Human Resources

Health Insurance (Optional)

State and Public School’s Health Insurance Plan

Administered by Blue Cross Blue Shield of Mississippi
Post Office Box 23071
Jackson, MS 39225-3071
1-800-709-7881

AHS State Network

The State Employees’ Health Insurance Plan is provided for employees who are employed as a full-time or part-time employee and who work assignments are one-half time or more. The Plan is self-funded by the State of Mississippi which means claims are payable from the actual premiums received from other University or state agencies. The Claims Administrator, Blue Cross Blue Shield, processes all medical claims. The AHS State Network contracts with physicians, hospitals, and other health care providers to provided negotiated discounts in a defined geographic area. The Pharmacy Benefit Manger, CVS Caremark, processes retail pharmacy claims and provides a pharmacy mail order service. The Utilization Review Manager, CareAllies, determines medical necessity for inpatient admissions and certain outpatient services, as well as provides case management services.

The University bears 100% of the premium for each covered employee, and the employee pays the total premium of dependent coverage through payroll deduction.

Employees electing coverage within the first 31 days of hire are covered as of their date of employment. If you waive coverage or do not enroll your eligible dependents at the time of your initial enrollment, you may later enroll yourself or add dependents during a regular open enrollment, generally in October, or special enrollment period. A special enrollment period arises when you or an eligible dependent lose coverage under another health plan or when you gain a new eligible dependent (marriage, birth, adoption, legal guardianship, Qualified Medical Child Support Order, and/or Dependent returning to full-time student status). To enroll yourself or your new dependent for coverage under these circumstances, you must submit an Application for Coverage form within 60 days and make the proper premium payments. You may be required to provide proof of the qualifying event. Assuming these requirements are met, coverage under the Plan will take effect immediately as of the date of the qualifying event.

Please note that all new employees and their dependents that initially applied for coverage are subject to a 12-month pre-existing condition exclusion period. Those that enroll during a regular open enrollment will be subject to an 18-month pre-existing condition exclusion period. The number of prior creditable health coverage may reduce this period.  You will receive credit for prior creditable coverage that occurred without a break in coverage of 63 days or more. Any coverage occurring to a break in coverage of 63 days or more would not be credited against an exclusion period.

The Plan provides for in-network and out-of-network coverage for both you and your covered dependents, whether you live within the State of Mississippi or outside of its boundaries. Using providers that are in-network ensures you receive the maximum benefits available through the Plan.

The AHS State Network helps you manage your overall health care needs through a network of physicians, hospitals, and other health care providers. Providers included in the Network must agree to accept pre-negotiated fees set by the Network. When you visit in-network doctors and facilities, you will receive maximum benefits available under the Plan.

There are two types of plans to choose from: Select Coverage and Base Coverage.  Choice Coverage is available to employees with dependents who wish to participate in a Health Savings Account (HSA).

Complete plan details are available online at Know Your Benefits.

Select Plan

SELECT PLAN

 Premium Class

Monthly Rates (Effective Jan 1, 2024)
Active
University Portion
Legacy Employee Portion
(Employees hired before January 1, 2006)
Horizon Employee Portion
(Employees hired after January 1, 2006)

Employee

$459

$20

$48

Employee + Spouse

$459

$591

$619

Employee + Spouse +
Child(ren)

$459

$854

$882

Employee + Child

$459

$221

$249

Employee + Children

$459

$422

$450

Participants may choose any covered participating or non-participating provider, primary care or specialist; however, using providers that participate in the Network provides participants the maximum benefits available through the Plan. Participants choosing to use providers that do not participate in the Network are responsible for paying any fees charged over the allowable charge, in addition to paying a higher annual deductible and coinsurance.

To find a participating provider, participants can access the AHS Network directory through the Plan’s web site at knowyourbenefits.dfa.ms.gov or may call the Network at 1-800-294-6307.

Select Plan Health Insurance Deductible and Co-Insurance/Co-payment Amounts 

Individual Calendar Year Medical Deductible

The calendar year medical deductible is the amount of medical costs you must pay each year out of your own pocket before the Plan begins to pay its share of medical costs. Once the calendar year deductible is met, the Plan pays a percentage of the allowable charge for covered medical services.

The initial $1,800 of covered medical expense will apply to both the in and out-of-network deductible. After the initial $1,800 has been applied, only services rendered by a non-participating provider will be applied to the additional $1,000 out-of-network deductible.

Family Calendar Year Medical Deductible

Once a family has paid the family medical deductible in a calendar year, all covered participants in that family will be considered to have satisfied their individual medical deductibles for that calendar year. The family deductible amount is twice the calendar year deductible for one individual ($3600). The family medical deductible also applies when both husband and wife are covered separately as enrollees and both are enrolled in Select Coverage. No individual family may contribute more than $1,800 to the in-network family medical deductible or more than $2,000 to the out-of-network family medical deductible. The initial $2,000 of covered expense will apply to both the in and out-of-network family medical deductible. After the initial $2,000 has been applied, only services rendered by a non-participating provider will be applied to the additional $2,000 out-of-network family medical deductible.

Coinsurance

Once a participant has me the calendar year medical deductible, the Plan pays a portion of the allowable charge for covered medical expense. The participant pays the remainder in the form of coinsurance. Any fees charged by a non-participating provider that are above the allowable charge are not part of the coinsurance amount. The Plan will not pay any portion of these charges.

Individual Medical Coinsurance Maximum

The out-of-pocket maximum is the maximum amount that you and your family have to pay out of your own pocket for eligible medical expenses in a calendar year. However, what you pay toward meeting the calendar year deductible does not count toward satisfying the out-of-pocket maximum. You must meet the deductibles and out-of-pocket maximum separately. Essentially, the out-of-pocket maximum protects you from having to pay extraordinary medical bills in a given year. Once your out-of-pocket maximum costs meet the annual out-of-pocket maximum, the Plan covers 100% of the allowable charge of your eligible medical expenses for the remainder of that calendar year. Please refer the Summary Plan Description for a complete listing of expenses that will and will not count towards the out-of-pocket maximum (page 7).

Below is a summary of the deductibles and insurance payments for both in- and out-of-area participants.

*Most medical services are paid at 80% once the calendar year deductible is met. Please refer to the Summary Plan Description for information regarding specific medical benefits. The following expenses do not count towards the calendar year medical deductible:

  • Prescription drug deductible
  • Expenses in excess of the allowable charge
  • Expenses in excess of Plan maximum limits
  • Services not considered medically necessary
  • Emergency room co-payment
  • Prescription drug co-payments
  • Utilization review penalties
  • Private room co-payment
  • Services not covered by the Plan

Individual Prescription Drug Deductible

Before the Plan will pay any of the cost for prescription drugs, each participant must first satisfy a $75 prescription drug deductible each calendar year. The prescription drug deductible and co-payment amounts will not apply toward satisfying the medical calendar year deductible or co-insurance maximum.

Base Plan

BASE/CHOICE PLAN

Premium Class
Monthly Rates (Effective Jan 1, 2024)
Active
Total Premium
University Portion
Employee Portion
Employee
$459
$459
-0-
Employee + Spouse
$961
$459
$502
Employee + Spouse + Child(ren)
$1,223
$459
$764
Employee + Child
$589
$459
$130
Employee + Children
$792
$459
$333

Base Coverage for individuals and Choice Coverage for employees with dependents (spouse and/or child or children) meet the federal government’s criteria of a qualifying high deductible health plan (HDHP) under Section 201 of the Medicare Prescription Drug Improvement and Modernization Act of 2003. The Participants enrolled in the HDHP may establish a Health Savings Account (HSA). HSAs are portable, interest bearing, funded accounts to provide for tax-free savings for medical expenses. HSAs allow individuals to pay for current health expenses and save for future qualified medical and retiree health expenses on a tax-free basis. HSAs must be funded through a trust or custodial account. Permissible trustees and custodians include banks, insurers, or any entity that has been approved by the IRS to be a trustee of an individual retirement account or Archer MSA.  The Base Plan for employees with dependents does not meet these criteria and is not eligible for HSA participation.

The following is a summary of the benefits for the HDHP.

In-Network
Out-of-Network
Employee Only Calendar Year Deductible
$1,800
Employee Plus Dependents
Calendar Year Deductible
$3,600
Employee Only Out-Of-Pocket
Maximum
$3,000
$4,000
Employee Plus Dependents
Out-of-Pocket
$5,500
$7,500
Co-Insurance for In-Area
Participant
80%
60%
Co-Insurance for Out-of-Area
Participant
80%
75%

 

Base/Choice Plan Health Insurance Deductible and Co-Insurance/Co-payment Amounts


Calendar Year Deductible – Individual Coverage
The calendar year deductible is the amount of covered expense a participant must pay each year before the Plan begins to pay its share of covered expense. All expenses, medical and pharmacy, apply toward the calendar year deductible. Once the calendar year deductible has been met, the Plan pays its portion of the allowable charge for covered expenses, and the participant pays prescription drug co-payments of the allowable charge for covered medical expenses

Coinsurance/Co-payment Maximum – Individual Coverage
The coinsurance maximum is the maximum amount that an enrollee with individual coverage has to pay in coinsurance and co-payments for covered expenses in a calendar year before benefits will be paid at 100%. The amount paid toward meeting the calendar year deductible does not count toward satisfying the coinsurance/co-payment maximum. The initial $2,450 of coinsurance is applied to both the in and out-of-network coinsurance/co-payment maximum. After the initial $2,450 has been met, only the coinsurance amount for services rendered by non-participating providers will be applied to the additional $1,500 out-of-network coinsurance. Once the annual coinsurance/co-payment maximum is met, the Plan pays 100% of the allowable charge for covered medical expenses and prescription drugs for the remainder of that calendar year, except as otherwise specified.


Calendar Year Deductible – Family Coverage

If an employee has family coverage, there is no separate deductible for each individual in the family. Benefits will not be paid until the Family Deductible for all participants under that ID number has been satisfied. The family deductible also applies when both husband and wife are covered separately as enrollees, one of the enrollees has dependent coverage, and both are enrolled in the Base Coverage.

If both husband and wife are covered employees, one carries dependent coverage, and only on of them elects Base Coverage, calendar year deductibles and coinsurance/co-payments amounts are not shared.

If both husband and wife are covered employees with employee only coverage, and both elect the Base Coverage, the calendar year deductible and coinsurance-co-payments amounts are not shared.

The following expenses do not count towards the calendar year deductible for Individual or Family Coverage:

  • Expenses in excess of the allowable charge
  • Utilization review penalties
  • Expenses in excess of Plan maximum limits
  • Services not considered medically necessary
  • Services not covered by the Plan including those found in Medical Limitations and Exclusions section.

Coinsurance Maximum – Family Coverage

The coinsurance/co-payment maximum is the maximum amount that an enrollee with family coverage has to pay in coinsurance and co-payments for covered expenses in a calendar year before benefits will be paid at 100%. If an enrollee has family coverage, there is no separate coinsurance/co-payment maximum for each individual. The family coinsurance/co-payment maximum also applies when both husband and wife are covered separately as enrollees, one of the enrollees has family coverage, and both are enrolled in the Base Coverage. The amount paid toward meeting the calendar year deductible does not count toward satisfying the coinsurance/co-payment maximum.

The initial $4,900 of coinsurance and co-payments is applied to both the in and out-of-network coinsurance/co-payment maximum. After the initial $4,900 has been applied, only the coinsurance amount for services rendered by non-participating providers will be applied to the additional $3,000 out-of-network coinsurance/co-payments maximum. Once the annual coinsurance/co-payment maximum is met, the Plan pays 100% of the allowable charge for covered medical expenses and prescription drugs for the remainder of that calendar year, except as otherwise specified.
The Plan will never pay 100% for those expenses that do not apply toward satisfying the coinsurance/co-payment maximum.

Select and Base Plan Benefit Highlights

SELECT AND CHOICE/BASE PLAN BENEFIT HIGHLIGHTS


Lifetime Maximum

The maximum benefit you can receive from the Plan during your lifetime is $1,000,000. This lifetime maximum benefit of $1,000,000 applies to each covered employee or dependent under the Plan. This maximum applies to your entire lifetime, regardless of whether you’re an active employee, retiree, COBRA participate, surviving spouse, or dependent. This maximum also applies regardless of any break in coverage or service.

Out-of-Network Review

If you need specialty services that are not available from an in-network provider, you will need to contact CareAllies and request that they review the availability of the services you need. This is called an out-of-network review and must be requested prior to receiving a medical service not available in the network. If CareAllies certifies that the service you need is not available within the network, that service will be covered at the in-network benefit level, even it if is provided by an out-of-network provider. Although approval to use an out-of-network provider may be granted, you will still be responsible for amounts charged by the out-of-network provider that exceed the Plan’s allowable charge.

Health Insurance Benefits

 (A) Hospital Benefits: Inpatient benefits are provided for covered hospital services and supplies subject to the calendar year deductible and the private room co-payment of $20 per day. All inpatient hospitalizations are subject to certification of medical necessity by the Plan’s Utilization Review Program. See the Summary Plan Description for a complete listing of hospital and physician services covered under the Plan (page 27). The private room co-payment will not be charged after a participant in Base Coverage has met the coinsurance/co-payment maximum. Once a participant has me the calendar year deductible, the Plan pays a portion of the allowable charge for covered medical expense. The participant pays the remainder in the form of coinsurance. Any fees charged by a non-participating provider that are above the allowable charge are not part of the coinsurance amount. The Plan will not pay any portion of these charges.

(B) Emergency Care: Benefits are provided for treatment in a hospital emergency room. The State Health Insurance Plan will pay a $50 Emergency Room co-payment per visit after the first visit in any calendar year. The $50 Emergency Room co-payment will not apply to the calendar year deductible or the out-of-pocket maximum (page 26). The emergency room co-payment will not be charged after a participant in Base Coverage has met the coinsurance/co-payment maximum.

(C) Maternity Benefits: The Plan provides maternity benefits to covered employees or to a covered spouse of a male employee. Other female dependents are not eligible for maternity benefits. The attending physician will be reimbursed for covered routine prenatal care and delivery at 100% all the allowable charge (90% for out-of-network physician), not subject to the calendar year deductible. Benefits for prenatal laboratory and diagnostic procedures will be provider at 100% of the allowable charge (90% for out-of-network physician), not subject to the calendar year deductible. Regular Plan benefits will be provided for other prenatal laboratory and diagnostic procedures, inpatient hospital delivery, and other covered services. See the Summary Plan Description for a complete listing of eligible services (page 28).

Plan participants should contact CareAllies within the first four months of pregnancy to participate in the voluntary maternity management program. This program is an educating and monitoring service that identifies risk factors in early pregnancy, including high-risk screening processes, pregnancy education and support. As part of the program you will receive an educational book and other brochures on pregnancy and childbirth. Participants who do not notify Intracorp/CareAllies will be responsible for certifying their hospital admission for delivery. Participants must notify CareAllies within 48 hours of admission for delivery, and should the newborn require additional hospital stays beyond the mother’s length of stay, CareAllies should be notified.

(D) Well Child Care: Benefits are provided for well-child services for covered dependents up to age 18. All benefits are subject to the individual calendar year deductible for Select Coverage and family calendar year deductible for BaseCoverage. Benefits are only provided when a participating provider renders services.

Well-newborn nursery care while a newborn is hospital-confined after birth is covered at 100%. Well-newborn nursery care includes room, board, and other normal care provided for which a participating hospital or physician makes a charge. Also, well-child physician office visits and certain diagnostic tests are covered at 100%. Immunizations are covered at 80%.

A list of covered wellness/preventive services can be found at the Plan’s web site, http://knowyourbenefits.dfa.ms.gov or can be obtained by calling Blue Cross & Blue Shield of MS.

(E) Wellness/Preventive Coverage for Adults: Wellness/preventive services for participants, ages 18 and older, are limited to a maximum benefit of $250 annually. If a participant completes a Health Risk Assessment (HRA) on or after January 1, 2007, he will be eligible for an additional $50 to be applied toward wellness/preventive services. The HRA can be found at the Plan’s web site. Benefits will be provided 100% of the allowable charge, for office visits and certain diagnostic tests as defined by the Plan. The diagnostic tests are based on age and gender. These services are not subject to the calendar year deductible.

A list of covered wellness/preventive services can be found at the Plan’s web site, http://knowyourbenefits.dfa.ms.gov or can be obtained by calling Blue Cross Blue Shield of MS.

Benefits are only provided when a participating provider renders services. Unused benefit amounts do not carry over into subsequent years.

FOR A COMPLETE LISTING OF ALL COVERED SERVICES, PLEASE REFER THE PLAN DOCUMENT, PAGES 24-34.

Prescription Drugs

State of Mississippi Health Insurance Plan

CVS Caremark
Caremark.com

Pharmacy Plan – Included in the State of Mississippi Health Insurance Plan

1-888-996-0050

Note: This information does not apply to Medicare eligible retirees, Medicare eligible surviving spouses,or Medicare eligible dependents of retirees and surviving spouses.

The Plan includes a copayment program for prescription drugs. This page summarizes the details of the program and how it works. An enrollee must elect health insurance coverage in order to participate in the prescription drug program. Refer to the webpages on Base Coverage and Select Coverage for information on deductibles.

To be covered under the Plan, prescription drugs must be:

  • Available on the formulary managed by the Plan’s pharmacy benefit manager;
  • Prescribed by a physician,
  • Dispensed by a licensed pharmacist,
  • Found to be medically necessary for the treatment of the participant’s illness or injury,
  • Food and Drug Administration (FDA) approved; and
  • Not otherwise excluded from coverage under the Plan.

Participants may purchase medically necessary prescription drugs at participating retail pharmacies or by mail through the Plan’s pharmacy benefit manager (PBM), CVS Caremark. (See Diabetic Management Program and
Pharmacy Mail Order Program sections for more detail.) Specialty medications must be purchased through participating specialty drug providers. Coverage for prescription drugs purchased at a retail pharmacy is limited to a 90-day supply. Coverage for prescription drugs purchased through the pharmacy mail order program is limited to a minimum 60-day supply and a maximum 90-day supply. Coverage for prescription drugs purchased through the specialty pharmacy program is limited to a 30-day supply.

When a covered prescription drug is purchased at a network retail pharmacy, the participant is only required to
pay the appropriate copayment amount (after the applicable deductible is met) or the cost of the drug, whichever is less. There is no claim form to file. When a prescription drug is purchased at an out-of-network pharmacy, the participant must file a claim with CVS Caremark. The prescription drug claim form is available to be downloaded and submitted online at www.caremark.com or the paper claim can be returned to CVS Caremark. Payment of the claim will be made based upon the Plan’s allowable charge. The participant is responsible for any amount in excess of the allowable charge, plus the applicable  deductible and/or copayment.

In most instances, when a generic drug is available and the participant purchases the brand name drug instead, the participant will pay the difference in the cost of the brand name drug and the generic drug, plus the brand copayment amount.

CVS Caremark Customer Care

CVS Caremark is available 24/7 to provide assistance to participants. If a participant should experience a problem having a prescription filled or have a question regarding coverage, they may contact CVS Caremark at 888-996-0050.

Copayments

The copayment amount of certain covered prescription drugs may be reduced, increased or eliminated to assist in controlling prescription drug costs.

Coordination of Benefits

When a participant has other health insurance coverage that is primary, a prescription drug claim may be filed for secondary coverage under the Plan. To file a claim, a copy of the explanation of benefits from the primary insurance carrier along with a copy of the receipt from the pharmacy must be attached to a prescription drug claim form. This form is available at www.caremark.com. The claim is processed by CVS Caremark and reimbursement is made to the participant based upon the Plan’s allowable charge, less the amount paid by the primary carrier, less the applicable copayment for that prescription drug.

Formulary

The formulary is a list of medications covered by the Plan. The formulary consists of both brand and generic drugs. Sometimes, several drugs can treat the same condition, and the Plan may choose some drugs over others. Covered drugs are chosen based on their clinical appropriateness and cost effectiveness. While the formulary may be modified at any time, changes are typically made quarterly. A copy of the Plan’s drug formulary may be obtained through the Plan’s website at http://KnowYourBenefits.dfa.ms.gov or by contacting CVS Caremark directly.

Generic Drugs

Typically, generic drugs cost less than equivalent brand drugs. Because the generic drug copayments are less, participants save money when purchasing generic drugs. Participants are encouraged to use generic drugs whenever possible. To be covered by the Plan, a generic drug must:

  • Contain the same active ingredients as the brand-name drug (inactive ingredients may vary);
  • Be identical in strength, form of dosage, and the way it is taken;
  • Demonstrate bio-equivalence with the brand-name drug; and
  • Have the same indications, dosage recommendations, and other label instructions (unless protected by patent or otherwise exclusive to the brand-name).

Vaccine Program

Benefits will be provided at 100 percent of the allowable charge for annual influenza (flu), pneumococcal infection
(pneumonia), Haemophilus influenza type b (Hib), Hepatitis A and B, HPV, measles, mumps, rubella, varicella,
meningococcal, polio, rabies, rotavirus, tetanus, diphtheria and acellular pertussis (whooping cough) vaccines
administered by an immunization-certified pharmacist at a network pharmacy. In addition, based on the Centers
for Disease Control and Prevention (CDC) recommendations, benefits will be provided at 100 percent of the allowable charge for non-Medicare participants age 50 and over for the appropriate herpes zoster (shingles) vaccine. Participants must use a pharmacy that participates in the CVS Caremark Vaccine Network in order to receive benefits. A trained clinician administers the vaccine on-site according to state regulations. A prescription may be required. Participating vaccine network pharmacies may be found using the CVS Caremark Vaccine Network tab on www.caremark.com or by contacting CVS Caremark Customer Care at 888-996-0050.

Pharmacy Mail Order Program

Participants can utilize the convenience of receiving medication(s) by mail by using the CVS Caremark Mail Order Pharmacy program. To get started, register at www.caremark.com or contact CVS Caremark Customer Care at
888-996-0050.

Please note: Participants should allow 7-10 days for delivery and plan accordingly.

A prescription submitted to CVS Caremark Mail Order Pharmacy for less than a 90-day supply will be charged the same copayment as for an entire 90-day supply. Coverage for prescription drugs purchased through the mail order pharmacy is limited to a minimum of 60 days and a maximum of 90 days. CVS Caremark Mail Order Pharmacy may suspend service if participants carry an unpaid balance.

Prior Authorization

Certain prescription drugs require prior approval. The prescribing provider must contact CVS Caremark at 800-294-5979 for prior authorization. The provider must provide appropriate documentation of medical necessity. Only the provider can request prior authorization approval. Examples of prescription drugs requiring prior authorization include, but are not limited to, medications for treating acne, androgens and anabolic steroids, growth hormones, and medications for treating Hepatitis B and C. The quantity of some prescription drugs may be limited based on drug indications or medical necessity. If the quantity of a covered prescription drug, as prescribed by the provider, is not approved by CVS Caremark, the provider must contact CVS Caremark for prior approval of additional quantities. Approval will require appropriate documentation of medical necessity. The fact that a provider has prescribed, ordered, recommended or approved a prescription drug, does not, in itself, make the prescription drug medically necessary for purposes of coverage under the Plan.

Step Therapy

Some prescription drugs require step therapy. Step therapy is a process that optimizes rational drug therapy while controlling costs by defining how and when a particular drug or drug class should be used based on a patient’s drug history. Step therapy requires the use of one or more prerequisite drugs that meet specific conditions before the use of another drug or drugs.

Quantity Limits

Quantity limits have been established by CVS Caremark for certain drugs based on the approved dosing limits established during the FDA approval process. Your provider must submit a prior authorization request form to CVS Caremark for approval of amounts that exceed the established quantity limit.

Early Refills

There are some circumstances when a participant will be allowed to obtain an early refill of a prescription drug for purposes such as going on vacation, for a dosage change during the course of a treatment, or for lost or destroyed medication. The participant’s pharmacist may contact CVS Caremark to obtain authorization for an early refill or advance supply of a medication. Early refills are limited to two refills per medication per 12 months.

CVS Caremark Specialty Drug Management Program

The Specialty Drug Management Program provides access to specialty medications with the convenience of express mail delivery. Specialty medications are limited to a 30-day supply, and must be purchased through an
approved network specialty pharmacy. Participants have access to a Specialty Care Team staffed by experienced pharmacists specially trained in complex health conditions and the latest medication therapies. Participants can
call CVS Specialty at 800-237-2767 for more information on the Specialty Drug Management Program, or for information on other approved specialty network pharmacies.

Specialty pharmacies provide medications for many chronic conditions, such as:
• Multiple Sclerosis
• Rheumatoid Arthritis
• Gaucher’s Disease
• Cystic Fibrosis
• Hepatitis C
• Anemia
• Respiratory Syncytial Virus
• Growth Hormone Deficiency
• Crohn’s Disease
• Neutropenia
• Pulmonary Hypertension
• Hemophilia

Limited Distribution Drugs

Limited distribution drugs are only available through select specialty providers as determined by the drug manufacturer. Access to limited distribution drugs is available through other specialty providers in the Specialty Drug Management Program. For assistance with obtaining a limited distribution drug and with locating an approved distributor, contact CVS Caremark Customer Care at 888-996-0050.

What Drugs are not Covered?

For a list of drugs and medical items not covered, please see the current year plan document at Know Your Benefits or visit Caremark.com.

Medical Management & Utilization Review

CareAllies/Intracorp performs medical management services and utilization for the Plan.

Utilization review is a process to make sure that the care you receive is medically necessary, delivered in the most appropriate location, and follows generally accepted medical standards. Utilization review provides clinical review and certification of the medical necessity of care. Certification of medical necessity does not guarantee that services are covered. Benefits are subject to the patient’s eligibility at the time charges are actually incurred, and to all other terms, conditions, and exclusions of the Plan.

The following services require certification by CareAllies/Intracorp:

  • Inpatient Hospital Admissions
  • Outpatient CAT Scan
  • Outpatient MRI Scan
  • Private Duty and Home Health Nursing
  • Solid Organ and Bone Marrow/Stem Cell Transplants
  • Home Infusion Therapy
  • Skilled Nursing Facility
  • Long Term Care Acute Care Facility
  • Hospice Care Services
  • Wound Vacuum Assisted Closure

Notification Requirements

It is the participant’s responsibility to make sure that CareAllies/Intracorp is notified in advance of certain types of medical services. The notification requirements that apply to inpatient hospital admissions and specified outpatient diagnostic tests are detailed below.

Private duty and home health nursing services, solid organ and bone marrow/stem cell transplants, home infusion therapy services, Skilled Nursing Facility admissions, Long Term Care Facility admissions, Hospice Care Services, and Wound Vacuum Assisted Closure must be certified as medically necessary by CareAllies/Intracorp.

CareAllies/Intracorp must be contacted in advance of any anticipated non-emergency hospital admissions and immediately following an emergency admission by calling 1-800-523-8739. Failure to comply with notication requirements will result in financial penalities, reduction of benefits, or denial of benefits.

Inpatient Hospital Admissions:

For certification review of non-emergency admissions to a hospital or psychiatric or chemical dependency facility, you are required to call CareAllies/Intracorp at 1-800-523-8739 as soon as you are advised that your or your covered dependent may need to be hospitalized. In all cases, the call must be made as soon as possible but at least 5 days before the admission date. It is your responsibility to ensure that notification requirements are met. Intracorp will provide you a confirmation number once certification has been given.

Emergency Hospital Admission

When certifying an emergency hospital admission, CareAllies/Intracorp must be notified within 48 hours of emergency admission to a hospital. If the participant is unable to make the call, another party can make the call on the participant’s behalf. However, it is the participant’s responsibility to ensure that notification requirements are met.

Maternity Care and Hospitalization

There is an exception to the 5-day advance notification rule for maternity care. Because of the need to ensure that maternity cases receive the proper case management, CareAllies/Intracorp should be contacted:

  • as soon as a pregnancy is confirmed, and no later than the 4th month of pregnancy, and
  • within 48 hours of admission for delivery

CareAllies/Intracorp must also be contacted in the following instances:

  • if the newborn requires additional hospital days beyond the mother’s length of stay, or
  • if the mother is not a Plan participant but the child will be enrolled in the Plan.

 Notification Requirements for Inpatient Hospital Admissions

Type of Admission

Notification Requirement
Non-Emergency As soon as possible, but at least 5 days prior to admission
Maternity Within 48 hours of admission
Emergency Within 48 hours of admission

Please see the Summary Plan Description (page 36) for listing of Inpatient Financial Penalties for failure to meet the notification requirements.

Outpatient Diagnostic Tests

The following outpatient services will require pre-certification by CareAllies prior to services being rendered:

  • CAT Scan

Appeals Process

State and Public Schools’ Health Insurance Plan

If you believe Blue Cross Blue Shield incorrectly denied all or part of a claim, and you want to obtain a review, you must request a review in writing from Blue Cross Blue Shield. You have 60 days to request a review after receiving notice of denial. After this timeframe, your right to review is forfeited. After receipt of the claim, the decision will be sent to you in writing should the claim be denied again for payment. Reason will be provided with reference to the Plan provisions on which the decision is based.

Should you disagree with BCBS’s determination, you may submit your final appeal in writing to the Department of Finance and Administration, Office of Insurance within 30 days of the second denial. Your request should include a copy of Blue Cross Blue Shield’s review decision and all information pertinent to the claim.

Utilization Review Process

You or your provider may initiate the reconsideration process. The process is as follows:

Step 1:  The attending physician contacts CareAllies/Intracorp to discuss any findings of “not medically necessary”. Based on that discussion, a second CareAllies/Intracorp staff physician will determine whether the original decision should be affirmed or amended. The enrollee and attending physician will be notified in writing of the results of this review.

Step 2: When a disagreement between the attending physician and CareAllies/Intracorp staff physician is not resolved as a result of Step 1, the patient/enrollee or the attending physician may submit to CareAllies/Intracorp a written request for review, which outlines the reason for the request. A thorough review and discussion of medical records and other supporting documentation will be undertaken. Based on that review, a decision affirming or amending the original decision will be rendered and provided in writing to the enrollee and the attending physician.

Step 3: If the attending physician or the patient/enrollee is not satisfied with the outcome of Step 2, either of them may request an independent review by an independent physician under contract with CareAllies/Intracorp to conduct such reviews. The decision of the independent physician is final and not subject to further consideration.

Concurrent Review
Concurrent review is the process of review that occurs before medical services are provided. Its purpose is to help ensure that only quality, medically necessary services are provided. This review may result in a determination that reimbursement will be reduced or denied under certain circumstances.

Prospective Review
Prospective review occurs after medical services have already been provided. Its purposes is to help ensure that only quality, medically necessary services are provided. This review may result in a determination that reimbursement will be reduced or denied under certain circumstances.

Retrospective Review
Retrospective review occurs after medical services have already been provided. This review may result in a determination that reimbursement will be reduced or denied under certain circumstances. A retrospective review is performed when CareAllies/Intracorp is contacted after discharge from an inpatient admissions or 48 or more hours after an outpatient diagnostic test requiring certification was performed.

If a participant believes that Catamaran Rx incorrectly denied all or part of a prescription drug claim, he has the right to obtain a full and fair review. A request for review must be made in writing to Catamaran Rx.

The participant has 60 days from receiving notice of denial from Catamaran Rx to request a review. If the participant fails to request a review within this timeframe, the right to review is forfeited.

After the claim has been reviewed, if benefits are again denied, the decision will be sent to the participant in writing. The letter will include the reason(s) why benefits are denied, with reference to the Plan provisions of which decision is based.

If, after following the appeal procedure described above, the participant still disagrees with the determination, a final appeal may be submitted in writing to the Department of Finance and Administration, Office of Insurance within 30 days of the second denial. The request to the Office of Insurance must include a copy of the Catamaran Rx review decision and all information pertinent to the claim. The decision of the State Insurance Administrator with the Department of Finance and Administration, Office of Insurance is final and concludes all administrative levels of appeal.

Failure to request a review within the above time framed and in accordance with the procedures will result in the participant’s right to an appeal and rights to sue being forfeited.

This page is maintained by Lisa Giger. Send questions and comments regarding this site to lgiger@gofang.net