This is the fourth in a series in which Penn State Employee Benefits staff explain key concepts, terms and processes to help faculty and staff better understand and use their health benefits. For previous articles visit http://news.psu.edu/tag/understanding-your-benefits.
By selecting the Penn State health plan that is most appropriate for themselves and their family members, Penn State employees will put themselves in a position to receive the most appropriate level of healthcare for their money, while feeling like they may visit their physician when they need to without the accompanying stress of knowing that they are spending more money than they have set aside for care. Penn Staters can reap even greater rewards by becoming knowledgeable about some specific health plan details inherent to each of the Penn State plans. An understanding of these concepts can steer plan members in the direction of becoming savvy healthcare consumers.
Preventive vs. Diagnostic Care: Knowing the difference between preventive and diagnostic care may help plan members keep out-of-pocket charges reasonable by encouraging them to take advantage of preventive services that are covered at 100 percent. Examples of preventive services include annual physicals, vaccines, mammograms and cholesterol screening. To be considered a preventive service, the office visit or test should adhere to Highmark’s Preventive Schedule, which may be found on the Employee Benefits page of the Office of Human Resources website. Both of the Penn State plans provide full coverage for preventive care; in many cases, certain diseases may be prevented or minimized if the risk factors for them are detected early and acted upon.
While preventive care services are covered at 100 percent, services for diagnostic-related care are subject to deductibles, co-pays and co-insurance. Diagnostic care is typically care that is intended for the treatment or management of a disease or medical condition. Sometimes health plan members are surprised to receive an invoice for a procedure that is listed on the Preventive Schedule. In these cases, the reason for the billing is that the person has likely departed from the preventive schedule in some way. For example, if an individual has a doctor visit for an annual physical and the physician orders a lipid panel (cholesterol test), the visit and the lab work are covered at 100 percent. If that person’s cholesterol test results indicate out-of-range values and the physician orders annual lipid testing in order to monitor the person’s condition, the follow-up tests are no longer deemed preventive care, but rather, diagnostic-related care, and are covered at the standard benefit level, which means they are subject to the plan’s deductible and co-insurance.
In order for preventive care services to be covered at 100 percent, it is important to adhere to the services and the timelines listed in the preventive schedule. For example, the schedule for cholesterol testing is once every five years beginning at age 20. Penn State Highmark members are encouraged to consult the schedule before scheduling any tests or doctor visits for what may be perceived as a preventive service.
Prescription Drug Plan: Knowledge of the different pricing structures for various medications can help a person make key decisions about the medications he or she has been prescribed. Following are some areas to consider:
Generic vs. Brand name: Generic medications are almost always less expensive than brand-name medications, and sometimes the difference is significant. For example, for PPO Blue plan members, the out-of-pocket cost for a 90-day supply for the brand-name version of a lipid-lowering medication is $360 while the price of the generic form of the same drug is $4. For those in the PPO Savings plan, the costs are $520 and $21, respectively. Keep in mind that prescription drug expenses do not count toward the plan deductible or the out-of-pocket maximum in the PPO Blue plan, while they do in the PPO Savings plan.
Plan members should always ask their physician if a medication is available in generic form, and if it is, they should request that the physician write the prescription for the generic version.
Mail-order vs. Retail Purchasing: Plan members who take medications on a recurring, or maintenance, basis may purchase their medications as a 90-day supply through one of the approved mail-order venues within the Highmark plan. Maintenance medications are typically taken for long-term, chronic conditions where the patient receives a prescription of a year’s duration.
For PPO Blue plan members, a 90-day supply of the generic form of a common blood pressure medication is $4.50, while a 31-day supply for that same drug is $7 -- or $22 for 90 days’ worth. PPO Savings plan members would pay $22 and $44, respectively.
Ordering maintenance drugs through an approved mail-order pharmacy can save money for members of both plans. Approved mail-order pharmacies include Express Scripts and the University Health Services (UHS) Pharmacy located on the University Park campus. UHS patrons may pick up their prescriptions at the facility, or may have them shipped to their home or office.
The Highmark website contains a prescription drug price comparison tool that allows plan members to view the prices of various medications and their acceptable substitutes. After logging into the site, click on the “Coverage” tab at the top of the page, select “My Benefits” from the left-side menu, and then look for the icons on the right side of the screen to locate a line that says, “Compare Costs and Save”.
Worldwide Medical Coverage: Highmark provides world-wide coverage for its plan members. Before travel, plan members should print and cut out the BlueCard Worldwide Medical Services Card located on the Worldwide Care page of the Highmark website. This card contains instructions and the number for the BlueCard Worldwide 24-hour phone line, which offers 24-hour access to a medical assistance coordinator, who will provide help in arranging hospitalization or making an appointment with a physician. The BlueCard Worldwide program will pay for overseas inpatient hospital care at any hospital in the network; for out-of-network hospitals, members should call the assistance line and the staff will attempt to arrange direct payment with the hospital. For outpatient care, plan members are asked to pay for the services and then file a claim when they return to the United States.
Penn State employees who are well-versed in Penn State’s health plan and know which one is best for them are at a distinct advantage when it comes to selecting the most appropriate care for themselves and their families. Gaining an understanding of the various plan design concepts will assist them in getting the most out of their care dollar and may help them experience lower out-of-pocket medical expenses.