Pre-65 Retiree Health Plan
The Medical portion of the retiree health plan is administered by Highmark Delaware.
The plans are supported by a Blue Cross/Blue Shield national network of medical providers and allow you to seek the care of any physician or facility without the need to choose a primary care physician (PCP) or seek referrals. If you were enrolled in one of the two plans noted below, PPO or EPO, then that is the plan that will be continued in retirement.
Preferred Provider Organization (PPO) plan:
The PPO will provide low out-of-pocket expenses at point-of-service. Services provided by in-network providers are covered at higher rates than out-of-network providers.
Exclusive Provider Organization (EPO) plan:
The EPO will result in higher out-of-pocket expenses at point-of-service. If you use a doctor or facility that isn’t in the national network, you will have to pay the full cost of the services provided. Members are covered for emergency care – even from non-network providers – in their local service area or when away from home.
Medical Plan Comparison
Below is a brief side-by-side comparison of the Retiree Medical Plans. For more details, refer to the Summary of Benefits and Coverage (SBC) for each plan which you can find in the Links and Documents in the right menu bar. If there is any discrepancy between the following comparison and the insurance summaries or booklets, the provisions in the insurance summaries and booklets will prevail.
| Benefits | PPO | EPO | |||||
|---|---|---|---|---|---|---|---|
| In-Network | Out-of-Network1, 5 | In-Network Only2, 6 | special | ||||
| Major Medical3 | sub | ||||||
| Deductible | N/A | $300 IND / $900 FAM | $200 IND / $400 FAM | ||||
| Coinsurance Percent | 100% | 80% | 100% | ||||
| Out-of-Pocket Maximum (Medical & Pharmacy Copays Only) |
N/A | N/A | N/A | ||||
| Total Out-of-Pocket Maximum4 (Medical & Pharmacy Combined) |
$8,700 IND / $17,400 FAM | N/A | $8,700 IND / $17,400 FAM | ||||
| Lifetime Benefit Maximum | Unlimited | Unlimited | Unlimited | ||||
| Physician Office Visits | $15 copay | 80% | $15 copay | ||||
| Specialist Office Visits | $20 copay | 80% | $35 copay | ||||
| Diagnostic X-Ray | sub | ||||||
| Hospital Facility | $80 copay | 80% | $80 copay | ||||
| Non-Hospital Facility | $20 copay | 80% | $20 copay | ||||
| Lab Services | sub | ||||||
| Hospital Facility | $80 copay | 80% | $80 copay | ||||
| Non-Hospital Facility | $20 copay | 80% | $20 copay | ||||
| MRIs, CT scans, and PT Scans | sub | ||||||
| Hospital Facility | $225 copay | 80% | $225 copay | ||||
| Non-Hospital Facility | $75 copay | 80% | $75 copay | ||||
| Wellness/Routine Care | sub | ||||||
| Routine Annual Physical | 100% | 80% | 100% (no deductible) | ||||
| Periodic Hearing Exam | 100% | 80% | 100% | ||||
| Well-Child Care (includes immunizations) | 100% | 80% | 100% (no deductible) | ||||
| Annual Gyn. Exam (including Pap Test) | 100% | 80% | 100% (no deductible) | ||||
| Routine Mammograms | 100% | 80% | 100% (no deductible) | ||||
| PSA Test | $20 copay | Not Covered | $35 copay | ||||
| Periodic Vision Exam | |||||||
| Therapies | sub | ||||||
| Physical, Occupational and Speech Therapy | 80% (60 visits per condition per calendar year) | 80% (60 visits per condition per calendar year) | 80% (no deductible) (60 visits per condition per calendar year) | ||||
| Radiation Therapy and Chemotherapy | 100% | 80% | 100% (no deductible) | ||||
| Hospital Benefits7 | sub | ||||||
| Inpatient (including maternity/delivery) | $75/day copay for four (4) days, $300 maximum copay | 80% | 100%, after deductible | ||||
| Outpatient | 100% | 80% | 100%, after deductible | ||||
| Emergency Room (waived if admitted to the hospital for treatment) |
$150 copay | $150 copay | $150 copay | ||||
| Urgent Care Center/Medical Aid Unit | $20 copay | 80% | $35 copay | ||||
| Ambulance Service | $25 copay | $25 copay | $25 copay | ||||
| Miscellaneous: | sub | ||||||
| Maternity (Prenatal and Postnatal) |
100% | 80% | 100%, after deductible | ||||
| Inpatient Mental Health, Substance Abuse, and Intensive Outpatient Care | $75/day copay for four (4) days, $300 maximum copay | 80% | 100%, after deductible | ||||
| Chiropractic Care (Max of 30 visits per year) |
$20 copay | 80% | $35 copay | ||||
- All Out-of-Network benefits are subject to balance billing. 80% Coinsurance, after the deductible is met.
- There are no Out-of-Network benefits in the EPO, such expenses are the sole responsibility of the member.
- All Deductibles and Out-of-Pocket Maximums are reset every January 1st.
- The in-network Total Maximum Out-of-Pocket (TMOOP) is mandated by the federal government. TMOOP must include medical and prescription drug deductibles, coinsurance, and copays.
- All Out-of-Network benefits are subject to balance billing. 80% Coinsurance, after the deductible is met.
- There are no Out-of-Network benefits in the EPO, such expenses are the sole responsibility of the member.
- Most non-emergency hospital stays and voluntary surgical procedures must be pre-authorized.
Prescriptions
The Prescription drug portion of the retiree health plan is provided through Express Scripts, Inc. (ESI) and is included with each of the medical plans noted above. The Prescription co-pays are based on Drug Tier as shown in the table below.
| Drug Tier | PPO / EPO |
|---|---|
| Retail Pharmacy- Generic (per 30-day supply) | $10.00 copay |
| Retail Pharmacy- Preferred Brand (per 30-day supply) | $20.00 copay |
| Retail Pharmacy- Non-Preferred Brand (per 30-day supply) | $35.00 copay |
| Mail Order (up to 90-day supply) | Same as 1x retail copay |
The Authority subscribes to ESI’s Generic Preferred Program. If you have a prescription for a brand name drug and a chemically equivalent generic drug is available, the generic will be supplied. You will have the option of choosing either the generic equivalent or the brand name drug but if you choose the brand name drug, you will pay the brand name co-pay plus the difference in cost between the generic and the brand name drug.
The Authority also subscribes to ESI’s Advantage-Plus Utilization Management program which includes the following requirements for certain prescription drugs: Select Home Delivery – Incentive Choice, Quantity Management, Prior Authorization, and Step Therapy. Your pharmacist will advise you if your prescription is subject to one of these requirements.
- Under the Select Home Delivery – Incentive Choice (SHD-IC) option, The Authority is encouraging participants to utilize Mail-Order services to re-fill maintenance drug prescriptions rather than re-fill maintenance drugs at the Pharmacy. If you re-fill a maintenance drug at the Pharmacy you will have to pay a copay for each 30-day supply. You will pay 1x the applicable copay for a 30-day supply; 2x copay for a 60-day supply; and 3x copay for a 90-day supply at the Pharmacy. Through Mail-Order you can fill 30, 60 or 90-day supplies and pay only 1x copay. Express Scripts will send letters to members who are affected. You will be allowed two (2) refills at the Pharmacy before the higher copay levels will apply.
- Drug Quantity Management (DQM) will limit how much medicine a member can obtain at one time for certain prescriptions (like opioids) while ensuring that the member receives the safest, most effective medicine available. This also helps lower overall drug costs by reducing the waste of unused medications.
- Under Prior Authorization (PA), certain prescriptions will require review by Express Scripts before the drug can be filled and covered by the Plan. Member’s doctor will need to provide Express Scripts with detailed information about the member’s drug treatment plan to ensure its use falls within the Plan rules. The purpose of this requirement is to make sure members get the safest, most effective medicine available at reasonable cost to you and the Plan.
- Under Step Therapy (ST), certain prescriptions will no longer be covered without a trial of preferred alternatives first and will cost the member more. Member’s doctor will need to provide Express Scripts with confirmation that preferred alternatives were tried and failed before the prescription will be filled and covered by the Plan. Preferred generics or lower-cost brand medicines work just as well for most people and typically cost a lot less. You can find a list of the National Preferred Alternatives on the Express Scripts website.
In addition, the Authority utilizes a mandated specialty pharmacy service through ESI, in partnership with Accredo, which will provide specialized support and service to employees and dependents taking specialty medications, including manufacturer discount offers that may reduce your co-pay to $0 through an additional partnership with Saveon. Information will be mailed to your home containing detailed information if you or your dependent qualify for the specialty pharmacy service or a manufacturers’ discount.
Telemedicine
Additional telemedicine services are provided to retirees through Teladoc. This program is provided at no cost to retirees and their covered dependents enrolled in one of the Authority’s health plans.
This benefit is a convenient alternative to urgent care or emergency room visits for non-emergency medical issues. You can access U.S. board-certified physicians in internal medicine, family practice, emergency medicine or pediatrics who resolve most non-emergency medical issues via phone or online video with no copay. The physician can diagnose and prescribe medication, if medically necessary, electronically to the pharmacy of choice.
There is no Consultant co-pay required when you use Teladoc services if you are enrolled in either the PPO or EPO health plan.
You must register on the Teladoc website or call customer service and complete a profile for yourself and each covered dependent to use the plan.
You can access Teladoc online at www.teladoc.com or call at 1-800-835-2362 to complete a profile.
Age 65 Health Plan Transition
Retirees and/or their covered spouses will be moved to a Medicare Advantage Plan upon reaching age 65, effective upon retirement or upon their 65th birthday, whichever is later.
To qualify for the AMA plan, individuals must enroll in Medicare (Parts A and B) and pay the Part B premiums that may apply. Typically, Part B premiums are deducted from the individual’s Social Security Retirement annuity, or they can be paid directly to the Center for Medicaid and Medicare Services (CMS). The Authority is not responsible for your Part B premiums.
The Medicare Advantage plan is fully insured through the Aetna Insurance Company. The Aetna Medicare Advantage (AMA) plan includes Medicare coverages under Part A (Hospital) and Part B (Visits and Testing) and covers Prescription Drugs also.
Note: A covered spouse is moved to the AMA plan as an individual subscriber, however, the covered spouse will remain covered as a dependent under the retiree’s dental and vision plans, if applicable.