The following benefit changes will affect State, Non-State and Non-Medicare Retiree members and their enrolled dependents beginning July 1, 2016.
- Deductibles and Out-Of-Pocket Maximum amounts are increasing for all plans. See the premium charts on pages 28-31 of Shopper’s Guide for details.
- Medical Home office visit copayment increases to $20 per visit for PEIA PPB Plans A, B and D.
- Urgent Care copay increases to $50 for PEIA PPB Plans A, B and D.
- For Comprehensive Care Partnership (CCP) Program members, ANY non-CCP office visit now requires the $40 specialist office visit copay.
- The Face-2-Face Diabetes Program will be limited to two years. Current F2F members will be permittedtwo more years of services starting July 1, 2016, as long as they continue to meet the other requirements of the plan.
- PEIA PPB Plan B benefits reduced to 70/30 for all services that require coinsurance. Member coinsurance will be 30% after deductible.
- All out-of-state (including contiguous counties), in-network services require 30% coinsurance in PEIA PPB Plans A, B and C.
- Out-of-state, non-network services are no longer covered in any of the PEIA PPB Plans. Patients will be responsible for 100% of billed charges from non-network providers outside West Virginia, except in a medical emergency or when approved in advance by HealthSmart. PEIA PPB Plan members who reside more than one county outside of West Virginia may use in-network providers where they live without prior approval from HealthSmart, as long as PEIA has been notified of your residential address.
- Facility- fee limits for select facility-based services. If the member chooses a facility that charges more than
the PEIA facility fee limit, the member will be responsible for the difference between PEIA’s payment and the facility’s charge. See page 13 of Shopper’s Guide for details.
- Additional emergency room copay of $500 for high-risk behaviors, such as:
- Accidents while driving motorcycle or UTV/ATV without a helmet
- DUI/DWI or drug -related accidents
- Failure to wear seatbelt(s)
- Prescription deductibles and out-of-pocket maximums are increasing for all PEIA PPB Plans.
- Preferred brand drugs and non-preferred Specialty drugs will require 30% coinsurance for PEIA PPB Plans A, C and D; 35% for Plan B.
- Opioid pain medications will have a quantity limit (QL) of 540 units per 180 days for all medications in the opioid class. Additional quantities require Prior Authorization.
- Provider reimbursements will be reduced to 100% of the Medicare allowance over the next three (3) years.