Health Insurance: OKHEEI FAQ

Yes, BCBSOK coordinates with other Group Blue Cross Plans (including Oklahoma) the same way it would with another carrier.

No, just as it was with OSEEGIB, "double OKHEEI" coverage will not be allowed.

No. If dependent coverage is selected, it must always be the same coverage as the employee selects.

To find a PPO provider, you can access the online provider directory at www.bcbsok.com and click on the "Search for doctors, dentists, hospitals and other health care providers with our Provider Finder" link on the left side of the page. The Network Type for your group is "BlueChoice ". To locate a provider outside of Oklahoma, click on the same link and then in the bottom left corner click on "Find U.S. Providers Outside of Oklahoma" in the More Searches section. Once there, until you have your BCBSOK ID card, click on "Guest" and then do your search for PPO/EPO providers.

BCBSOK has contracted providers in over 185 countries outside the US. To locate those providers you can call 1.800.810.BLUE or visit the Provider Finder on our Web site at www.bcbsok.com. Please note that you must have a member number to access the directory for the BlueCard WorldWide network, so you won't be able to access this function until you have received your Blue Cross and Blue Shield ID Card.

Yes, as long as those treatment centers are in the BlueCard PPO Network, you will have the same in-network benefits as you do for seeing local BlueChoice providers. Both MD Anderson and Mayo are in the BlueCard PPO Network. To find network providers, please visit our Web site at www.bcbsok.com.

Please visit www.bcbsok.com and go to "Search for doctors, dentists, hospitals, and other health care providers with our Provider Finder". Click on "Find a Dentist" at the bottom left corner and select the network: BlueCare Dental (formerly LINCS Dental Connection Traditional).

Yes, lifetime max will begin at $0 regardless of previous or current other coverage.

We will consider increasing the lifetime maximum for the group after one year of being on the BCBSOK plan.

Any inpatient hospital stay, home health or hospice care, skilled nursing facility services, and private duty nursing care. Some outpatient surgeries and diagnostic imaging services require pre-certification as well. If you use a BlueChoice PPO provider in Oklahoma for your services, your provider will automatically request pre-certification for you. The member is responsible for obtaining pre-certification for services received outside of Oklahoma or from an out of network provider.

Yes.

Yes. Coverage will end at the end of the month in which they turn 25.

No, providers that are in-network will file the claims with BCBSOK. If a provider is out-of-network, they may require you to file the claim yourself. Claim forms can be found at www.bcbsok.com and should be mailed to: Blue Cross and Blue Shield of Oklahoma, PO Box 3282, Tulsa, OK 74102-3282.

You will receive new ID cards on or before January 1, 2010. For single coverage you will receive one card; for family coverage you will receive two cards. Once you've received your initial ID card(s), additional cards can be ordered online through Blue Access for Members or by calling customer service. ID cards will list the employee's name only. Spouse and dependent information will not be on the card.

Yes, if you don't enroll during the upcoming/initial enrollment period (January 1, 2010), you cannot sign-up until the next annual open enrollment which occurs each year, unless you have a qualified status change during the plan year. In addition, if you do not enroll during this time (January 1, 2010), you may also be subject to pre-existing conditions. Blue Cross and Blue Shield has waived pre-existing conditions for all employees and eligible dependents that enroll for January 1, 2010.

A condition (whether physical or mental), regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received within the six-month period ending on the enrollment date. In order to be taken into account, the medical advice, diagnosis, care, or treatment must have been recommended by or received from an individual licensed or similarly authorized to provide such services under state law and operating within the scope of practice authorized by the state law. A pre-existing condition does not include pregnancy, nor can it be applied to a newborn or adopted child under age 18, as long as the child became covered under the certificate within 31 days of birth or adoption.

Pre-existing Condition Exclusion:
A 12-month or 18-month period during which no benefits will be provided for a condition for which medical advice, diagnosis, care or treatment was recommended or received within the six-month period before the enrollment date.

Your benefits under this certificate are subject to a pre-existing condition exclusion period. However, the pre-existing condition exclusion will only apply to you and/or a dependent if the following conditions are met:

Six-month Look-back Rule:
The pre-existing condition exclusion must relate to a condition (whether physical or mental, and regardless of the cause of the condition) for which medical advice, diagnosis, care, or treatment was recommended or received within the six-month period ending on the subscriber's enrollment date.

In order to be taken into account, the medical advice, diagnosis, care, or treatment must have been recommended or received from an individual licensed or similarly authorized to provide such services under state law and operating within the scope of practice authorized by state law.

The six-month look-back period is based on the six-month "anniversary date" of the enrollment date.

Length of Pre-existing Condition Exclusion Period:
The exclusion period cannot extend for more than 12 months (18 months for late enrollees) after the enrollment date. The 12-month or 18-month "look forward" period is also based on the anniversary date of the enrollment date.

Reduction of Pre-existing Condition Exclusion Period by Prior Coverage:
In general, the pre-existing condition exclusion period must be reduced by the individual's days of "creditable coverage" as of the enrollment date. Creditable coverage includes coverage from a wide range of specified sources, including group health plans, most individual health insurance coverage, Medicare, and Medicaid. However, days of creditable coverage that occurs before a significant break in coverage (63 or more consecutive days) will not be counted in reducing the pre-existing condition exclusion period.

In addition, the pre-existing condition exclusion period will be waived for an individual with prior creditable coverage through a health maintenance organization, and who enrolls under this certificate without a significant break in coverage.

Elimination of Pre-existing Condition Exclusion for Pregnancy and for Certain Children:
A pre-existing condition exclusion cannot apply to pregnancy. In addition, a pre-existing condition exclusion period cannot be applied to a newborn, an adopted child under age 18, or a child placed for adoption under age 18, if the child becomes covered within 31 days of birth, adoption, or placement for adoption.

Notice to Subscribers The plan may only impose a pre-existing condition exclusion with respect to a subscriber by notifying the subscriber, in writing, of the existence and terms of any pre-existing condition exclusion under the plan and of the rights of the subscriber to demonstrate creditable coverage. The plan will assist the subscriber in obtaining a certificate of coverage from any prior health plan or issuer, if necessary.

The plan may, without waiving the above provisions, elect to provide benefits for care and services while awaiting the decision of whether or not the care and services fall within the above pre-existing condition limitations. If it is later determined that the care and services are excluded from the subscriber's coverage, the plan will be entitled to recover the amount it has allowed for benefits under this certificate. The subscriber must provide the plan with all documents it needs to enforce its rights under this provision.

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Deductible amounts will remain the same as what they were on HealthChoice in 2009.

No, they do not apply and will remain separate.

No, Blue Cross also pays 80% of allowed charges after the annual deductible has been met.

Mental health will be paid as any other illness.

Yes, two full 90 day courses of any FDA approved tobacco cessation drug are covered. Over the counter drugs and other smoking cessation related services are not covered.

Some services related to the diagnosis and treatment of infertility are covered, as well as prescription drugs for treatment of infertility. Family planning services provided in a physician's office, including surgical procedures for sterilization, injections, IUDs, and internally time-released implants are also covered. Prescription drugs for birth control are covered under the pharmacy benefit. Artificial insemination, embryo transplant, invitro fertilization, surrogate parenting, ovum transplant, donor semen, gamete intrafallopian transfer (gift), zygote intrafallopian transfer (zift), and reversal of voluntary sterilization are all excluded.

No, they are not a covered benefit. For more information regarding medical policy for these procedures, you can visit www.bcbsok.com and go to "providers" then "medical policy".

No, this is not a managed care or HMO plan, so you can select your provider at the time of service.

BCBSOK does not require a primary care physician referral to see a specialist; however, the specialist may require a referral from your primary physician before seeing you.

Once you are enrolled in the plan (after January 1, 2010) you may contact BCBSOK directly using the customer service phone number listed on the back of your ID card. They will ask for your name and member id in order to reference your plan's coverage information.

Once your BlueCross coverage is effective, contact Customer Service to discuss a transition of care plan. BCBSOK will work with you to make sure you receive the appropriate care you need for your medical situation. If it is determined that you need to complete your treatment with your existing provider, BCBSOK will cover those eligible charges at the in-network benefit level. Payment will be made based on the BCBSOK allowable amount, which means the provider could balance bill you for any charges that exceed our allowed amounts.

No, weight loss services, including surgery, will not be covered under the benefits of the Plan, just as they aren't covered through the OSEEGIB High and Basic Option benefits.

BCBSOK will waive the entire 12 month waiting period for orthodontia for those eligible dependents enrolled on January 1, 2010. This will apply whether the dependent is in the middle of treatment on 1/1/10, or if the dependent starts treatment some time during 2010. For those that enroll after 1/1/10, there will be a 12 month waiting period for orthodontia coverage.

Please visit www.bcbsok.com/okheei and go to "Search for Doctors & Hospitals in your area". Click on "Find a Dentist" at the bottom left corner and select the network: BlueCare Dental (formerly LINCS Dental Connection Traditional).

Yes, subject to professional dental review and necessity for the procedure. A predetermination of benefits is highly recommended. If approved, benefits will be paid under the Major Care provision of your benefits.

Blue Cross will cover these services in accordance with the benefits of the plan, provided the tooth was lost while you had dental coverage through OSEEGIB. Verification of that may be required through your Dentist and employer.

The prescription drug plan is administered by Prime Therapeutics. If you elect BCBSOK medical coverage, you automatically are covered under the prescription drug plan.

No, they will remain the same; however BCBSOK's formulary (drug list) does differ from HealthChoice so your co-pay amount may change due to how your specific prescription drug is classified.

Members will pay one co-pay for a 90- day supply of maintenance medications purchased through mail order or at a retail pharmacy. The quantity limit for a 90 day prescription is 300 units, rather than the current limit of 100 through the HealthChoice Plans.

BCBS does not have a specific exclusion list for just medications. Any medication used to treat conditions listed on our standard exclusion and limitations list would not be a covered benefit.

Yes, the Prime Therapeutics plan utilizes a formulary. A formulary is a list of brand-name prescription drugs that are available through Prime Therapeutics at the "preferred brand" co-payment. If you fill a brand-name prescription drug that is not on the formulary, you pay the "non-preferred brand" co-payment. To see if your prescription is on the formulary or if there is a generic available, access our web site at www.bcbsok.com, click on "Members" then "Prescription Drug Information" to find the BCBSOK drug formulary.

No, you would pay the applicable co-pay for a non-preferred prescription drug.

Yes, as long as the prescription is FDA approved for your covered medical condition. Due to the numerous drugs on the market today, the formulary (drug list) only includes all of Tier 2 drugs and a partial listing of Tier 1 and 3 drugs.

Is it the same as my medical insurance card? You will receive an ID card from BCBSOK which is for both your medical and prescription drug coverage.

Prescriptions can be filled at any participating retail pharmacy and through the Prime Therapeutics mail order program. To find a participating retail pharmacy, visit www.bcbsok.com/okheei and click on "Search for Doctors, Dentists, Hospitals & other providers in your area". Next, click on "Find a Pharmacy" in the "More Searches" section of the screen. Next, click on "Other BCBSOK Prescription Drug Plans - Prime Therapeutics Network", then "Find a Pharmacy" near the top right corner of the Prime Therapeutics screen.

BCBSOK requires pre- authorization or step-therapy on some medications. After January 1, 2010 when your BCBSOK benefits become effective, there will be a 90-day grace period when you will not be required to obtain pre-authorization or undergo step therapy. After the 90-day grace period, approximately April 1, 2010, pre-authorization and step therapy will be required for certain drugs. Example: If you are currently taking Prevacid, or will start taking Prevacid between January 1, 2010 and March 31, 2010, you will not be required to obtain pre-authorization or undergo step therapy for this medication as long as you get the prescription filled during the first 90 days. However, if after the first 90 days of 2010 you begin taking Prevacid, or if you wait until that time to get an existing prescription refilled for the first time in the year, you will be required to start the pre- authorization and/or step therapy process.

Step therapy helps ensure your safety while managing the cost of specific medications. Step therapy typically targets high-cost drugs and drug classes of drugs, which should have careful assessment of patient selection or prior treatment before providing the drug. Drugs included in this program require that a prerequisite drug be tried before the step therapy drug will be approved for coverage. If the member meets the initial step therapy criteria, then the requested medication will be covered automatically under the member's current prescription benefit. To see a list of drugs and drug groups subject to step therapy, review BCBSOK's drug formulary. Visit www.bcbsok.com, click on "Members", then "Prescription Drug Information".

On the BCBSOK drug formulary, "SP" stands for "Specialty Pharmacy". Specialty pharmacy medications are used to treat chronic and/or complex medical conditions such as multiple sclerosis, hepatitis C, and rheumatoid arthritis. BCBSOK's specialty pharmacy provider is Triessent. Specialty drugs can be obtained for a maximum of a 30 day supply and they are sent directly from Triessant to your home or to your health care provider.