Health Insurance: Providers Major Point List

BCBSOK Health Insurance

1. BCBS is a national (including Texas in particular) network. The PPO network providers are considered in-network. BCBS will reach out to any non-network providers (physicians and dentists) as requested by RUSO. Any specific provider information should be provided to BCBS so outreach can be done.
2. Preexisting will be waived for all at initial enrollment period this fall of 2009 for insurance coverage effective as of January 1, 2010. Look back period is 6 months with a 12 month limitation. Late enrollees will have an 18 month limitation.
3. No medical accumulations will be transferred from the prior carrier (HealthChoice).
4. Members can self-refer to a specialist. No referral is required by BCBS.
5. BCBS lifetime maximum is $2 million, which starts over 1/1/10 with BCBS regardless of your current lifetime max balance with HealthChoice. BCBS will review lifetime max next year following claims experience data for possible increase to $3 - $5 million. (OSEEGIB has unlimited lifetime max)
6. $2 million lifetime maximum is calculated on actual dollars paid out by BCBSOK on claims; member deductible and other out-of-pocket expenses do not count toward the lifetime maximum.
7. Mammogram benefits will follow the OK state mandated benefits. If a member goes to an out-of-network provider, they could be balance billed. If the mammogram is submitted as non-routine, charges will be subject to deductible/coinsurance.
8. If in hospital at year end, hospitals in OK will know to separate bill at calendar year end.
9. ID cards will be mailed directly to employee homes at initial enrollment and ongoing. All cards will display the subscriber's name only. For single coverage, one card will be sent. All other coverage levels will receive two cards. If the member needs additional cards they can be ordered through Blue Access for Members or by calling customer service.
10. Medical/prescription drug and dental ID cards will be separate.
11. A 90 day step therapy and prior-authorization waiver will be in place beginning 1/1/10. If member purchases a script within the 1st 90 days that would normally require step therapy or prior-authorization, the claim will be allowed and member will not be required to go through those processes. If member purchases one of these drugs on or after 4/1/10, they will be required to obtain the appropriate prior-authorization or go through the step therapy program.
12. The BCBSOK pharmacy formulary is available at www.bcbsok.com to determine requirements and tier level in effect. Some members may see a difference in co-pays due to the different formulary.
13. No drugs are required to be purchased through the mail order prescription program. Some specialty medication must be purchased from the BCBSOK specialty pharmacy vendor Triessent.
14. If generic drug is on formulary it is not required - however it will be cheaper
15. High cost injectibles may go through specialty pharmacy, which may be through mail.

BCBSOK Dental Insurance

1. Medical coverage is not required for members to obtain dental coverage.
2. No dental accumulations will be transferred from the prior carrier. The orthodontic maximum will start over.
3. Pre-existing across dental (including ortho) will be waived for the open 1/01/10 enrollment.
4. For 1/1/10 any dental waiting periods (including ortho) will be waived. Includes ortho already in progress before 1/01/10.
5. Dental benefits will have a separate ID card.

VSP (Vision Service Plan)Vision Insurance

1. 95% of NSU faculty/staff are currently enrolled in VSP through OSEEGIB
2. VSP provider list is established in this area
3. 2 year guaranteed premium rate