Take 2 - Spring 2000 - Volume XIII, No.1

 

Long-Term Care Insurance Begins May 1

This is a reminder that enrollment in the new Long-Term Care Insurance Plan, underwritten by the John Hancock Mutual Life Insurance Company, begins May 1, 2000. If you enroll before June 30, 2000, you may qualify for coverage by answering only two medical questions.

Purchasing long-term care insurance is completely voluntary. While the Health Plan will not be paying for the cost of this coverage, Participants will get the benefit of group rates and less stringent underwriting requirements.

Eligibility

All Health Plan Participants are eligible for long-term care insurance, as well as the Participant’s:

  • spouse;
  • surviving spouse;
  • qualified same-sex domestic partner;
  • parents, grandparents, parents-in-law and grandparents-in-law.

Long-term care insurance is coverage that helps to protect you against the costs associated with extended health care situations, such as an accident, a long-term illness or the effects of aging. This insurance covers care at home, in a qualified adult day care center, residential care facility, or nursing home. Call John Hancock Customer Service toll free: 1-800-828-3823 for more information on this new plan.

Attend a Long-Term Care Insurance Workshop

Representatives from the SAG - Producers Health Plan and the John Hancock Insurance Company will offer two workshops on the new program. Please join us.

New York:

  • April 10, 2000 at 6:00 p.m.
    Hilton New York
    Beekman Parlor
    1335 Avenue of the Americas (at 53rd St.)
    New York, NY 10019

    Los Angeles:

  • April 18, 2000 at 3:00 p.m.
    DGA Auditorium
    7920 Sunset Boulevard
    Theatre #2
    Los Angeles, CA 90046

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    New Phone Number for Prescription Pre-Authorizations

    (800) 841-5345

    Commencing April 1, 2000, all prescription drug pre-authorization requests should be made by your doctor directly to Merck-Medco Managed Care at (800) 841-5345. Requests for pre-authorization for prescription drugs are currently made by calling the Burbank Plan Office.

    Under the PAID Prescription Drug Program, eligible Participants can fill most prescriptions at a participating retail pharmacy simply by showing their PAID Prescription I.D. card and paying the appropriate copayment. However, certain drugs require pre-authorization from Merck-Medco Managed Care before they are considered for payment.

    Drugs requiring pre-authorization are listed below:

    Drugs requiring Pre-Authorization:

    • Adderall
    • Celebrex
    • Desoxyn
    • Dexedrine
    • Dextrostat
    • growth hormones
    • Immunoglobin
    • Lotronex
    • Lutrepulse
    • myeloid stimulants - Neupogen, Leukine and Neumega
    • Proleukin
    • Provigil
    • Vioxx
    • Relenza - pre-authorization for refills only
    • Tamiflu - pre-authorization for refills only

    How Do I Obtain Pre-Authorization?

    To obtain pre-authorization, simply have your doctor call Merck-Medco Managed Care at (800) 841-5345. In some cases, pre-authorization can be given immediately over the telephone.

    In other cases, additional information may be required from your doctor. However, the pre-authorization process should be completed within 24 to 48 hours.

    Once received, pre-authorizations are valid for six to twelve months, depending on the drug being authorized. During this time, you can receive your prescriptions at a retail pharmacy or from the mail service pharmacy.

    Why Does The Plan Require Pre-Authorization?

    In some cases, pre-authorization is required because of limits on the Plan's coverage. For example, the Plan specifically excludes coverage for weight loss. Dexedrine can be prescribed for weight loss as well as for Attention Deficit Disorder. Since the Plan will not cover the cost of Dexedrine when prescribed for weight loss, pre-authorization is required to determine why your doctor is prescribing it.

    In other cases, pre-authorization is required because of FDA approval limits on the drug itself. The Plan specifically excludes coverage for drugs which are not FDA approved for the treatment rendered. As an example, Celebrex has been approved by the FDA only for the treatment of osteoarthritis, rheumatoid arthritis and Familial Adenomatous (rare condition of polyps). Since the Plan will not cover the cost of Celebrex when prescribed for anything other than these diagnoses, pre-authorization is required to determine the reason your doctor is prescribing it.

    If you have any questions about the pre-authorization procedure, please call the Plan Office or Merck-Medco Managed Care.

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    Prescription Co-payment Update

    This is a clarification of the $35 maximum co-payment per retail prescription which became effective October 1, 1999.

    The $35 maximum co-payment does not apply if you request the prescription be filled with a brand name drug when a generic is available. If your doctor has not indicated "DAW" (dispense as written) on the prescription and you request that the pharmacist fill the prescription with a brand name drug when a generic is available, you are responsible for the difference in price between the generic and brand name

    prescription, plus the regular co-payment without the $35 cap.

    For example: Your doctor gives you a prescription for a brand name drug for which a generic is available and your doctor does not indicate DAW on the prescription. If you request the pharmacist to fill that prescription with the brand name drug instead of the generic the $35 co-pay maximum does not apply. Your co-payment is the cost difference between the generic drug and the brand name drug, plus the greater of $10 or 20% of the cost of the generic prescription.

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    Eligibility for Terminal Illness Benefit Amended

    The "recent service test" is no longer an eligibility requirement for the Terminal Illness Benefit. The recent service test required you to have at least one year of Pension Credit in the six calendar year period preceding your Total Disability. This Pension Plan change is effective immediately.

    The Terminal Illness Benefit is available to non-retired Participants who are Totally Disabled and have less than one year to live. It provides a lump sum payment equal to one-half of the pre-retirement death benefit that would be payable upon your death.

    You are eligible for a Terminal Illness Benefit if you meet all the following conditions:

    1. You are younger than age 65;
    2. You have at least 10 years of Pension Credit;
    3. You are Totally Disabled and Terminally Ill, as defined by the Plan.

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    Are You Getting the Most from RAP Providers?

    If a network physician refers you to a non-network Radiology, Anesthesiology or Pathology (RAP) provider, you should get the network level of benefits for the RAP claims. When the Plan Office receives a claim from a non-network RAP provider, we do not always know whether you were referred by a network or non-network doctor. That means we will pay the RAP benefits as non-network unless you let us know you were referred by a network doctor. This also applies if you receive services as an inpatient or outpatient at a network hospital or facility. Be sure to check your EOB’s carefully so that you will receive the highest level of reimbursement.

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    In Memory

    Marshall Wortman, 1918 - 1999

    It is with great sadness that we say goodbye to Marshall Wortman who passed away on December 13, 1999, from cancer.

    Mr. Wortman served as a Trustee of the SAG-PPHP since 1963, and actively participated on several Board of Trustee Committees. Mr. Wortman was the Chairman of the Board of Trustees for 1996 and 1997.

    Mr. Wortman provided over 35 years of service to the Pension and Health Plans and the Participants they serve. Mr. Wortman will be greatly missed.

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