Active Member Info: Frequently Asked Questions
Eligibility
- My wife and I just had a baby. Is my child automatically covered for health insurance?
- My daughter is attending college. Does she still have coverage through the PEBTF?
- My spouse and I are getting divorced. How do I remove my spouse from coverage?
- My wife passed away. How do I report her death and remove her from benefits?
Managed Care
- If I'm enrolled in an HMO or Medicare HMO , how do I change my Primary Care Physician (PCP)?
- What if my Primary Care Physician (PCP) terminates affiliation with the HMO or Medicare HMO?
Basic Option - Pre-7/1/04 Non-Medicare Eligible Retirees
- How do I submit a claim to PEBTF Major Medical?
- Can I submit my out-of-pocket expenses to PEBTF Major Medical if my physician is a non-participating physician?
- Can I submit my prescription drug copayments under PEBTF Major Medical?
Supplemental Benefits
- I know generic drugs save me money. What is a generic drug?
- How do I know what drugs are on the Prior Authorization List?
- Why did I pay more than my copayment for my prescription?
Miscellaneous
- What is coinsurance?
- How do I obtain Durable Medical Equipment (DME), Prosthetics, Orthotics and Diabetic Supplies?
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.
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.
