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These frequently asked questions (FAQs) provide only an overview of benefit changes and clarifications effective Jan. 1, 2023. The respective plan documents and policies govern your rights. You should rely on this information only as a general summary of some of the features of the plans and policies. In the event of any difference between the information contained herein and the plan documents and policies, the plan documents and polices will supersede and control over these FAQs. The Partnership expressly reserves the right at any time and for any reason to amend, modify or terminate one or more of the plans or policies described in these FAQs.
If you are a new hire, you must complete the new hire benefits enrollment with 31 days of hire, including your date of hire. The benefits you elect will be effective on the 1st of the month following your hire date. If you are hired on the first of the month, then your coverage will be effective on your date of hire provided you enroll in benefits within the 31-day window.
Tria Health’s pharmacists act as your personal medication experts and work with you and your doctor(s) to improve health outcomes through appropriate medication use.
You will receive a $50 Tria Health Visa Rewards Card by attending pharmacist consultation(s). You can qualify to receive up to $150 by attending three consultations within a 12-month period.
When you enroll in the CDHP plan, you are not eligible to contribute to the Health Care FSA. You have an HSA that offers you tax-free savings for medical expenses, and the IRS does not allow you to have two tax-advantaged savings accounts. However, you are still eligible to enroll in the Dependent Care FSA.
You will receive 60% of your monthly earnings up to a maximum of $10,000 per month if you have a qualified disability, as approved by Sun Life. You must work an average of 35 or more hours per week to be eligible for this coverage.
We have created a variety of communication materials to help you learn about the benefit programs. In addition to these FAQs, you’ll find other helpful information here like a virtual benefits meeting, the Medical Match Up interactive feature that can help you see which medical plan could be right for you and your family, and the Benefits Guide.
SurgeryPlus is a free supplemental program provided with your medical benefits. It provides many common outpatient surgeries and inpatient surgical procedures to help you from head to toe. The experts at SurgeryPlus negotiate costs before you undergo surgery and only work with board-certified providers. As a result, they can get an unbeatable price with the highest quality surgeons.
The coverage, provided through Sun Life, provides lump-sum cash benefits to help you cover the out-of-pocket expenses associated with critical illness, like cancer or heart disease.
Yes, the Partnership provides several additional services designed to help
you manage several of life’s important tasks. Services include:
Please see the Benefits Guide for more details.
Yes. You can also purchase Supplemental Life and AD&D for you, your spouse and your child(ren). Please see the Benefits Guide for more details.
Yes. If you work an average of 35 or more hours per week, the Partnership provides you with Short Term Disability coverage. There will be a six-month waiting period before employees becomeeligible to receive benefits.
You will have one Dental Plan option, the Delta Dental Plan.
Yes. If you are enrolled in the PPO plan, you do not have a tax-advantaged savings account with your plan. Therefore, you are eligible to put money into a Health Care FSA.
Progyny provides comprehensive fertility benefits through dedicated Patient Care Advocates who will support you through your personal fertility journey. The Progyny Smart Cycles will assist you with the steps needed to guide you through the journey of starting your family.
If you work an average of 30 or more hours per week, you are eligible for medical, dental and vision benefits. You must work an average of 35 or more hours per week to be eligible for most other benefits, such as disability, Supplemental Life and AD&D. Please see your Benefits Guide for more details on who can be covered.
Yes. You will receive coverage in the amount of 1.5 times your annual earnings for Basic Life and AD&D, up to a $750,000 limit.
You may enroll yourself, your legal spouse and children up to age 26.
Sun Life administers Long Term Disability coverage.
SurgeryPlus is included as part of your ET medical coverage. You do not need to enroll. When you need to plan a surgical procedure, call 855-200-9512 to speak to a dedicated Care Advocate or go to ET.SurgeryPlus.com.
We know that you may have questions about your benefits. That’s why the Benefit Advocate Center is here to help you! The Benefit Advocate Center offers you a variety of services. The Benefit Advocate Center will help you:
Progyny is a special part of the Partnership’s medical plan and is subject to its own deductible and out-of-pocket maximum that are separate from those in the medical plan.
The Progyny plan features include:
Deductible - $4,000
Out-of-Pocket Maximum - $8,000
Co-insurance - Pays 80%, after deductible
The Partnership offers you a way to save money tax-free to use for eligible out-of-pocket medical expenses for you and any dependent(s) whom you claim on your taxes.
Delta Dental will administer the Dental Plan. To find a dentist in the Delta Dental network visit deltadentalins.com.
You may elect coverage for a legally married spouse, including common law spouse. You will be required to submit a Declaration of Marriage issued by the state of residence or, where not available, the Partnership's Affidavit of Common Law Marriage with supporting documentation requested.
Plan members (including dependents) taking multiple medications with a chronic condition:
Short Term Disability provides you with income replacement if you satisfy the elimination period (4 or 5 missed scheduled work days) due to an illness or non-work related injury. The amount you will receive is based on your completed years of service.
All illnesses/hospitalizations are subject to a four or five-day elimination period. Payments begin after elimination period. Available PTO, sick and accrued vacation must be used for the elimination period.
Your spouse will receive Basic Life in the amount of $20,000, and your child(ren) in the amount of $10,000. There is no Basic AD&D coverage provided for dependents.
You can contact the Benefit Advocate Center at email@example.com or call 1-855-562-5847 toll free.
The coverage gives your beneficiaries financial protection if you should die or are dismembered in an accident.
The SurgeryPlus program is included in your medical plan. Also, the Partnership picks up the entire cost of the surgery after your deductible is met. As an added incentive for employees enrolled in the CDHP plan, the Partnership will make an additional contribution to your HSA based on the type of surgery you receive, $250 for minor surgeries and $1,000 for major surgeries (limited to $1,000 total annual contribution).
Tria Health’s pharmacist will inform the member’s physician about Tria Health and our services. All necessary information and recommendations are provided to the members’ physician as part of our coordination of care.
No. Only those services provided by the Progyny fertility specialists after registration will be applied toward the Progyny deductible and out-of-pocket maximum. If you receive fertility care outside of the Progyny network or before you register with the Progyny service, it will not count toward the Progyny deductible or out-of-pocket maximum. However, it may be applied toward your medical plan deductible and out-of-pocket maximum. Conversely, the expenses incurred through the Progyny plan will not count toward your medical plan deductible or out-of-pocket maximum.
Yes. The Dependent Care FSA allows you to set aside tax-free dollars to use for qualified day care expenses. This account is not intended to be used to pay for any medical expenses.
No. Your covered dependents receive 50% of your basic-benefit amount.
The Dental Plan includes coverage for preventive care, basic, major and orthodontia services. You can find details on the Delta Dental Plan in the Benefits Guide.
Sedgwick administers Short Term Disability coverage.
You will receive Long Term Disability coverage at no cost to you. The Partnership covers 100% of the cost.
After speaking with your pharmacist, Tria Health may provide recommendations to you AND your doctor(s) to improve the outcomes you receive from your medications and/or lower your out-of-pocket cost. Any changes are left up to you and your doctor for approval.
You can contribute up to $2,500 to your Health Care FSA and up to $5,000 to your Dependent Care FSA.
You will receive a Delta Dental ID card only if you add dental coverage. You should continue to use your most recent Delta Dental ID card if you re-enroll for coverage. If you need a new ID card, please contact Delta Dental at 1-800-471-4920 or access your account at deltadentalins.com.
No. The benefit is portable, so you can take it with you if you leave the Partnership in the future.
To learn more about the Progyny benefit and get access to a library of learning videos, click here. When you’re ready to get started, 1-833-278-1139 to speak to a Patient Care Advocate.
You will be asked to name your beneficiaries when you enroll for benefits. You are automatically named the beneficiary of your dependents' life coverage.
You will receive Short Term Disability coverage at no cost to you. The Partnership covers 100% of the cost.
Yes, you are required to use SurgeryPlus for spine and bariatric surgeries. If you do not use a SurgeryPlus provider, these procedures will no longer be covered as of January 1, 2020. While SurgeryPlus also provides many other outpatient and inpatient surgeries, they are on a voluntary basis. SurgeryPlus can help you save money on pre-planned surgeries and procedures. Call 855-200-9512 to speak to a dedicated Care Advocate today!
To locate a provider in the SurgeryPlus network, you must first contact a Care Advocate at 855-200-9512 to register and discuss your case. The Care Advocate and the SurgeryPlus provider team will review your case based on your medical needs and other preferences to develop a list of providers who are the best fit possible.
You can pay for eligible expenses in one of two ways:
See your WEX Health FSA Guide for details on paying for eligible expenses.
You will have one Vision Plan option, the VSP Vision Plan.
No. You are not required to provide EOI to enroll in Critical Illness coverage.
Pharmacists will keep in touch 2-3 times per year depending on each member’s personal care plan that is discussed during the initial encounter. However, Tria Health members have unlimited access to the Help Desk where they can speak with a pharmacist if any medication issues arise.
Sun Life administers Basic Life and AD&D coverage.
You will receive Basic Life and AD&D coverage at no cost to you. The Partnership covers 100% of the cost.
Vision Service Plan (VSP) will administer the Vision Plan. To find an eye doctor in the VSP network visit vsp.com or call 1-800-877-7195.
Members can complete the online enrollment form at any time at www.triahealth.com/enroll. In addition, you may call Tria Health at 1-888-799-TRIA (8742) for assistance in completing your enrollment form.
The criteria that SurgeryPlus uses to select surgeons is more stringent than most health plan requirements. All SurgeryPlus doctors are board-certified and are the best in their specialty. Not only will your doctor be high quality, he or she has already performed your specific procedure many times with great results. Surgery is complicated. Getting a high-quality doctor no longer needs to be. Call 855-200-9512 to speak to a dedicated Care Advocate today!
The Cancer coverage, through Sun Life, pays for necessary services and treatment for a covered cancer or specified disease.
If you have funds remaining in your Health Care FSA on December 31, 2022, you may roll over up to $500 of your unused balance to 2023 if you elect the Health Care FSA for 2023.
The Vision Plan includes coverage for regular eye exams, glasses (lenses) and frames, and contact lenses. You can find details on the VSP Vision Plan in the Benefits Guide.
If you already working with a non-SurgeryPlus surgeon, it may not be too late to switch. Also, remember that all bariatric and spine surgeries must be performed with SurgeryPlus providers to be covered under your medical benefits. Experience the SurgeryPlus difference and call 855-200-9512 to speak to a dedicated Care Advocate today.
Yes. You may enroll yourself, your legal spouse and children up to age 26.
No. You will not receive a vision ID card from VSP. When you go to the eye doctor to receive services, they will ask for your Social Security Number to verify coverage.
Yes. Your covered dependents receive 100% of your basic-benefit amount.
No. Premiums are waived if you are totally disabled and unable to work for 90 days due to a cancer diagnosis.
The elections that you make during the Open Enrollment period take effect January 1, 2023.
Yes. When you select the CDHP, the Partnership will set up an HSA account for you and deposit either $1,000 (employee only coverage) or $2,000 (all other coverage levels) to help with your health care expenses.
Medicare is health insurance for:
You will have the choice between two medical plan options. The choices are:
Be sure to check out the Medical Matchup interactive feature so you can see which medical plan could be right for you.
No. The benefit is portable, so you can take it with you if you leave the Partnership in the future.
CVS Caremark is the Prescription Drug administrator for all plans. CVS Caremark is a market leader in mail order, retail, and specialty pharmacy services.
No. You are not required to provide EOI to enroll in Cancer coverage.
If you are a new enrollee or change medical plans for 2023, AmeriBen will send you new ID cards for you and your dependents. If you do not make any medical plan changes, you may continue to use your current ID cards. The ID cards will have the policy number, and the Customer Care Center contact numbers. Be sure that your home address in MyHR is correct. You should receive your new card in late December.
If you did not enroll during the 2023 Open Enrollment, your 2022 elections will roll over to 2023, except for FSA and HSA contributions. You may be eligible to make changes if you have a qualified change in status. Otherwise, you will have to wait until next fall’s Open Enrollment to make changes. See the Benefits Guide for more information.
If you are eligible for benefits as of January 1, you will receive all of your HSA dollars upfront at the end of January. You must be employed as of January 31 to receive the Partnership contribution. If you are eligible for benefits as of February 1, a portion will be deposited into your HSA each pay period.
The parts of Medicare cover different services:
No. You are not required to make a separate election for prescription drug coverage. Your prescription drug coverage is part of your Medical Plan. When you select a Medical Plan option, you will also be enrolled for prescription drug coverage.
Yes. The IRS maximum limit includes the Partnership and employee contributions.
No. If you and your spouse both work for the Partnership, you may each only be covered once. You may choose to each have employee only coverage, or one of you may choose employee plus spouse (family) coverage, but you may not have both. If you are covering your children, a child may only be listed under one employee’s policy, not both.
Medicare eligibility means you have met the requirements to qualify for Medicare Part A hospital insurance and are eligible to receive Social Security payments.
Medicare entitlement means that you are eligible, you have filed an application to receive Medicare Part A, or have been approved automatically, and your name is already in the system – or your application has been processed and you have been sent a Medicare card showing the date your coverage starts.
You will receive a CVS Caremark ID card only if you add Medical coverage. You should continue to use your most recent CVS Caremark ID card if you re-enroll for coverage. If you need a new ID card, just log in to your account at caremark.com, click on “My Account” and select “Print My Prescription Benefit Card” or contact CVS Caremark at 1-800-837-4092.
Effective January 1, 2023, the Partnership offers an Adoption Program through Progyny that will reimburse up to $10,000 for eligible adoption-related expenses including; adoption fees, home studies, legal fees and more.
AmeriBen is the medical plan claims administrator. You will continue to utilize the same BCBS network of providers. When you have a question, need to file a claim, or search for a doctor, you will reach out to the AmeriBen Customer Care Contact Center. Representatives will answer your questions and assist you as needed. AmeriBen also offers a suite of health and wellness support options.
To find an in-network doctor visit MyAmeriben.com and use the Find a Doctor feature or call 1-866-215-0976.
Yes. Make sure to show your ID card to your local retail pharmacist the first time you fill a prescription after receiving the card.
Medicare enrollment means you automatically enrolled in Medicare Part A and receiving Social Security payments.
No. Per the IRS regulations, you must be enrolled in a high deductible health plan in order to open and make contributions to a Health Savings Account (HSA).
AmeriBen is a private Third-Party Administrator (TPA) that specializes in administering complex benefit plans for over 80 self-funded employer groups and fully insured university plans totaling over 500,000 member lives. Energy Transfer engaged AmeriBen to work as our TPA to help us increase benefit plan member satisfaction, effectively manage claims administration, reduce employer and employee costs and improve customer satisfaction.
In-network providers should submit claims directly to the local BCBS network.
Out-of-network and all dialysis providers should submit claims to the AmeriBen claims address: PO Box 7186, Boise, ID83707.
AmeriBen relies on BCBS to “price” in-network claims and uses the discounts that BCBS negotiates with providers to get you extra savings. You see these discounts noted on your Explanation of Benefits (EOB) as Provider Discounts. The Provider Discounts reflect the amount deducted from your off of the provider’s billed charges that you are not required to pay, thanks to the BCBS network.
AmeriBen processes your claims based on the instruction we receive from your plan sponsor. We are required to pay or deny claims based on the language contained in the plan documents, including your SPD and SBCs. There are many reasons why claims might be denied, including limitations and exclusions placed on benefits, failure to pre-certify a service or failure to provide needed documentation that a service was medically appropriate.
For more information, please refer to your plan document or call AmeriBen’s Customer Support Center for specific questions.
Claims are often classified as pending when we require more information to process your claim properly. Two of the most frequent reasons that additional information is required are Accident Related Claims and Coordination of Benefits (COB).
If it appears that your claim may be accident related, a questionnaire is sent to you. Accident information is needed to identify if there is a third party, like an auto insurance policy, that may be responsible for damages. It is important that you include all the required information and complete all the fields on the form.
COB is intended to ensure that if other insurance exists, such as Medicare or other group coverage under a spouse or other employer, that benefits are coordinated correctly. You may update your COB information at any time online at www.myameriben.com.
Pre-certification is completed using nationally-recognized standards and guidelines while considering your individual clinical status. The AmeriBen physicians and Registered Nurses will review your doctor’s request for services for medical necessity and appropriateness of the recommended care.
The AmeriBen team realizes that there is a person behind every request and that your time is important; that is why they are committed to timely turnaround times when you are accessing care. With every request processed, they have the opportunity to ensure you are receiving quality, medically appropriate care.
If you are planning for a future medical procedure, be sure to review your plan document or call an AmeriBen Customer Care representative to determine if your procedure requires pre-certification.
Exclusions are in place to ensure that our medical plans make the best use of your healthcare dollars. Exclusions help to prevent the plan from paying for services that may be elective, such as cosmetic surgeries, or unproven, such as experimental, non-FDA-approved treatments.
Due to HIPAA requirements, each member over the age of 18 must create a separate account. When the account is created, they can list who may have access to their information.
In addition to claims management and finding doctors,AmeriBen offers many quality services to guide you through your health careneeds. These services include:
To access these services and more visit MyAmeriBen.com or call 1-866-215-0976.
The primary difference between a Health Savings Accounts (HSA) and a Flexible Spending Accounts (FSA) is that money contributed to an HSA carries forward to the following year if unused. In contrast, the FSA is mostly a “use it or lose it” account that limits you to a $500 carry over of unused funds. Also, in order to take advantage of the HSA you need to be enrolled in the CDHP.
Take the following steps to help ensure your annual wellness exam is billed correctly:
You will need the CVS Caremark ID card you receive in the mail. Go to caremark.com and look for the “Register Now” link. Registering only takes a few minutes and you will have a username and password to access all of your prescription information. If you need help, call 1-800-837-4092.
Yes. A person that is 65 years old can delay taking Social Security benefits and be eligible for HSA contributions as long as they are not enrolled in any part of Medicare, including A, B, C or D. You can delay enrollment in Social Security and Medicare Part A by contacting the Social Security Administration at 1-800-772-1213.
Note: If you apply for Social Security benefits at age 65 or older, enrollment in Medicare Part A is automatic.
Click here for a list of age-appropriate recommended preventive services. You can learn more about preventive care by visiting HealthCare.gov.
When you choose the CDHP, you will pay for care differently than with the PPO plan:
Want to see how the PPO stacks up to the CDHP? Click here to see how the plans compare in real-life situations.
Save time and money when you manage your medications at caremark.com or with the CVS mobile app. You may check drug costs and coverage with the Check Drug Cost tool both online and in the app, and also do a side-by-side comparison of your medications to see where you could save.
No. While you may add children up to age 26 to your medical plan, children ages 19 to 26 must be considered a tax dependent in order for their medical expenses to qualify for payment from a parent’s HSA.
Yes. Your eligibility to contribute to your HSA is determined by the status of the HSA account owner, not the status of your spouse or tax dependents. Your spouse can be on Medicare without disqualifying you from contributing to your HSA. If you have spouse or family coverage under the CDHP, you can still contribute up to the family maximum contribution. Please see the Benefits Guide for this year’s contribution limits. If you are age 55 or older, you may also contribute up to an additional $1,000 as a catch-up contribution.
No. You are not required to fill your prescriptions at a CVS retail store. The CVS Caremark network includes more than 67,000 pharmacies, including Walgreens, Wal-Mart, Target, and others. To find an in-network pharmacy in your area, call 1-800-837-4092 or visit caremark.com.
If you apply for and collect Social Security benefits, you will automatically be enrolled in Medicare Part A. Beginning the first month you enroll in Medicare, your HSA contribution limit is zero. If you turn 65 and become eligible in the middle of the year, your HSA contribution limit is prorated for the calendar year. As an example: You turn age 65 in July 2023 and enroll in Medicare. You enroll in employee-only coverage and eligible for an additional contribution of $1,000. Your contribution limit for 2023 will be $2,425 ($3,850 + $1,000 ÷ 12 x 6).
You need to contact the Benefits Department at firstname.lastname@example.org to stop your HSA contributions.
Note: This rule applies to periods of retroactive Medicare coverage, so if you delayed enrolling in or applying to Medicare and later your enrollment is backdated, any contributions made during the period of retroactive coverage are considered excess. In this situation, you need to be sure to stop all HSA contributions up to 6 months before you collect Social Security.
An HSA is a savings account that you own. Any funds that remain in the account are yours to keep. You can even save funds in your account to use toward eligible medical expenses into retirement.
Want to see how the PPO stacks up to the CDHP? Click here to see how the plans compare in real-life situations.
Visit triahealth.com/CTL-ET to learn about Tria’s Choose to Lose program that provides you tools and resources to achieve your weight loss goals.
Choosing how to fill your prescription depends on whether you are ordering a short-term or long-term medication:
No. Funds cannot be transferred between HSAs and FSAs.
No. If you are receiving Social Security benefits, you cannot decline Medicare Part A. Enrolling in Social Security benefits automatically enrolls you in Medicare Part A coverage, thus you are no longer eligible to open or make contributions to an HSA.
If you are entitled to Medicare because you signed up for Part A at age 65 or later, but have not yet applied for Social Security retirement benefits, you can withdraw your application for Part A. (To do so, contact Social Security Administration at 1-800-772-1213) There are no penalties or repercussions and you are free to reapply for Part A at a future date. (If any claims have been paid by Medicare Part A on your behalf, you would be required to pay those back.)
The CDHP and PPO plans are very different plans, but they do have some things in common. For example:
Yes. You can pay for eligible expenses from your HSA for yourself or your tax dependents, even if the dependent is not covered under your medical plan and even if he or she has other coverage. Eligible expenses include co-pays, deductibles, and other eligible expenses for which you will not receive reimbursement.
No. With the CVS Caremark Maintenance Choice feature, you can fill up to a 90-day supply of your long-term medications at a local CVS retail store.
There are several differences between the plans:
Click here to see how the plans compare in real-life situations.
The funds in your HSA are yours to keep and will go with you upon retirement or if you leave the company.
It depends on the type of surgery you need and where you live. Your SurgeryPlus benefit includes the cost of travel and lodging. If you do need to travel, your dedicated Care Advocate will make all your travel arrangements and handle all the travel bills for you.
Some non-emergency procedures such as MRIs, CT scans, and surgeries, require pre-certification. Whether you are considering an in-network or out-of-network provider, when your doctor mentions you need a non-emergency procedure or test, contact AmeriBen. The AmeriBen customer care representatives will walk you through the steps you need to take. Click here for a complete list of procedures that require pre-certification. Please note that if you do not receive pre-certification, your treatment may not be covered.
For more information about how the review process works, check out the pre-certification video.
Yes. Once your annual deductible has been met, the Partnership covers the full remaining cost of the surgery. This means that your coinsurance is waived completely. Additionally, if you are enrolled in the CDHP plan and you or a covered dependent use SurgeryPlus for a covered surgery, the Partnership will contribute extra money to your HSA: $1,000 for major surgery and $250 for minor surgery. The annual incentive maximum is $1,000 per family.
Yes. If you are entitled to Medicare because you signed up for Part A at age 65 or later, but have not yet applied for Social Security retirement benefits, you can withdraw your application for Part A. (To do so, contact Social Security Administration at 1-800-772-1213) There are no penalties or repercussions, and you are free to reapply for Part A at a future date. (If any claims have been paid by Medicare Part A on your behalf, you would be required to pay those back.)
Maintenance Choice is a program that gives you flexibility in how and where you get your maintenance medications. With Maintenance Choice, you can use the CVS Caremark Mail Service Pharmacy to have your medication sent directly to your home, or you have the convenience of getting your long-term medication at a CVS Caremark pharmacy at the mail-order cost.
When you enroll, you will need to indicate if you are a tobacco user or non-tobacco user by checking the appropriate box online for you and your covered dependents over the age of 18:
Remember, while the Partnership takes your self-elected designation with respect to your tobacco-free status, if it becomes known to the Partnership that you have misrepresented such status, you will be subject to removal from the Partnership's Medical Plans and additional discipline, up to and including termination.
You may fill maintenance medications up to two times at your local retail pharmacy. However, after the second fill, you’ll pay the entire cost of the drug if you continue filling at your local retail pharmacy instead of switching to the CVS Caremark Mail Service Pharmacy or a CVS Caremark retail pharmacy.
Log in to your individual account at caremark.com to view the most up-to-date drug list and check the cost of your drug.
To request a change to your HSA contributions, contact the Benefits Department at email@example.com.
Post-operative care is provided locally when appropriate to avoid additional travel disruption. However, if it is appropriate for a member to have a post-operative follow-up appointment with a SurgeryPlus provider, travel benefits will be provided as needed.
There are several ways to start using CVS Caremark Mail Service Pharmacy:
When filling a prescription drug, your payment will vary depending on which Medical Plan option you choose and the type of the prescription drug.
CDHP: If you are enrolled in the CDHP, certain preventive medications you take on an ongoing basis are covered at 100% before the deductible is met. Otherwise, you will pay the full cost of the drug (at the CVS Caremark discounted rate), until you have met your deductible, then you will pay your portion. Remember, you can also use your HSA card to pay for prescriptions.
PPO: You will pay a $150 per person or $300 family deductible for brand-named drugs. After you have met your deductible, you will pay a co-pay. Generic drugs are not subject to the deductible.
Generic drugs are approved by the U.S. Food and Drug Administration and are lower cost equivalents to brand drugs. When available, generics provide the lowest cost option while remaining just as safe and effective as brand drugs.
Preferred brand drugs that are preferred on the prescription plan and are lower in cost than non-preferred drugs. Non-preferred brand drugs are brand medications that are still covered by the plan but are the most costly option.
Please check caremark.com to see if you may have a generic or preferred brand alternative available for your medication.
Most of the time, yes. If you choose to purchase a brand-name drug instead of a generic alternative, you will be responsible for the difference in cost between the brand-name and the generic, in addition to the coinsurance. So generic drugs will cost less most of the time!
Yes. You can use your HSA funds to pay for Medicare Part A, B, C (Medicare Advantage plans), and D premiums.
The Tria Health Stop Tobacco use by Optimizing Pharmacists (S.T.O.P.) Program can help you or any of your covered family members over the age of 18 kick the tobacco habit. The program provides you with confidential telephone coaching with a Tria pharmacist and other tools and resources.
Visit Tria Health online to or call 1-888-799-(TRIA) 8742 to get started.
It is recommended that you call SurgeryPlus as soon as you learn you may need surgery.
Although you can no longer make contributions to your HSA once you enroll in Medicare, the money that has accumulated in your account remains yours to spend on eligible expenses, including Medicare copays, deductibles, vision and dental expenses.
Go to doctorondemand.com, select AmeriBen and enter the Member ID and Group ID from your insurance card to complete your registration. Then, be sure to download the convenient Doctor on Demand mobile app for on-the-go care.
If you drive a personal vehicle to a SurgeryPlus consultation and/or procedure, you will be given a flat-dollar allowance to cover travel expenses. For distances ranging from 0 – 99 miles, you will receive $25. For 100 – 199 miles, you will receive $50. For distances 200 miles and over, you will receive $100. When travel distance approaches 300 miles or more, airfare is generally recommended. Mileage allowances are loaded to a Swift debit card that you receive in the mail from SurgeryPlus along with your welcome letter. Funds are pre-loaded 48 hours prior to the appointment.
If your spouse is enrolled in Medicare, and you are covering both yourself and your spouse and you on your CDHP, you can contribute up to the IRS family maximum to an HSA in your name. If you are 55 or older, you will still be able to make the $1,000 catch-up contribution.
If travel is necessary, benefits may include airfare, hotel, mileage reimbursement, rental car and a meal per diem of $35 per person ($70 total per day). Your SurgeryPlus Care Advocate will book travel arrangements in advance for you when possible. When this is not a possibility, funds to cover the cost will be loaded to a Swift debit card prior to your travel start date to ensure you avoid unnecessary out-of-pocket spending.
As new drugs are continually coming to market and new generic alternatives being approved, the CVS Caremark drug list is updated to reflect these changes quarterly.
Yes. You need to go to doctorondemand.com and completethe registration process before you can use the service. Also, remember todownload the convenient mobile app for on-the-go care.
Thecost for each virtual visit varies based on the services needed.
Pharmacies will generally give you a generic drug, unless your doctor has asked for a specific brand-name drug. If your doctor has prescribed a brand-name drug (either preferred or non-preferred) when a generic is available, you will pay the difference in cost between the brand-name and generic drug.
If you travel for your surgery, travel benefits are provided until you have been cleared for travel back home by the surgeon. Travel benefits may include hotel and per diem amounts for food for you and your travel care companion.
There are several agencies that can answer your questions. Here are just a few resources that can help with your additional questions:
To help you save money on prescription costs, ask your doctor if there is a generic alternative that would work for you. If a generic equivalent exists, but you are prescribed a brand-name drug (either preferred or non-preferred), you will have to pay the difference in cost between the brand-name drug and the generic drug.
If you are in the PPO plan, you will pay a $150 per person or $300 family deductible on brand-name drugs before the copay will apply.
Yes. A travel care companion is permitted to accompany you for procedures. The travel care companion can be a family member or other individual of the patient’s preference. Airfare, if needed, will be provided as well as the daily $35 per diem for meals loaded to the patient’s Swift card prior to the travel date.
Yes, when necessary for a travel care companion.
For some drugs, a prior authorization from your physician may be required. In these cases, your physician will need to provide proof that the drug being prescribed is the appropriate therapy. Physicians can send prior authorizations to CVS/caremark electronically, via fax or via phone.
For some higher cost drugs, there may be drugs available that are less costly that work the same function as the more costly medication. In these cases, a patient may need to try the lower cost drug before they may “step” to the higher cost medication. Once the member has tried the lower cost drug, they will be able to fill the higher cost drug, if needed.
Quantity limits are usually set for any of the three following reasons: the drug is FDA-approved only for short-term use, it may cause dangerous side effective when overused, or it carries the risk of being inappropriately overused.
In some cases, there may be products that were once only available via prescription, that are now available over the counter. In these cases, our prescription plan would not cover a medication if it is also available over the counter.
A surgeon is welcome to apply to join the SurgeryPlus network. Interested providers must be able to meet contractual and credentialing requirements in order to join the network. A physician can reach out directly by emailing the SurgeryPlus provider team at EDHCProviderTeam@edhc.com or by calling 855-200-2099.
Yes, epidurals are covered as part of conservative pain management services by some SurgeryPlus providers. For more information about this procedure, please reach out to a Care Advocate.
The SurgeryPlus Network includes both Orthopedic Spine Surgeons (must have fellowship training specific to the spine) and Neurosurgeons. Depending on the specific details of the surgery, S+ will recommend the most appropriate surgeon to perform the procedure required.
The ExtraCare Health Card will provide you with a 20% discount on thousands of CVS pharmacy brand health-related items, from cold and cough remedies and vitamins to first-aid supplies and nicotine replacement products.
Yes. Please see the Benefits Guide to learn about step therapy, prior authorization, and drug quantity management.