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Current and Pre-Medicare Members
Starting Jan. 1, the HealthChoice High and High Alternative plans
will have a $100 pharmacy deductible per person with a $300 maximum per family.
This deductible is for pharmacy only and must be met before the pharmacy copay
structure applies.
HealthChoice will also
implement the HealthChoice Preventive Medication List Jan. 1 for all
non-Medicare plans that have a pharmacy deductible, which includes the High and
High Alternative plans and High Deductible Health Plan. This list of generic
medications is not subject to the deductible, and you pay the generic copay of
up to $10 for a 30-day supply and up to $25 for a 90-day supply. You can access
this list at https://www.ok.gov/sib/documents/HCPreventiveMedicationList.pdf.
Medicare Supplement High Option Members
Beginning Jan. 1, members on the HealthChoice SilverScript High Option Medicare
Supplement Plan will be subject to a $100 pharmacy deductible per person. This deductible is for pharmacy only and must be met before the pharmacy copay structure applies.
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Effective Jan. 1, HealthChoice has made formulary changes within
several therapeutic categories. HealthChoice encourages the prescribing of
generics as the first line of therapy in order to help manage health care
costs. You can access the HealthChoice Standard Medication List* and the
HealthChoice Drug Removal List* on our pharmacy benefits web page at https://www.ok.gov/sib/Member/Pharmacy_Benefits_Information/index.html.
*These medication lists are not all-inclusive. HealthChoice
prescription benefits may not cover certain products or categories, regardless
of their appearance in these documents. Products recently approved by the FDA may
not be covered upon release to the market.
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Always check your
Confirmation Statement when you make changes to your coverage, or when you
reenroll in coverage during Option Period. Only state employees must reenroll
each year.
If
your statement is not correct, employees contact your insurance/benefits
coordinator. Former employees/retirees call member services at 405-717-8780 or
toll-free 800-752-9475. TDD users call 405-949-2281 or toll-free 866-447-0436.
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Just like many others, you may use the social networking
website, Facebook, as a form of entertainment, as an information resource, or as
a way to share information with family and friends regarding any subject imaginable.
One idea recently circulated on Facebook and other sites is entitled “HIPAA
Medical Hack,” which can allegedly be used to convince health insurers to
overturn decisions to deny medical claims for particular health care services
or products. This hack includes just enough factual information to look
convincing, but is actually not accurate.
Although the intent of the “HIPAA Medical Hack” is to be
helpful to plan members, it is NOT an efficient way to address a claim denial
and could actually slow down the process of getting a claim reviewed. There are
a number of reasons a “HIPAA Medical Hack” is not the correct approach to take
if you as a HealthChoice member want to contest a denied claim, such as:
- Claim denials are not considered HIPAA violations. HIPAA rules are violated when personal information about an individual is disclosed improperly.
- The privacy officer is not the appropriate person to call regarding a claim denial.
- Under HIPAA, an insurer like HealthChoice is not required to account for all appropriate internal disclosures as they relate to claims payment and its operations.
- Claim denials often occur due to billing errors or because evidence of medical necessity is crucial in the processing of claims. In these cases, claims are reprocessed when providers supply corrected billings or further information is received to establish medical necessity.
- HIPAA does not require insurers to base claim denials on the decision of a physician. In fact, these issues are usually regulated by state insurance laws.
You have the right to request a review if your claim is denied. You
must submit your request in writing to the EGID claims administrator at:
Medical Claims Review
P.O. Box 24110
Oklahoma City, OK 73124-0110
405-416-1800 or toll-free 800-782-5218
The most
effective way to challenge a claim denial is to follow the appeals/grievance
procedures established for HealthChoice members. You may file an appeal or
grievance in the EGID Legal Grievance Department. For more information,
contact:
EGID Legal Grievance Department
3545 N.W. 58th St., Ste. 110
Oklahoma City, OK 73112
405-717-8701 or toll-free 800-543-6044
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