Open enrollment is over; What do I need to do now?

New "quantity vs. time" limits program equals changes for your drug refills

HMO vs. POS

Winter 03 Q&A

Q. During open enrollment I changed my benefits plans. What else do I need to do?

A. The following is a list of actions you may take:

• If you added or dropped a dependent from your plans, review your check stub to be sure you are paying the correct amount.

• Your ex-spouse is ineligible for coverage under all city benefits plans. If the divorce decree orders you to provide health coverage, you may choose COBRA medical and dental plans or select another source.

• If you added or dropped a dependent from your medical or dental plan, please review your life insurance as well. Be sure that it also covers everyone you want and update your beneficiary as necessary. If you want your ex-spouse to remain as your beneficiary, you must designate him or her on a new life insurance beneficiary change form.

• If you did not provide documentation to add a dependent to your HMO plan, you may submit the paperwork and wait 90 days. Provide a marriage license, birth certificate, adoption or placement papers, or whatever documentation applies.

• If you dropped a dependent from your medical and dental plans, the dependent is entitled to COBRA coverage. COBRA allows the dependent to keep the city medical plan but pay a higher premium. You must notify the benefits division, (713) 837-9400.
• If you provide life insurance coverage for dependents over age 21, be sure they qualify. They must be full-time students for a claim to be paid, and you must submit documentation proving they are full-time students. You will not receive a refund of premiums.

ID cards were mailed to all participants beginning May 31. Check your new card.

Q. I went to the pharmacy for a pain medication prescription refill, but the pharmacist would not fill it. He told me a refill would exceed the clinically appropriate amount of medication for a 30-day period. He said my doctor had to approve an override for me to receive my medication. This has never happened to me before. Why is it happening now?

A. This is to prevent inappropriate use of prescriptions. HMO Blue Texas implemented a program May 1 called "Quantity vs. Time limits" or QVT. The program limits quantities dispensed for proton pump inhibitors and pain management drugs such as Prevacid, Prilosec, Nexium and Oxycontin, medications designed to be used for a limited period of time – usually 180 days.

We provided information regarding this new program in the May 1 open enrollment guide. HMO Blue Texas also mailed letters to members affected by QVT limits explaining the program. If you need a prescription before the 180 days end or to go beyond the 180-day period, you must consult your doctor. Your doctor will contact Pharmacy Programs at (972) 766-2725, by fax at (800) 986-9980 or by e-mail at clinical_pharmacy@bcbstx.com.

Q. During open enrollment, I changed from the HMO to the POS so I could keep my doctor and use the hospital of my choice. I am paying a higher premium and more money when I receive treatment. Why? When can I go back to the HMO?

A. In the HMO, a primary care physician coordinates your medical care. Your PCP is part of a group of doctors, hospitals, and other medical providers who are in the HMO Blue Texas provider network. Your PCP diagnoses your condition properly, sees that you receive the correct level of care and refers you for specialty care. Participation in the HMO also helps control medical plan costs.

In the POS in-network plan, a PCP coordinates your health care. In the POS out-of-network plan, you coordinate your health care and use providers of your choice. Use of a PCP and network providers allows you to have lower out-of-pocket payments for your medical care.

When you don’t have a PCP coordinate your care, or you use providers who are not in the network, you will have higher out-of-pocket payments. Each time you need medical care, you make a choice to use network or non-network providers. Click on the chart to the right for examples of your costs in the different plans.

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Pulse readers can get answers to their medical, dental and insurance benefits questions from the Human Resources Benefits Division's customer service representatives. Veronica Rodriguez answers your questions in this issue.

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Winter 04 Q&A

Fall 03 Q&A

Summer 03 Q&A

Winter 03 Q&A

Click here to see examples of your costs in the various health plans offered by the city.