- What is a primary care physician and what is a specialist?
Under the A&M Care and Graduate Student health plans, a primary care physician (PCP) is a general or family practitioner, an internal medicine doctor, a pediatrician or an obstetrician/gynecologist. All other doctors under these plans are considered specialists.
- I understand that there is a 90-day waiting period for the employer contribution for medical insurance coverage for new faculty. Would there be a waiting period for my wife and stepchildren after the wedding?
No, there is no new waiting period when you add a new dependent to your coverage.
- If I'm a graduate student, do I have to enroll in the Graduate Student Health Plan to have health coverage?
No. You can choose between the Graduate Student Health Plan and the A&M Care plan.
- Does the Graduate Student Health Plan's repatriation benefit meet the visa requirements for foreign nationals?
Yes, the Graduate Student Health Plan is the only A&M System health care plan that offers repatriation benefits, and those benefits do meet the visa requirement for foreign nationals. However, the Basic Life plan also offers repatriation benefits, so if you enroll in any health plan through the A&M System you will have Basic Life and therefore medical evacuation and repatriation coverage.
- My doctor has prescribed a particular medicine for me, but my health plan says it’s not on the plan’s formulary. What does that mean?
All of our health plans use formularies. Formularies are lists of drugs the health plan prefers that you take for various illnesses. Each health plan has its own formulary, so a drug may be on the formulary of one plan, but not on another. These drugs cost less for the health plan to dispense because they are purchased in bulk with special discounted pricing from the manufacturer. A&M System health plans have a three or four-tier copayment system. These consists of three or four copayment levels with the lowest copayment for a generic drug, a higher copayment for a brand-name drug on the formulary, and a higher copayment for a brand-name drug not on the formulary, and in some cases, a coinsurance amount for very expensive injectables or biogenetic drugs.
The formulary may change during the year, but the Texas Department of Insurance now requires health plans to notify you 90 days in advance if they will be removing a drug you are taking from the formulary list, so you will have a chance to try another drug or request an appeal.
- If I'm an A&M Care plan participant, can I get prescriptions filled at my favorite pharmacy?
The ExpressScripts network is a nationwide network of more than 55,000 pharmacies, so the chances are good that your pharmacy is participating. To see if your pharmacy belongs to the ExpressScripts network, or to locate a participating pharmacy near you, call ExpressScripts toll-free at (866) 544-6970, or access ExpressScripts web site at www.express-scripts.com
- What happens if I use an out-of-network pharmacy?
As an A&M Care plan member, you must pay, up front, the full cost of a prescription if you use a pharmacy that is out of ExpressScripts network of pharmacies. You must then file a claim with ExpressScripts to be reimbursed for covered medications. After you've met your deductible, your copayment is deducted and then ExpressScripts will reimburse you 75% of the remaining reasonable and customary cost. Contact your Human Resources office for out-of-network claim forms or call ExpressScripts toll-free at (866) 544-6970.
- Under the A&M Care plan, how do I determine whether to have my prescriptions filled at my local pharmacy or the mail-order pharmacy?
Your local pharmacy should be used for short-term or acute medications such as antibiotics or pain relief medications. For long-term or maintenance medications, you should use the mail-order pharmacy, ExpressScripts By Mail. Using the mail-order pharmacy, you can get up to a 90-day supply of your medication for only two copayments. Be sure your physician writes the prescription for 90 days worth of medicine, plus any needed refills. However, if you are getting a brand-name drug when a generic is available, you will have to pay the cost difference between the generic and brand-name in addition to the copayments. The only exception is if, before you submit the prescription, your doctor sends ExpressScripts a completed prior authorization form, available at www.express-scripts.com
, explaining why it is medically necessary for you to have the brand-name drug. ExpressScripts must approve the request.
- If Medicare is primary, do I have to use network doctors and hospitals?
No. In the A&M Care plan, you will receive the same benefits no matter which doctors and hospitals you use.
- If I have Medicare as my primary carrier, do I have to precertify with BlueCross BlueShield?
- If my doctor submits evidence that I must have a drug not on the formulary list for medical reasons, can I get the nonformulary drug by paying the formulary copayment?
If your doctor provides documentation to ExpressScripts before the prescription is filled stating that you have tried the formulary drug and you must have the nonformulary drug for medical reasons, and if ExpressScripts approves the substitution, you will pay only the formulary copayment. Formulary information is available at www.express-scripts.com
or from your Human Resources office.
- Under the A&M Care plan, how long will it take to get prescriptions filled through the mail-order program?
Once ExpressScripts By Mail receives a prescription and order form with all of the required information, your prescription is filled and mailed, on average, within three days for orders that do not require intervention. Orders sent by regular mail usually take an additional two to five days to arrive. If you want to ensure faster delivery, you may pay more for overnight delivery.
- What is a formulary list?
The formulary is a list of preferred brand-name drugs that have been compared and evaluated with other brands and provide maximum quality and value. Many therapeutic categories (for example, ulcer medications) have two or more brand-name drugs that are used for the same purpose.
To maximize your savings, you should present the list to your physician each time you are to receive a prescription and, when possible, ask your physician to consider the use of generically equivalent alternatives. You are not required to use the drugs on this list, and they are not the only drugs covered by the plan. If a drug you are using is not on the list, you may still have your physician prescribe that drug for your use, but you will pay a higher copayment.
- How will I know if my prescription will be filled with a brand-name or a generic medication?
Generic alternatives will be dispensed by the pharmacist whenever available and legally permitted, unless your physician specifically indicates on the prescription "dispense as written." The generic version of a drug has the same chemical compound as its brand-name counterpart. The use of generic drugs offers a simple and safe alternative to help reduce your prescription drug costs. If a generic drug is available and you have your prescription filled with a brand-name drug, the plan will pay only the cost of the generic. You will be responsible for paying the difference, plus the brand-name copayment. You pay only the brand-name copayment when no generic is available.
- Under the A&M Care plans, I understand some medications may be limited or require prior authorization. Which drugs are these?
Generally, the A&M Care plans will cover drugs that are prescribed for the medically necessary treatment of an injury, illness or disease. The plans do not cover drugs prescribed for fertility treatment or cosmetic purposes, including hair growth agents.
To obtain some drugs, you must first have your physician fax or mail documentation of the medical necessity of the drug using the preauthorization form available on the ExpressScripts web site, www.express-scripts.com. ExpressScripts will then determine whether to authorize coverage for the drug. If ExpressScripts does not authorize coverage, you may still obtain the drug, but you will pay the full cost.
Some drugs are restricted to certain ages, dosages or diagnoses and may require prior authorization.
Call ExpressScripts at (866) 544-6970 (toll free), or visit the web site at www.express-scripts.com, if you have a question about whether a medication is covered, requires prior authorization or is restricted.
- Why don’t retirees eligible for Medicare have to use network providers?
Medicare has already set the amount a doctor who accepts assignment may charge for services for those on Medicare. These rates are greatly reduced from what the doctor normally charges. In addition, since the A&M Care plan generally pays after Medicare, the balance due is relatively small. Consequently, making Medicare-eligible retirees use network doctors would generate little or no savings for the A&M Care plans.
- If I choose not to enroll in Medicare, will my benefits be paid the same way as an active employee’s are paid?
The answers depends on whether you are actively employed or retired. If you are actively employed with the A&M System, which is defined as working at the A&M System at least 50% time (20 hours a week) for at least 4½ consecutive months, you may postpone enrolling in Medicare until you retire. In this case, your benefits will be paid the same as other active employees. If you are retired and eligible for Medicare, the A&M Care plan will pay benefits as if you are enrolled in Parts A and B of Medicare, even if you are not actually enrolled. To get full health benefits, you must enroll in both parts of Medicare as soon as you become eligible.
I turned 65 this year. Does that mean I should enroll in 65 PLUS?
Not necessarily. You still have the choice of enrolling in the A&M Care plan. However, the 65 PLUS plan generally provides the best health care value for eligible retirees.
- If I buy a brand-name drug, do I just pay the formulary or nonformulary copayment?
That depends. If no generic equivalent is available, you pay the formulary copayment if you buy a brand-name drug on the formulary and the nonformulary copayment if you buy a brand-name drug not on the formulary. However, many plans have mandatory generic substitution. If a generic is available, many plans require that you pay more if you do not want to take the available generic. If you are covered by one of the A&M Care plans, your doctor can submit medical evidence that you need the brand-name drug because you can't take the generic drug, and ExpressScripts|Medco, the A&M Care drug plan administrator, may approve payment of the brand-name formulary or nonformulary copayment.
- Can I add or drop dependents from my health plan during the plan year?
If you have a Change in Status, you may add or drop the dependent affected by the change to or from your health, dental or vision plan within 60 days of the change. Otherwise, you may not add or drop dependents except during Annual Enrollment (effective Sept. 1). Changes in Status are:
- Employee’s marriage, divorce or death of employee’s spouse
- Birth, adoption or death of a dependent child
- Child becoming ineligible for coverage due to reaching age 25 or marrying (age 26 for health coverage)
- Change in employee’s, spouse’s or dependent child’s employment status that affects eligibility for coverage
- Change in employee’s, spouse’s or dependent child’s residence that affects eligibility for coverage
- Employee’s receipt of a qualified medical child support order or letter from the Attorney General ordering the employee to provide (or allowing the employee to drop) medical coverage for a child
- Changes made by a spouse or a dependent child during his/her employer’s annual enrollment period
- The employee, spouse or dependent child becoming eligible or ineligible for Medicare or Medicaid
- The employee/retiree or dependent child loses coverage under the State Medicaid or Child Health Plan or becomes eligible for premium assistance under the Medicaid or Child Health Plan.
- Significant employer-initiated or carrier-initiated changes in or cancellation of the employee’s, spouse’s or dependent child’s coverage
- Change in day care cost due to a change in provider, change in provider’s fees (if the provider is not a relative) or change in number of hours the child needs care (for Dependent Day Care Spending Accounts)
A court order against the spouse of an A&M System employee does not constitute a Change in Status. Also, a change in income, which may affect coverage affordability, does not constitute a Change in Status.
- Are the A&M Care plans the same as the BlueCross BlueShield (BCBSTX) plans?
Yes. BCBSTX administers the A&M Care plans for the A&M System.
- What are the key phone numbers for BlueCross BlueShield of Texas?
Member services: (866) 295-1212
Precertification: (800) 441-9188
Mental health precertification: (800) 528-7264
BlueCard (for network physician information outside Texas): (800) 810-BLUE
Both precertification numbers can be dialed directly or accessed by calling member services. Member services representatives will be available from 8 a.m. until 8 p.m., Monday through Friday.
- How do I know if I live in a BlueCross/BlueShield network area?
BlueCross/BlueShield of Texas (BCBSTX) has networks in all 50 states and provides coverage worldwide.
- What network benefits are available for employees and retirees living or traveling outside Texas?
A&M System employees and retirees have access to network doctors nationwide through BlueCross BlueShield's BlueCard program. Your ID card has a toll-free number you can call to get information on providers in your area. Unless you are eligible for Medicare and not working for the A&M System, you must use a network provider to receive the highest level of benefits.
- How do the network and out-of-network deductibles and out-of-pocket maximums work together if I sometimes go to network doctors and sometimes to out-of-network doctors?
Out-of-network provider expenses will apply only to the out-of-network deductible and out-of-pocket maximum. Network expenses will apply only to the network deductible and network out-of-pocket maximum.
- Why are out-of-network deductibles more than network deductibles?
A&M Care participants pay the higher, out-of-network deductible when they choose to visit a care provider not in the network. This provision encourages plan participants to visit network providers, with whom BlueCross BlueShield of Texas has contracted to provide certain services at lower costs, and helps hold down the premium costs for all employees.
- How do I get prescription medicine through the A&M Care plans?
ExpressScripts is the drug plan administrator for the A&M Care plans. If you enroll in one of the A&M Care plans, you will receive a ExpressScripts drug card. You can use this card at more than 55,000 chain and independent pharmacies throughout the U.S. for a 30-day supply of medicine. You pay a $50 deductible on your first prescription drug purchases each year for each covered family member. Then you pay $10 for each generic prescription, $35 for each brand-name formulary prescription and $60 for each brand-name nonformulary prescription if you buy drugs at a local pharmacy. You can also order up to a 90-day supply of maintenance medications through ExpressScripts mail-order program, ExpressScripts By Mail. If you use the mail-order program, you pay two copayments for a 90-day supply after the $50 annual deductible. If you buy a brand-name drug when a generic is available, you pay the difference in cost in addition to the $35 or $60 brand-name copayment, unless your doctor provides information in advance that you cannot take the generic drug for a documented medical reason and PharmaCare approves the brand-name drug. For more information on obtaining prescription medicines, call ExpressScripts toll-free at (866) 544-6970.
- Under the A&M Care plans, do I need to file a claim to get reimbursed for short-term drugs?
You file a claim only if you use a pharmacy that is not in ExpressScripts network. Out-of-network pharmacies require you to pay the full cost of the drug at the time of purchase.