***********************************
May 2009

Shingles Vaccine- Clarification has been provided by Vz on the distribution/availability of the Shingles Vaccine, Zostavax. Due to the necessity for this vaccine to remain frozen up to the point of dispensing, members will not be able to pick up this vaccine at a Retail pharmacy or Mail Order. This is a Manufacturer distribution issue, not a plan design issue. Your physician may order the vaccine for you and then administer it to you. Only physicians who have the facilities to keep this vaccine frozen will be able to order it. Many doctors do not, so you may have to contact another doctor to receive this vaccine. Individual doses may be ordered by the physician through the Aetna Specialty Pharmacy (your physician is aware of how to do this). This applies to the MCN/MEP/PPO plans. If you are in an HMO, please call member services for coverage details and availability.

AETNA- retroactive denial of chiropractic and physical therapy claims. An issue has existed with claims denied after services were rendered, leaving our member responsible for claims that they had no idea were not going to be paid. Many providers are not providing clinical information to substantiate the "medical necessity" of these claims. Aetna is then denying payment and then the provider is coming to the member for payment. The Union is currently is working on a resolution to this issue with Vz and Aetna. Although we have agreed in principal, the fix is not complete yet. Please be patient and remind your provider to submit all supporting documentation for claims when requested and in a timely fashion. DO NOT SIGN WAIVERS stating you will be responsible. Our next meeting with Vz is set for June 17 but if a resolution comes before that I will post to this site immediately.

 

Health Net HMO UPDATE- Please call member services (877-747-9577) to see if your lab charges were reprocessed prior to seeking reimbursement from your provider. This will save you a trip!

Original message-Health Net HMO- For the plan year 2009, many members were being charged a $10 co-pay for lab work. Health Net will be reprocessing those claims. Please contact your doctor for a refund of lab charges that you may have paid for services in network.  

 

In Unity,

Karen

 

*********************************************

Karen Lane
Health Care Benefits Coordinator
Local 827 IBEW
800-870-6354
570-424-5110 (Fax)
karen.s.lane@verizon.com
 

April 2009

 

 

MCN- Effective 1/1/09 the network that is used for MCN is the Aetna Choice POS II (Open Access). This bargained for change of network actually expanded the network of doctors available by well over 600 and no doctors were lost. This plan does not require a referral to see a specialist. This is an important change! Members are now responsible for verifying that the doctor that you choose participates in the Choice POS II. If you do not, the $250 out of network deductible will apply and out of pocket costs will be measurably higher. Verify that your doctor is in network with this plan by calling Aetna member services at 800-247-5482. Don’t ask the doctor if they “take Aetna”, ask if they “participate in the Choice POS II”, it makes a big difference. Most doctors take any insurance and then bill you the remainder (more on the waiver issue below). If you can't find a specialist within the network you still need to go back to your primary care doctor and involve him or her in the request for a waiver to see a non-participating doctor before those services will be considered in network, due to network deficiency     MCN, MEP/PPO- Urgent Care Centers (in or out of network) are now covered for a $15 co-pay. If you use an out of network facility you may have to pay the entire charge (credit card?) and then put in a claim to be reimbursed. Emergency Room co-pay is $25, waived if admitted.    Prescription plan changes-   Retail (30 day supply) - Generic- no change 15% of DNP up to $25 max out of pocket - Brand name, no generic- 20% DNP up to $45 max out of pocket - Brand name, generic avail. (includes DAW)-30% of DNP up to $55 max out of  pocket  Mail Order (90 day supply) -  Generic- no change lower of $8 or DNP - Brand,no generic avail.-lower of $17 or DNP - Brand name, generic avail. (includes DAW)-lower of $25 or DNP Generics no change (retail or mail order). Brand drugs and Brand drugs when generic available-max out of pocket percentage of Discounted Network Price (DNP) remains the same , out of pocket max increased by $5.    Aetna- MCN, MEP/PPO are our Union bargained for plans. They are terrific plans but you may have noticed a few things different lately. -Experimental and Investigational (E&I) procedures. E&I is not new... what is new, is that Aetna is making the member responsible for charges that are not covered. The cases that have been sent to me, involve specific blood testing which previously was covered and paid for. The Local is trying to resolve this and will need every example:   1. claim was paid, member not responsible   2. claim not paid/member not responsible   3. claim is denied/member responsible.   You should save your documents for your own records and also forward to me (EOB, appeals documents, denial letters). This is not the agreed upon application of this Plan and these charges were never our member’s responsibility. It is ludicrous for Aetna or Vz to expect a member to ask the doctor for each and every billing code for all procedures, tests or operation that are prescribed by a participating provider. Will your doctor wait while you call Aetna from the examining room, or worse yet…the operating table? You have never been responsible for telling your doctor that you don’t think you need “that test”? You must appeal these denials as directed in the Explanation of Benefits to protect your rights legally. Ask your doctor to write a letter to be included in your appeal which explains your diagnosis code and the reason for requesting that particular test. Send this letter along with your appeal. The Union is investigating legal avenues for this diminishment of benefits. If your Explanation of Benefits states that your blood work was deemed Experimental and Investigational, your claim is denied and Aetna is stating it is your financial responsibility, please send copies of your appeal and all documentation to Union Headquarters, to my attention.    -Waivers-Do not sign a waiver at any participating provider’s office or facility. If you are uncomfortable with that, write on the form that “I am only responsible if I lose insurance coverage. You are a participating provider”.  If you sign this you are legally signing away any rights you may have and assuming responsibility for all charges above what the insurance reimburses the provider.   -LabCorp is no longer a participating lab. Quest Diagnostics is the participating lab for Aetna and should be utilized to get the highest level of benefits. When in doubt, call Aetna Member Services to check on a facility. Just because you went somewhere in the past, does not’t mean that facility still participates.   -EISP and the $100,000 lifetime max- Every time there is an offer the language that Vz uses in the package concerning this issue, generates calls. This language applies if you go out of the network and have out of pocket expenses for “other covered charges”. This language is found in the Medical SPD. If you stay in the network, this will not affect you.   Medco- mailings or email may have been sent to you this past year explaining that generic drugs may be available for the current medicines that you take. Generics or alternative drugs may or may not be appropriate for your individual situation, discuss these options with your doctor. Only your doctor will know if this voluntary program is an appropriate choice for you. By taking advantage of this program, you will save yourself money and help contain health care costs. Be informed and make a smart choice based on your individual needs.   HURRY- LIMITED TIME OFFER- The Local has  signed an agreement with Vz to do a “Free Generics by Mail Order Trial”. If you use mail order to fill a prescription and use generics, your first 90 day supply is free. This applies to a new script only, not refills of an existing script. Reminders of this offer were sent to all members recently. Contact Medco for more information and to complete your order.   -Mail Order, utilization of this service may greatly reduce your out of pocket expenses. You can get up to a 90 day supply of a medication for a fraction of the retail cost. This is a terrific benefit. You can print out a form to take to your doctor so they can fax in a script to Medco. I use it myself and it works terrifically! Call me if you need help.   -Liberty and Accredo  are used for Medicare reimbursable prescriptions. You may receive a letter or call from this vendor on behalf of Vz. This process allows VZ and Medco to submit to Medicare for reimbursement of nearly 400 drugs under Medicare Part D, diabetic supplies is most common. You will be sent an Authorization for Billing/AOB (required form); this allows reimbursement to Medco/Vz. This helps Vz contain costs and receive eligible reimbursement under the law. This works well for us, as Union members, as we work to be proactive in containing costs.   -Vaccine for Shingles, a new vaccine has come on the market and is recommended for anyone who is 60 yrs of age or older. It helps prevent shingles, a very painful condition that is actually similar to chicken pox but affects adults. Zostamax is a temperature sensitive vaccine (must remain frozen up to point of dispensing) and it is best if your physician orders it directly to be shipped to their office. Single doses can be ordered, and is a covered service with Aetna. Many doctors are giving our members a script to go to the pharmacy to pick it up and bring back with them (you pay Medco co-pay then submit a claim to be reimbursed the $34). There are many unresolved issues with this, but I am working on it. Until further notice, tell your doctor that they have to order it. The vaccine is destroyed if it becomes unfrozen before administering.   HMOs- remember, HMOs are an option that Vz provides to you because in most cases it is cheaper for the company. There is no requirement that Vz provide an HMO option. Vz is required to provide the MCN (in covered areas) and the MEP/PPO( in areas where the MCN is not available). Members ask “which is best”? Personally, I think the MCN is unmatched. In reality, the best plan is a personal choice, usually determined by which plan your doctors participate in. Remember , all HMOs imposed a $150 co-pay per confinement to the hospital and a $10 co-pay for out-patient surgery (not required under the MCN plan)  Health Net HMO- For the plan year 2009, many members were being charged a $10 co-pay for lab work. Health Net will be reprocessing those claims. Please contact your doctor for a refund of lab charges that you may have paid for services in network.

Karen Lane
Health Care Benefits Coordinator
Local 827 IBEW
800-870-6354
570-424-5110 (Fax)

 12/9/08

 Due to an administrative error, Health Net HMO located in New Jersey and Pennsylvania (options 639 and 838) erroneously mailed letters to participants in their plans indicating that their coverage will end on December 31, 2008. This mailing was totally an error on Health Nets part and, in fact, the existing Health Net plans for associates will remain in place for 2009.The Verizon Benefit Center has been advised of this mailing error and has been provided a script to address any questions they receive from callers. In addition, Health Net is drafting a retraction letter that they will mail to covered employees as quickly as possible.

 

 

 HEALTH PLANS

 

MCN	2008 Benefit	2009 Benefit
Emergency room visits   In and out of network benefits	$15 co payment per visit, (waived if admitted)	$25 co payment per visit (waived if admitted)
Urgent care visits   In and out of network benefits	Not covered	$15 copayment per visit
Referral for specialist In network	Required w/ OV to PCP	No referral necessary

 

 

 

 

 

 

MEP/PPO	2008 Benefit	2009 Benefit
In- and Out-of-network Benefits
Emergency room visits	Covered at 100% (no deductible)	$25 copayment per visit (waived if admitted)
Urgent care visits	Not covered	$15 copayment per visit
Out-of-network Benefits
In-hospital physician’s visits	Covered at 90%; plan also pays 80% of your remaining 10% coinsurance, after deductible	Covered at 98% (no deductible)
Inpatient pre-natal and post-natal care	Covered at 95%; plan also pays 80% of your remaining 5% coinsurance, after deductible	Covered at 98% (no deductible)
Inpatient newborn baby care	Covered at 90%; plan also pays 80% of your remaining 10% coinsurance	Covered at 98% (no deductible)
Inpatient surgery	Covered at 95% (no deductible); plan also pays 80% of your remaining 5% coinsurance, after deductible.	Covered at 98% (no deductible)
Outpatient surgery	Covered at 95% (no deductible); plan also pays 80% of your remaining 5% coinsurance, after deductible	Covered at 98% (no deductible)
Anesthesia	Covered at 90% (no deductible); plan also pays 80% of your remaining 10% coinsurance after deductible	Covered at 98% (no deductible)

 

 

Q & A -

 

Q. Which Aetna Choice POS II plan is it? I see at least 2 Aetna
> Choice POS II (Aetna HealthFund) and Aetna Choice POS II (open access)?

A. The correct plan beginning on 1/1/09 will be the Choice POS II-Open Access. Referrals will no longer be necessary, BUT the member must make sure that the doctors that they choose to see are participating in the Choice POS II. The best way to check this is to call member services at Aetna or to register on Aetna Navigator. When the member signs into the website it automatically will select the correct network. If the member simply goes to the website, but does not log on, they must then select the correct network. New ID cards will be issued which will indicate the Choice POS II network as well as stating that this is the MCN.

 

 

 

___________________________________________________________________________________________

 .

Dear Member,
On November 25, 2008 Verizon notified the Union that Horizon BC/BS HMO, Medicare and pre-Medicare plans (option 611, 905 and 945) will be terminating their partnership with Children's Hospital of Philadelphia. We have requested notification by Verizon to all affected plan participants, but that will not come before the end of Benefits Renewal. I want all of our members to be aware of this and to make an informed choice in which benefit plan you need for 2009. If this information leads you to a change in your medical selection for 2009, let me know BEFORE the end of the year. I can not assist in any benefit changes after 12/31/08. I have heard that Newton Memorial Hospital in Newton, NJ is terminating also. We are waiting for additional information on this. You may contact the health plan, customer service number is located your ID card, for additional information.
In Unity,
Karen