Medicare HMO?

A:

You may choose another PCP or you may change plan options at that time.  Active members should contact the HR Service Center or their local HR Office.  Retiree members should contact SERS to change plan options.  Medicare HMO members should contact the Medicare HMO to discuss other network providers. 

Basic Option - Pre-7/1/04 Non-Medicare Eligible Retirees


Q:
How do I submit a claim to Major Medical?

A:

For claims incurred prior to December 31, 2012, you may print the PEBTF Major Medical Claim Form from this website.  It appears under the Resources section.   You must complete the form in its entirely in black or blue ink and attach the original itemized bills.  Please complete a separate claim form for each patient.  The claim form and the itemized bills should be mailed to the PEBTF at the address that appears on the claim form. For claims incurred on or after January 1, 2013, please contact Capital BlueCross.

Q:
Can I submit my out-of-pocket expenses to Major Medical if my physician is a non-participating physician?

A:

Because you received care from a non-participating provider, the provider may not accept the Capital BlueCross allowance as payment in full.  You may submit any remaining balance to the PEBTF for payment consideration (for claims incurred prior to December 31, 2012).  For claims incurred after January 1, 2013, please submit to Capital BlueCross.

If you go to a non-participating provider for a covered routine or well care service, such as an annual routine gynecological examination or pediatric immunization, you will be reimbursed according Capital BlueCross's UCR. A claim for a non-participating provider must be submitted by you to Capital BlueCross for reimbursement. You are required to pay the non-participating provider's fee directly. Any difference in the covered expense and the actual fee for a covered routine or well care service is your personal responsibility and is not reimbursable under Major Medical.

Q:
Can I submit my prescription drug copayments under Major Medical?

A:

No, prescription drug copayments are excluded under Major Medical.

Prescription Drug Plan


Q:
I know generic drugs save me money. What is a generic drug?

A:

A generic drug is a duplicate of a brand name drug.  Most generics are equivalent because they contain the same active ingredients and deliver the same amount of medication to the body and in the same amount of time.  A generic drug may be available once the patent on the brand name drug has expired and the manufacturer no longer has the exclusive rights to make the drug.  On average, generic drugs cost 30 to 50 percent less than the brand-name drug.

Q:
What is the difference between brand name and generic drugs?

A:

A drug's brand name is the name that appears in advertising. The name is protected by a patent so that only one company can produce it for a certain amount of time. After the patent expires, other companies may manufacture a generic that is just like the brand-name drug and follows FDA rules for safety. A generic is essentially a chemical copy of the brand-name drug. The color and shape of the tablet or capsule may be different, but the active ingredients are the same. Your prescription drug plan is a mandatory generic reimbursement plan and you will be charged the cost difference between the brand and the generic if you do not purchase the generic drug.

Q:
How do I know what drugs are on the Prior Authorization List?

A:

The PEBTF includes the Prior Authorization List on this Web site under Resources.  You may also contact the PEBTF or the prescription drug plan to determine if a drug appears on the Prior Authorization List.  Otherwise, you will be told that the drug appears on the list when you try to fill the prescription at the pharmacy.

Q:
Why did I pay more than my copayment for my prescription?

A:

You are enrolled in a mandatory generic reimbursement drug plan. If you obtain a brand-name drug when a generic equivalent is available, you are  responsible for the difference between the price of the brand name and the generic in addition to the copayment.  You may contact CVS Caremark at 888-321-3261 or log on to the CVS Caremark Web site, http://www.caremark.com/, to price a prescription drug.

Q:
What is a formulary or a "preferred formulary list"?

A:

A formulary or a "preferred formulary list" is a list of prescription drugs covered under your plan.  It is created, reviewed and updated by a team of doctors and pharmacists. The formulary list of drugs contains a wide range of generic and brand-name prescription medications that have been approved by the FDA. The team of physicians and pharmacists meets regularly throughout the year to review and update the list. Physicians may use the list to select medications that are clinically appropriate to meet their patient's needs, while helping maximize prescription drug benefits.

You may access the preferred formulary list at the PEBTF's website under the heading, Publications and Forms/Prescription Drug Plan.

Q:
What is the difference between a preferred brand-name drug and a non-preferred brand-name drug?

A:

A prefered brand-name drug, also known as a formulary drug, is a medication that has been reviewed and approved by a group of physicians and pharmacists. it is chosen for your formulary because it has been proven to be safe and effective.

A non-preferred brand-name drug, or non-formulary drug, is a medication that has been reviewed by the same team of physicians and pharmacists. They decide that this drug is less cost effective than others on the formulary.

Q:
Are only low-cost drugs on the formulary list?

A:

No. Cost becomes the determining factor in a drug's selection only when all other parameters, such as safety and effectiveness have been considered.

Q:
Does the preferred formulary list change?

A:

The preferred formulary list is updated each quarter. A team of physicians and pharmacists meets to review and update the list as necessary. As the FDA approves new drugs they are considered for addition to the preferred formulary list. If the generic equivalent of a brand-name drug becomes available during the year the generic may be changed to the preferred drug on the preferred formulary list during the year. 

Q:
How do I find out what my prescription costs are? Is my prescription covered and is it on the preferred formulary list?

A:

You may call the PEBTF at toll free (800) 522-7279 or visit the PEBTF website to view the preferred formulary list using the following link: http://www.pebtf.org/General/Publications.aspx

You may also log onto the CVS Caremark web site, http://www.caremark.com/ or the SilverScript web site at http://www.rehp.silverscript.com/ (Medicare-eligible retirees) to price medications. Follow the log-in instructions.

Q:
How will my physicians know what drugs are on the preferred formulary list?

A:

Preferred formulary lists are available on the PEBTF website. Pharmacists also have access to the information and they can call your physician with a list of alternatives when your physician prescribes a non-preferred formulary list drug.

Q:
My doctor has prescribed a drug for me that is not on the preferred formulary list. What should I do?

A:

You will receive the most from your prescription drug plan if your doctor prescribes medications that are on the preferred formulary list because your copayment will be lower. You may ask the pharmacist to contact your physician to suggest an alternative that is on the preferred formulary list. If your doctor agrees to change the prescription, the alternative medication will be dispensed and you will pay the lower copayment.

Q:
I am a retiree on a fixed income and have trouble paying my bills. Is there any assistance out there to help retirees pay for prescription drugs?

A:

Retirees who have limited income of less than $16,335 (Individual) or $25,260 (married couple, living together) may qualify for extra help through the Social Security Administration.  The extra help could be worth more than $4,000 per year. Retirees who may qualify for this program should call Social Security at 1-800-772-1213.

In addition, retirees who have limited total income of less than $23,500 (Individual) or $31,500 (married couple) may qualify for the commonwealth's PACE or PACENET programs offered through the Office of Aging.  Retirees who may qualify for this program should call PACE at 1-800-225-7223.

Medicare


Q:
When do I elect Medicare?

A:

REHP members should contact Medicare for enrollment in Medicare Parts A and B. You should receive a red, white and blue Medicare card from the Social Security Administration a couple of months before you turn 65. Disabled members under age 65 may also be enrolled in Medicare. You may choose a Medicare Advantage Plan (HMO or PPO) and you will automatically be enrolled in the SilverScript prescription drug plan. Contact the PEBTF for more information on your Medicare Options or visit the home page of this web site and click on "Retiree Turning 65."

Miscellaneous


Q:
What is coinsurance?

A:

It is the percentage of the costs of medical services paid by the member.  Under Major Medical, the Plan would pay 80 percent of the UCR costs and the member would be responsible for 20 percent, after the annual deductible has been met.  Coinsurance will also be incurred if members receive out-of-network care under the PPO, CDHP, Mental Health and Substance Abuse Plan and the DMEnsion DME Carve-out.

Q:
How do I obtain Durable Medical Equipment (DME), Prosthetics, Orthotics and Diabetic Supplies?

A:

For all members except members enrolled in the CDHP: Contact DMEnsion Benefit Management at 888-732-6161 or log on to the DMEnsion web site (see Links) for a network provider to receive the highest level of benefits.

Equipment or supplies dispensed in a physician's office or emergency room setting, provided as part of Home Health Care, Skilled Nursing Facility care, Hospice, dialysis or home dialysis will continue to be paid by your medical plan. 

Pre-7/1/04 Non-Medicare Eligible Retirees: Continue to obtain diabetic supplies through the Prescription Drug Plan.