Benefit Changes: Frequently Asked Questions

Eligibility

Managed Care

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

Supplemental Benefits

Medicare

Miscellaneous

Retiree Plan Changes

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 should contact their local personnel office to complete a PEBTF-2 form to add the child child.  Retiree members should contact the State Employees Retirement System (SERS).

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

Dependent coverage ends on the child's 19th birthday unless the child is a full-time student attending an accredited educational institution.  Members must certify their dependents as full-time students twice a year.  Dependent children, who are full-time students, may remain on the PEBTF coverage until age 23, as long as you continue to recertify them.

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

It is your responsibility to notify your local Human Resource Office (Active members) or SERS (Retiree members) within 60 days of the date of the divorce.  Your ex-spouse may elect COBRA coverage.  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 their local Human Resource Office.  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 their local Human Resource Office.  Retiree members should contact SERS to change plan options.  Medicare HMO members may disenroll by contacting the Medicare HMO and will be returned to traditional Medicare. 

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

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

You may print off a copy of the PEBTF Major Medical Claim Form from this Web site. It appears under the Resources section. Or you may contact the PEBTF to have a form mailed to you. 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.

Q:
Can I submit my out-of-pocket expenses to PEBTF 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 Blue Cross allowance as payment in full. You may submit any remaining balance to the PEBTF for payment consideration. Payment is limited to the Usual, Customary and Reasonable (UCR) charge and subject to the annual deductible and copayment.

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 Blue Cross's UCR. A claim for a non-participating provider must be submitted by you to Blue Cross 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 PEBTF Major Medical.

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

No, prescription drug copayments are an exclusion under PEBTF Major Medical.

Supplemental Benefits

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:
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 Medco at 800-899-2674 or log on to the Medco Web site, www.medco.com, to price a prescription drug.

Medicare

Q:
When do I elect Medicare?
A:

REHP members should contact Medicare for enrollment in Medicare Parts A and B. In addition to Medicare, you may choose the Medicare Private Fee-for-Service (PFFS) Plan.  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.   A Medicare Advantage Plan (HMO or PPO) is another option, if one is available in your county of residence.  You may contact the PEBTF for more information on your Medicare Options.

Miscellaneous

Q:
What is coinsurance?
A:

It is the percentage of the costs of medical services paid by the member.  Under PEBTF 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 Keystone Health Plan West HMO and 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.

Retiree Plan Changes

Q:
Why is the administration making these changes?
A:

There are several compelling reasons:

1. Effective July 1, 2008, the Government Accounting Standards Board (GASB) Rule 45 requires us to account for the value of all benefits that will be paid to retirees throughout their lifetime as they earned, rather than on a pay-as-you-go basis as before.  This liability must be reported and it affects the interest rate that the commonwealth is charged for borrowing, and therefore plays a large role in fiscal planning.

2. To be more consistent with benefit levels of comparable organizations:

  • Currently, there is no premium cost to employees who retired prior to July 1, 2005. Almost every other comparable state requires a retiree contribution for this coverage. The current flat retiree prescription copayment means that as prescription costs continue to escalate each year, the commonwealth absorbs more of the cost, while the retiree pays less as a percentage of actual cost. This means the commonwealth has been taking on a greater percentage of the costs due to the spiraling cost of health care. The commonwealth has made incremental changes to the benefits, without causing a significant cost shift to retirees. The commonwealth must make up the cost difference without putting additional strain on the commonwealth's budget and wishes to do this with as little impact on benefits as possible.

3. Continuing a long-standing practice of prudent management.  The commonwealth has consistently made incremental changes over time. Some benefits have been improved, while others have been limited or curtailed.  For example:

  • 2007
    • Survivor spouses of retirees who were covered under PSERS, TIAA-CREF, or other Approved Retirement Program were permitted to elect self-paid coverage in the REHP
  • 2006
    • Added coverage for preventative tests, immunizations and vaccines, including Pediatric Immunizations, Hepatitis A, Pneumococcal [PCV], Meningococcal [MCV4], sigmoidoscopy, colonoscopy, fecal occult blood tests, PSA Antigen testing,  tetanus, chicken pox, Hepatitis B, and measles/mumps/rubella vaccines.
    • Cancelled coverage for bariatric surgery.
  • 2005
    • Required retiring employees with 15 years of credited service at superannuation age (60) or 25 years of credited service to contribute one percent (1%) of their final base salary towards the cost of REHP coverage.
    • Changed years of credited service needed to retire with REHP coverage from 15 to 20 years of service at superannuation age (kept the other qualifier of 25 years of credited service at any age).
  • 2004
    • Employees retiring after July 1, 2004 have the same plan of benefits as active employees, and subject to the same changes made for actives
  • 2003
    • HMO copayment increased for regular HMOs from $5 to $15
      o Disease Management Program offered to annuitants and dependents covered under the basic and PPO programs statewide.
  • These are just a few samples - there are many, many others

The commonwealth remains committed to offering excellent benefits to its dedicated public servants. These changes will allow the commonwealth to work toward continuing to offer quality health care benefits and ensure that future health care costs do not undermine the financial stability of the commonwealth.

At the same time, these changes will help to maintain one of the best retiree health care plans in the country as a reward for our employees, who dedicated much of their lives to public service.

Q:
What has the commonwealth done to save money without changing benefits?
A:

A) The commonwealth continually monitors programs looking for cost-saving alternatives. The following is a list of just some of the key initiatives that have occurred over the last four years:

  • Competitively bid the prescription drug program to select the most cost-effective prescription benefits manager (7/1/05). Estimated Annual Savings $29,000,000
  • In 2005, the PEBTF required all medical plans to submit proposals that would provide cost savings without changing benefits resulting in lower administrative costs and increased clinical programs for the retirees. Estimated Annual Savings $3,000,000
  • In 2006, the commonwealth elected to participate in the Medicare Part D subsidy program in which the commonwealth was reimbursed for a percentage (about 21%) of prescription expenses in return for continuing to offer an employer-sponsored prescription program that provides a better benefit then Medicare Part D.  (2006)  Estimated Annual Savings $41,000,000
  • Selected a Durable Medical Equipment (DME) company to administer the DME benefit.  By negotiating directly with the providers for discounts on DME supplies, the PEBTF was able to provide the same level of coverage at a lower price.  (1/1/06) Estimated Annual Savings $1,000,000
  • Provided telephonic-based Disease Management programs for 14 chronic conditions to retirees (2003) Estimated Annual Savings $3,000,000
  • Added Medco's RationalMed, Specialty Pharmacy, and Clinical Management Program Enhancements.  These programs identify potential patient safety issues regarding prescription drugs and provides retirees with additional information and support.  (2007) Estimated Annual Savings $1,000,000
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 medication that have been approved by the FDA. The team of physicians and pharmacists meets regularly throughout the year to review and update the lists. 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 can access the preferred formulary list at the PEBTF's website using the following link: http://www.pebtf.org/resources/

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

A preferred 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 preferred 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 year. At the end of each contract year, 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 prescriptions 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/resources/

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

Preferred formulary lists are available to retirees 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 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 $15,315 (Individual) or $20,535 (married couple, living together) may qualify for extra help through the Social Security Administration.  The extra help could be worth more than $3,300 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.

Q:
Is the commonwealth planning on making any other changes to retiree benefits?
A:

These changes assure that the commonwealth can continue to offer one of the most generous benefit packages in the country.  As in the past, the commonwealth will continue to evaluate new technologies, advances in science, and changes in the insurance industry to determine what changes are appropriate for retirees.  

Q:
What is next?
A:

More information will be coming in the form of direct letters and retiree newsletters. Also, Open Enrollment meetings will be provided to allow retirees to ask questions and explore their different options. Watch your mail over the next few weeks for more information.

Q:
What do I have to do?
A:

Read information as it is sent to you and, if possible, attend an Open Enrollment Meeting. If you have questions contact the PEBTF at Toll Free (800) 522-7279. 

Q:
Who can I contact if I have further questions?
A:

Questions can be directed to the PEBTF:

Website

http://www.pebtf.org/

Telephone Hours

  • 8 a.m. to 5 p.m. Tuesday through Friday
  • 8 a.m. to 6 p.m. Mondays or the first day following a holiday weekend

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