Frequently Asked Questions (FAQs)

COBRA Notification Requirements: Administrators of group health plans must ensure that each covered employee, spouse, and dependent receives written notice, by mail, of his or her right to continuation of coverage.

Prescription Drug Coverage

Highmark Blue Shield of Northeastern New York  offers a Three-Tier Prescription Program as well as a mail order option to provide you with access to a wide selection of prescription products, while helping you manage your prescription drug costs. These products, administered by Blue Shield and Express Scripts (formerly Medco),  our pharmacy benefit manager,  provide both coverage and convenience for our members.

Three Tier Prescription 

• This program gives you the opportunity to lower your out-of-pocket cost by using generic or lower cost brand name drugs whenever possible.
  
• Members must use a participating pharmacy: refer to our Pharmacy Services web page.
  
• Members' prescriptions will be filled for up to a 30-day supply (including insulin) when filled at a participating pharmacy, nationally and locally.

Prescription Copayments Based on a Three Tier Program

• Tier 1 - Formulary Generic (lowest copay)
• Tier 2 - Formulary brand name
• Tier 3 - Non-formulary generic and brand name (highest copay)

What is a Formulary?

The Highmark Blue Shield of Northeastern New York Medication Guide or Formulary is a preferred list of the quality, cost-effective medications that can be prescribed by your physician and are covered under your prescription drug rider. Using a formulary helps us keep premiums as low as possible by controlling the rising cost of prescription drugs. For more information on formularies please refer to the "Pharmacy Services" section of this web site.

Express Scripts - Home Delivery of Prescription Drugs

Why Use Express Scripts By Mail?

Blue Shield offers the Express Scripts By Mail pharmacy service to all of our employer groups. The advantages for members using Express Scripts By Mail are:

CONVENIENCE

When members use Express Scripts By Mail for medications taken on an ongoing basis, they enjoy greater convenience as demonstrated by the following:

• Mail order offers the convenience of free shipping directly to the member's home or office
• Members can easily order medications via the phone, mail, internet, or fax from their doctor
• Members enjoy fast turnaround tomes from mail order. Upon receipt, prescriptions are electronically routed to the pharmacy best able to expedite the members' order
• Members with internet access may submit prescriptions online as well as access leading health-related content and applications, including automated email refill reminders, all from the convenience of their home or office
• Members can access Express Scripts website through the Blue Shield website to compare differences in drug coverage and pricing between mail order and retail
• The 90-day supply available from mail order decreases the number of refills required and eliminates extra trips to the retail pharmacy

SAVINGS

Members save money and time through the use of mail order as demonstrated by the following:

• Members save time by eliminating trips to the retail pharmacy
• Standard shipping is always free
• Members can receive up to a 90-day supply of medication for their mail-order copayment, which is frequently less than the cost of obtaining three, 30-day scripts at retail price

QUALITY AND SERVICE

Express Script's mail-order pharmacy has been recognized by third party research groups and by its own members for the highest quality and service.

• Express Scripts Customer Service Satisfaction Survey results indicate that 95% of Express Scripts customers are satisfied and plan to continue to use mail order
• All prescriptions undergo Express Scripts' extensive Drug Utilization Review (DUR) process to check for potentially serious drug interactions
• Express Scripts' registered pharmacists are available 24-7 through a toll-free phone line to answer member questions and to expedite emergency prescriptions when necessary
• Comprehensive drug information leaflets are available with each new prescription. Leaflets include easy to understand information about the drug, the conditions it is used for, instructions on proper use, and a description of possible side effects. 

For more information and instructions on how to start using Express Scripts by mail, call the Express Scripts Member Service Department toll free at 1-800-939-3751 or access the Express Scripts website. 

Highmark Blue Shield of Northeastern New York offers group plans to employers with two or more eligible employees. When a business has multiple locations in and outside of our service area, employees will be combined to determine the size of the group. Please refer to our Participation Requirements (Underwriting Guidelines) for details about eligibility requirements for groups.

New Employees

Enrollment applications must be submitted within thirty calendar (30) days of the eligibility date, which is determined by your probationary (waiting) period. After thirty calendar (30) days, employees must wait for the open enrollment period to submit their applications.

Eligible Dependents

Health plans that provide dependent coverage are required by law to make this coverage available until age of 26, regardless of group size or funding arrangement.

Dependent coverage is available to young adults up to age 26 even if they:

• No longer live with their parents
• Are not listed as a dependent on a parent's tax return
• Are no longer a student
• Are married (spouses and children of the young adult do not qualify)

Grandfathered Plans

Grandfathered health plans are not required to make this Age 26 coverage available to their employees' dependents until January 1, 2014 (per Health Care Reform law) if they are eligible for coverage aside from their parent's plan. If and when you do offer the coverage, confirmation of the young adult’s eligibility for their own employer-sponsored coverage is your responsibility.

New York’s Age 29 Law

Revisions to New York State insurance laws in 2009 provide the following coverage opportunities for young adults who are 29 years of age or younger, when they meet specific criteria.

• "Young Adult Option” – allows eligible, unmarried young adult children who exceed the age for dependent coverage under their parent’s group health insurance policy to purchase individual coverage through their parent’s group policy, regardless of their financial dependence.
• "Make Available Option”– is available when the group or contract holder purchases a rider to extend dependent coverage through age 29 under family coverage. This allows eligible, unmarried young adult children to remain a dependent on their parent’s policy through age 29, regardless of their financial dependence.

Medicare Eligibility

You must submit a Medicare Certification form within ninety (90) days of a member’s Medicare effective date. This applies to anyone on Medicare regardless of age, including disabled individuals. Please submit this information on an enrollment application with a copy of their Medicare card.

Employees who do not enroll in Part B may incur more out-of-pocket expenses. For more information, visit medicare.gov

Eligibility Questions

Contact your dedicated account specialist or call Billing and Enrollment at 1-800-430-7984.

OBRA, TEFRA and DEFRA are laws that enable active employees and their spouses, enrolled in a group health plan, to make their Blue Shield coverage primary to Medicare.

OBRA: Affects employers with 100 or more full-time and/or part-time active employees. 

TEFRA/DEFRA: Affects employers with 20 or more full-time and/or part-time employees and that offers health insurance through the group.

OMNIBUS Budget Reconciliation Act - Federal (OBRA)

OBRA Specifications. This law affects employers with 100 or more employees.

When an active employee/dependent is covered by his/her employer enrolled in the active group and has Medicare due to a disability other than End Stage Renal Disease, the group coverage is primary to Medicare.

• If the individual chooses Medicare as his or her primary insurance, he or she must be removed from the employer's group insurance plan
• When an employee retires from the employer group, that employee or contract holder or a disabled dependent with OBRA coverage would cease to be eligible for OBRA. 
• Medicare becomes primary and that employee's Blue Shield coverage class should be changed to over 65. 
• When a person who is covered by OBRA reaches age 65, he or she ceases being covered by OBRA, but may be covered by TEFRA/DEFRA.

End Stage Renal Disease

If an employee (and/or dependent) is diagnosed with ESRD, the group health insurance remains primary for the 30-month period, after which Medicare becomes the primary carrier.

Tax Equity and Fiscal Responsibility Act of 1982 - Federal (TEFRA)
Deficit Reduction Act of 1984 - Federal (DEFRA)

TEFRA and DEFRA Specifications affects employers with 20 or more employees and that offer health insurance through that group.

• In multi-employer groups, if only one employer has more than 20 employees, the regulation affects all groups.
• Blue Shield will treat all employees the same unless the employer notifies Blue Shield and Social Services to exclude specific groups of under 20 employees and their members.
• To notify Blue Shield of a subscriber's situation, the group must submit a change form (application) or a TEFRA/DEFRA election form on which the person chooses Blue Shield as his or her primary insurance carrier.
• The election form can be used to notify Blue Shield of TEFRA, Medicare eligibility or the choice of Medicare as primary.
• The change form should be sent to us at least 30 days before the person reaches age 65 or as soon as an employee 65 or older, or an employee with a spouse 65 or older, is hired.

If either the employee or his or her spouse chooses Medicare as the primary insurance carrier, that individual must be removed from the employer's group insurance plan. When the contract holder retires, TEFRA no longer applies, Medicare becomes primary and Blue Shield classes should be changed to Over 65.

If a member is changing his or her coverage to Medicare primary, please submit a copy of the Medicare card showing Part A and Part B effective dates.

The preceding summary is not intended as legal advice or intended to be a legal analysis upon which you can rely for a definitive explanation of the statute. Blue Shield recommends you contact your attorney and accountant to advise you of the applicability of the law to your group and the provisions and the penalties for noncompliance.

All members with Point of Service contracts have the option to seek care from non-participating ("out-of-network") providers, at a higher out-of-pocket cost.

• Members are responsible for an annual deductible and coinsurance for these services, as well as any charges over our allowance.
• Members should check their contracts for their specific deductible and coinsurance amounts.

The plan that does not have a clause or does not comply with Regulation II NYCRR 52 is primary. 

The benefits of a plan that cover the person as an employee, member, or subscriber are primary before those of a plan that cover the person as dependent.

In situations of dependent children of divorced or separated parents: 

If two or more plans cover a person as a dependent child of divorced or separated parents, benefits for the child are determined in this order: 

1. The plan of the parent with custody of the child(ren) is primary.

2. The plan of the spouse of the parent with custody of the child(ren).

3. The plan of the parent not having custody of the child(ren). 

NOTE: If the specific terms of a court decree state that one parent is responsible for the healthcare expenses of the child, and the entity obligated to pay or provide the benefits of the plan of that parent has actual knowledge of those terms, the benefits of that plan are determined first. This paragraph does not apply with respect to any Claim Determination Period or plan year during which any benefits are actually paid or provided before the entity has that actual knowledge.

When two plans cover the same child as a dependent of both covered parents, the following applies:

1. Parent Birthdays - Benefits of the parent's plan who birthday falls earlier in the year are determined before those of the parent's plan whose birthday falls later in the year.

NOTE: the word "birthday" refers only to the month and day in a calendar year, not the year in which the person was born.

2. Parents with the same birthday - If both parents have the same birthday, the benefits of the plan which covered the parent longer are determined before those of the plan which covered the other parent for a shorter period of time. If the other plan does not have the rule described above - but instead has a rule based upon gender of the parent - and if, as a result, the plans do not agree on the order of benefits, the rule in the other plan will determine the order of benefits.

Primary Coverage as an employee

If the benefits of a plan that covers a person as an employee who is neither laid off nor retired (nor is the employee's dependent) are determined before those of a plan that covers that person as laid off or retired employee (or as that employee's dependent). If the other plan does not have this rule and if, as a result, the plans do not agree on the order of benefits, this rule is ignored.

If none of the above rules determines the order of benefits, the benefits of the plan covering an employee, member or subscriber the longest are determined before those of the plan, which covered that person for the shorter time. 

If a member's plan requires referrals to visit a participating specialist, the member's Primary Care Physician needs to issue a referral before the member sees the specialist in order to be covered.

Urgent care is treatment for medical situations that require prompt attention but are not life threatening.

Examples include:

• Suspected sprained ankle
• Skin rashes
• Ear infection
• Flu

Urgent Care Within the Service Area: (For members with HMO and POS coverage). 

• Members faced with an urgent care situation while in Blue Shield's local service area should contact their primary care physician. 
• The PCP will direct them to the most appropriate care, which may be the doctor's office, an urgent care center, or the emergency room.
• If it is after hours or on the weekend, the physician's answering service will either contact the doctor or advise how to contact a covering physician. 
• In the event members are unable to contact the PCP and seek treatment in an emergency room, they should contact their PCP within 48 hours to coordinate any follow-up care. 
• If you require emergency care when your health condition is in serious jeopardy, proceed to the nearest emergency room. 

Urgent Care Outside the Service Area (For members with HMO and POS coverage).

Members are covered for urgent care while traveling outside the home service area through a network of Blue Shield providers participating in the BlueCard® program.

• Urgent care should be coordinated by the members' PCP prior to obtaining services.
• If the member can't reach the PCP, the member can call Health Advocate services at 800-359-5465 for assistance.
• If the PCP recommends treatment, members should call BlueCard at 800-810-2583, or visit BlueCard online to locate a participating provider.
• If there is not a participating Blue provider in the area, members should seek care at the nearest medical facility or health care provider.