Additional Healthcare Information

Express-Scripts Mail Order

Once a member creates an account with Express-Scripts, the provider can either call or fax a script to be filled for that member. It is IMPORTANT for the member to first ask the doctor if there are Generic equivalents prior to the script being written. Brand Name scripts (on the formulary) that say “dispense as written” are being filled by Express-Scripts and costing the member the ancillary fee (difference in cost of Generic vs. Brand) in addition to the tiered copay without advance notification. (This is because our plan has mandatory generic fill for scripts with the same chemical make-up as the brand name) Since the scripts are sent from the provider after the account and payment options are created, members are not aware of the additional cost until their credit card is charged and the medication is filled / delivered.

Virtual Visits

Visits are both convenient and cost-effective at half of the normal Office Visit copay. However, a handful of staff members have received a bill after paying the copayment for this visit. Apparently the Anywhere Care virtual visit app and the UPMC eBilling sites are not integrated so the claims are not processing correctly through the insurance. If a member receives a bill (typically $39) for the remaining cost of a virtual visit, he/she must call member services to have the bill processed through the insurance. Please notify Katie Goehring if this occurs so I can continue tracking this with UPMC on our weekly calls.

Level 1 Provider Services

If a staff member is using a Level 1 Provider and he/she requires surgery or outpatient services, the Level 1 provider should be scheduling the procedures at a Level 1 Facility. Some instances where this did not occur resulted in rescheduled outpatient services for our members. Most typically, this resulted from surgeries that were scheduled prior to the change in coverage, but staff should still be aware of the potential. It is important to check both the provider and facility for Level 1 participation in the UPMC MyCare Advantage PPO plan.

Level 2 Provider Services

If a staff member is using a Level 2 Provider but obtaining services at a Level 1 facility (think hospital-setting), the portion of the bill that pertains to the hospital (room/bed) will be covered at the Level 1 benefit. Conversely, the portion of the bill that pertains to the provider (surgery/services) will be subject to the Level 2 benefits and assessed the $250 individual deductible and 20% coinsurance.

ID Cards

This should be cleared up by now, but if a staff member has not received ID cards, please have him/her contact Katie Goehring directly. Most employees received 2 or 3 sets of cards at this point and were advised to use the most recent.

Behavioral Health Visits

In-network behavioral health providers are listed somewhat differently with network participation. Instead of a Level 1 or Level 2 designation, behavioral health providers with a green checkmark next to the MyCare Advantage PPO Plan will be assessed at the Level 1 benefit.