Anthem's Shingle Vaccine Update!

For the last several months, Anthem's shingle vaccine age minimum has been 50.  However, that is all about to change once again.  Effective 11/16/2012, Anthem will be changing the age back to 60.  For anyone interested in the vaccine who may be between the ages of 50 and 60 and have Anthem insurance may want to get the vaccine while it will be covered for them.  Otherwise, you will have to pay full out of pocket expense or wait until you are at the minimum age.  If you have any questions about this update, please feel free to contact the Customer Care Team!

Customer Care Is Your Advocate

Here at McGohan Brabender, the Customer Care Team's role is the advocate for our client- facilitators between customers, providers, and their insurance companies.  All of our reps are trained in cross-functional roles and empowered to provide customers with assistance in most insurance related issues.

The first point of contact for our clients is Member Services (located on the back of your ID card).  Most issues can be resolved with the carrier; however, if assistance is still needed our team is here to help!

The role of the customer advocate is three-fold:

• To be the point of contact for the customer in handling a question or problem and keeping the customer updated with timely and frequent updates to inform the progress being made towards a resolution.
• To facilitate a resolution by bringing together the approrpriate department heads to escalate issues if they are urgent.
• To implement procedures that ensures the problem does not occur again and educate members about their plan.

Please feel free to reach out to our Customer Care Team.  Our business hours are 8 to 5 Monday through Friday.  You can reach us locally at 937-260-4300 or toll-free at 877-635-5372.

HOT OFF THE PRESS...Anthem And Walgreens Reach Multi-Year Deal

Anthem has announced that Express Scripts, Inc. (ESI) and Walgreens have reached an agreement for Walgreens to participate in Anthems retail pharmacy network and members will be able to use their pharmacy benefit at Walgreens stores beginning September 15, 2012.  This will impact members in commercial, Medicare and Medicaid.

Also, Walgreens-owned pharmacies including BioScrip, Duane Reade, and Happy Harry's will be part of the pharmacy network.  Express Scripts members can log in to www.express-scripts.com to search in network pharmacies and starting September 15th, this will include Walgreens pharmacies.

Anthem is currently working with Express Scripts to ensure there are no problems for members who may want to transfer prescriptions to Walgreens.  Usually, members an take their medicine bottle to the new drug store.  However, some state regulations as well as certain medications will require members to contact their doctor to have them call the new store with prescription details.  To make sure there is no delay in receiving medications, you may want to contact your local Walgreens prior to needing your prescription filled to clarify the best way for the prescription to be transferred.

Helpful Hints for HSA's

Due to an increase in our calls lately on this subject, our team felt like it might be helpful to provide an explanation for HSA's (Health Savings Accounts). Understandably, this is a confusing topic and knowing how to navigate your benefits is important so the maxiumum outcome can be achieved.

A HSA is a tax exempt savings account whose funds:

1.  Are not subject to federal income tax at the time of deposit.
2.  Roll over and accumulate year to year if it is not spent and is yours to keep if you leave employment.
3.  The money can only be used to pay for qualified medical and prescription expenses at any any time without federal tax liablility or penalty.

It is important to remember that the HSA:
1.  Is a bank account.
2.  It cannot have funds withdrawn without your permission from the carrier; however, if you leave your card information on file with a provider, they may automatically run it.
3.  It can be subject to overdraft fees.
4.  They do not communiate with the carrier or vice versa.
5.  It is not the same as your deductible.

If you have any questions, please contact Member Services on the back of your ID card or you can call the MB Customer Care team for assistance.

Can my doctor ask for money before services?

With the popularity of high deductible health plans, it is becoming a common practice among many facilities and doctors to ask for money upfront before surgery and other higher cost procedures.  Many doctors have had problems of never receiving payment by members and this has led them to take payment in advance.  Unfortunately, our customer care team and your insurance carrier cannot stop this from happening.  The biggest issue with this is that you may have multiple claims pending and you can end up paying the provider too much once the claims have processed.  If you paid your provider in advance and met your deductible before that specific claim processed, the provider should owe you a refund.  If you have already met your deductible or out of pocket max or are very close to meeting it and your provider is trying to collect a larger amount than what is left, let your provider know and try to have the amount adjusted. If the provider does not budge our customer care team can try to verify with your carrier where you are on your deductible and out of pocket max and try to confirm with the provider what is left and the amount they can collect. If you do pay in advance, be sure to know what you pay in advance and make sure you do not pay the amount again when you receive a bill. 

Certificate of Creditable Coverage- WHAT IS IT AND WHY DO I NEED IT?

"Certificate of Creditable Coverage" or commonly referred to as a "COCC" is a written document provided to you by an insurance company after you terminate their coverage.  Most healthcare programs impose a waiting period for a pre-existing condition for all new or reinstated members who have had a break of coverage for 63 days or more.  The certificate of creditable coverage indicates the length of time you have been continuously covered under the plan and allows waiver of any waiting period related to a pre-existing condition.  This is part of the Federal Health Insurance Portability and Accountability Act of 1996 (often referred to as HIPAA) and this provision provides that once you have been continuously insured for at least 18 months there is no need to satisfy another waiting period when you change health insurance.
Certificates are generated automatically within a few weeks of a member's termination.  If you do not receive a Certificate by mail within 30 days of termination, contact the carrier by calling Member Services on the back of your ID card to verify your mailing address and request another Certificate to be sent.

HSA Limits for 2013

The Internal Revenue Service has released the 2013 inflation adjustments for HSAs:

2013 Annual Contribution Limit:
 Single coverage: $3,250 (up from $3,100 in 2012)
Family coverage: $6,450 (up from $6,250 in 2012)

2013 Minimum Deductible for HDHP:
 Single coverage: $1,250 (up from $1,200 in 2012)
Family coverage: $2,500 (up from $2,400 in 2012)

2013 Maximum Out-of-pocket:
 Single coverage: $6,250 (up from $6,050 in 2012)
Family coverage: $12,500 (up from $12,100 in 2012)

I Need A Precertification. What Is That?

A precertification is a process of confirming medical necessity and collecting information prior to inpatient services and other specialty types of services.  Without a precertification for these services, your health plan may not provide coverage and may deny any claims related to these services.  Some providers may list a precertification procedures list online.  If you are going through a network facility, the facility should automatically do a precertification.  However, that is not always the case.  If a precertification was not done and your claim is denied, often a retro precertification can be submitted.  When these types of services are done, it is up to the doctor to prove that the procedure was medically necessary.  Each carrier has a specific list of criteria that must be met in order to deem a procedure medically necessary.  If you have any questions about a precertification that is needed or your services are being denied, you can always call the number on the back of your ID card to seek help.  As always, our Customer Care Team is here to help as your advocate.

Prescription Prior Authorization- It's Easier Than You Think!

Prior authorization is a requirement for your physician to obtain approval from your health plan to prescribe a specific medication for you. Without this prior approval or authorization, your health plan may not provide coverage, or pay for your medication.  The authorization requirements may vary depending on the carrier. Online drug lists often indicate which medications require prior authorization.  There are some medications that authorizations can be required for due to quantity limitations. If your doctor feels that it is appropriate for you to receive more or less of a medication, they will need to provide the insurance company with documentation. Some insurance plans also have a generic preferred requirement and if your doctor prescribes the brand name only, it may require a prior authorization. Certain medications may require prior authorization depending on the condition that it is being prescribed for. Medications are often approved for treatment of certain conditions; however, if your physician feels that another condition can be treated with a specific drug, they will need to provide the insurance company with that information. There is no guarantee that submitting the information for a prior authorization is going to ensure your insurance company will approve it. If a medication is denied, the insurance company may give suggested preferred alternatives or you, or your doctor can appeal their decision. Again, even with an appeal, there is no guarantee the decision will be overturned. Calling Member Services, the number on the back of your ID card, is the best place to start.  Also our Customer Care Team is available to help as your advocate, if needed.

Be sure to follow us for future post on medical pre-cert!

Anthem Care Comparison

How do you know what the costs of procedures are at different facilities within a certain area?  Anthem has a convenient and easy to use tool to compare facilities for your health care.  You can see a variety of sources about inpatient and outpatient services as well as cost and quality.  Please note, you must be an Anthem member to utilize this tool.

To use this tool, login to Anthem.com

Click on the Estimate Your Cost link on the bottom right side of the page.

Click on the Start Cost Search button.





If you have any questions, you can contact Anthem Member Services or you can contact the Customer Care Team for assistance.





Joint Township District Memorial Hospital and Hospital-Based Physicians Termed 4-13-12

This is to make Anthem members that utilize Joint Township District Memorial Hospital aware that as of 4/13/2012 this provider will no longer be in-network.  This is due to contract negotiations where a new contract could not be reached.  In addition to JTDMH, all hospital-based physicians have been terminated as of 4/13/2012 as well.  Attached is a list of these affected providers.  Since Anthem's website takes time to update, it may still show this hospital and these physicians as in-network.  Please contact Anthem member services at the number on the back of your ID card for help locating a network facility or physician for services.

JTDMH Physicicans Termed

Healthcare Reform and Anthem's Preventive Care for Women

As most of us know, there is change on the horizon.  Keeping you informed is one way to empower healthier living for you and your family.  Attached is a FAQ sheet from Anthem detailing how they will be covering preventive care for women after certain healthcare reform changes take place.  This particular article will be valid for palns starting on 8/1/2012 or later.


Women's Preventive Care

Aetna 2012 Drug List and More

Each year insurance carriers may change their drug formularies and preferred drug lists for tiered plans.  The link below is the 2012 Aetna drug list to help maximize your benefits for the 2012 calendar year.  There is also a FAQ for answers about generic vs. name brand and about preferred drugs.  If you have any further questions, you can always contact the Customer Care Team at (937) 260-4300 or toll free at (877) 635-5372.

2012 Aetna Drug List and More

Meet the Customer Care Team: Ben

We have been introducing a member of the Customer Care Team over the past months to help put a face to a name or a voice on the phone.  This week we are introducing: Ben

Ben has been with the company since November of 2007 starting in another role before coming to the Customer Care Team.  Ben has a high level of expertise in all areas of customer service.  He truly possesses a unique sense of humor which makes his influence with the team very positive.  Ben resides in West Carrollton, OH.  He enjoys spending time with his fiance.  He has a real passion and talent for music, singing, and playing the guitar.  He is also an avid runner.  We are thrilled to have Ben, who is such an asset to the team.
Say Hello to Ben!

2012 Anthem Formulary

Anthem has a formulary list of preferred drugs for tiered drug plans.  Attached below is the most current drug list. In order to maximize your benefits, the formulary drug list shows you the drugs and tiers of each.  The  associated cost of the tiers could be different depending on what plan you are enrolled in.  Additional information can be viewed online at www.anthem.com under member services or by contacting Anthem at the member number located on the back of your current ID card.  You can always contact the Customer Care team for additional assistance as well at (937) 260-4300 or toll-free (877) 635-5372.

2012 Anthem Drug Formulary

You HAVE The Right To Appeal!

It’s easy to write an appeal…

The option to appeal is a right you have when you disagree how services (claims/prescriptions/benefits) are processed with the carrier.  When you begin to write the appeal there are certain pieces of information you should include to enable the appeal to be reviewed.   

1.    Always have the word "appeal" somewhere in the letter.

2.    Make sure you include the policyholder's insurance information (member ID or social security number, date of birth).  You will also need to include the patient name and date of birth.  See example below:

Policy Holder- John Smith
ID# xxx-xx-xxxx
DOB xx/xx/xxxx
Patient Judy Smith
DOB- xx/xx/xxxx

3.    Make sure to include all dates of service you are appealing in the letter.

4.    Include the reason you are appealing.  (Tell your story/situation)

5.    Include any supporting documentation from your doctor or health professional.

An appeal can take up to 30 days. The explanation of benefits (EOB) gives the information where to send the appeal to. Remember to keep copies of what you send for reference or if you would want to appeal on a higher level with the carrier. Carriers notify in writing directly to the member when the appeal is received and also when the resolution on appeal has been rendered.

The Customer Care Team is available to help with questions on the appeal process.  Please feel free to contact us  Direct  (937-) 260-4300 or toll-free  877-635-5372

2012 UHC Formulary Release!

Below is the 2012 United Healthcare Drug lists for Traditional and Advantage Coverage.  Please review for answers to questions on drug coverage and a whole lot more. If you have any questions please refer to the number on the back of your Identification Card or you can access the United Healthcare website : www.myuhc.com

UHC 2012 Advantage Plan Formulary List

UHC 2012 Traditional Plan Formulary List

Anthem Ends Brand Name Lipitor Drug Coverage

Beginning April 1, 2012, brand name Lipitor will no longer be covered by Anthem Blue Cross and Blue Shield's prescription drug benefit plans. The generic for Lipitor, atorvastatin, will continue to be covered.

Late last year atorvastatin, a new generic for the brand name Lipitor, was added to Anthem's drug list. Atorvastatin is covered by the prescription drug benefit plans. This change means members can save money on their prescription drug costs without giving up quality.

As of mid-January, 84% of members have successfully switched from Lipitor to atorvastatin. Anthem's goal is to encourage all members currently taking Lipitor to switch to atorvastatin to save money on their prescription drug costs without giving up quality.

MEDS FOR little BUCKS!

Here is a website where you can research the popular $4.00 list for medications. It's a really great site to find out if your prescriptions are on $4 list and at what stores. Happy savings!

medtipster.com

Emergency Room or Urgent Care?

Is it serious enough for the ER? Or would it be better off going to an Urgent Care?    The determining factors in choosing is based on how someone is feeling…such as when you have a life-threatening situation, such as chest pain, or a sudden and severe pain, the emergency department of the nearest hospital is the only option. If you went to an Urgent Care Clinic, they'd most likely just send you on to the ER in an ambulance. But if your condition is less serious, but still requires immediate attention, choosing an urgent care facility can save you loads of time and money, as well as keeping the emergency room free to handle more serious situations.  

When you need to go to the Emergency Room: If you have a serious condition - stroke, heart attack, severe bleeding, head injury or other major trauma - go straight to the nearest ER. The ER is the best place for these and other critical conditions, including:

• Chest pain
• Difficulty breathing
• Severe bleeding or head trauma
• Loss of consciousness
• Sudden loss of vision or blurred vision

When an Urgent Care Center is the faster/more cost-efficient choice:

• Minor burns or injuries
• Sprains and strains
• Coughs, colds, and sore throats
• Ear infections
• Allergic reactions (non-life-threatening)
• Fever or flu-like symptoms
• Rash or other skin irritations
• Mild asthma
• Animal bites
• Broken Bones

And when in doubt, call ahead. If the Urgent Care Clinic in question can't accommodate your condition, they will advise you to go the nearest emergency facility. 

Meet the Customer Care Team: Nick!

       We are going to introduce a member of our Customer Care Team over the next couple of weeks.  We hope this helps you to get to know us better.  Along with putting a face to a name or voice on the phone.  This week we are introducing: Nick.

       Nick has been with the team since September of 2011.  He is one of our newer members, but already possesses a wealth of knowledge.  Nick has had experience in customer service and came to our team ready to learn.  Nick's knowledge base and desire to go the extra mile for our members makes him a great addition to our team.  Nick resides in Bellbrook, OH with his wife.  He enjoys spending time with his family and exercising.  We are all glad to have Nick on the team.  Say Hello to Nick!

Sometimes You May Need to Have a 2nd Opinion....

Below is a current article on ways to make sure you get what you are requesting in a "second opinion". You may also want to check with your particular carrier if there are any specific steps to take when requesting a "second opinion".  A good source for reference is always the Member Services number on the back of your ID card. If you need further information you can always reach our team for assistance as your advocate.

Second Opinion Article

Tips if you have not received your ID card

Happy 2012!  The New Year often brings issues for employers/employees to deal with.  Here are some tips if you have not received ID cards for the 1/1/2012 renewal and need services or prescriptions:

• 1. You can pay for a prescription upfront and have the pharmacy re-run it through insurance as soon as ID cards are received.  Most pharmacies are able to re-run prescrpitions up to 2 weeks after it was filled. Time frame can vary depending on pharmacy.
• 2. Give our CCT number for providers to call to verify coverage or call our team and we will personally reach out to providers to verify coverage and explain the delay in ID cards being received.
• 3. Pay upfront for services and submit a claim form to the carrier for reimbursement.  We are able to help getting the claim processed.
• 4. Call HR for instructions how to handle per group.
• 5. Request that the provider holds the claim until ID is received. Usually if this is a doctor you see regularly they will understand and work with you.
• 6. Have providers call carrier to verify coverage if loaded but no ID card was received. 

Please know that if you experience difficulty obtaining services, CCT as your advocate is always here to help. Our hours are 8-5 Mon-Fri.