COLORADO WHC FAQs (Updated 9/27/16) Q. How are compounded prescriptions covered? Are there any exclusions? Compound drugs are covered when a commercially available dosage form of a Medically Necessary medication is not available, all the ingredients of the compound drug are FDA-approved and require a prescription to dispense, and is not essentially the same as an FDA-approved product from a drug manufacturer. Ingredients that are not FDA-approved, such as bulk chemicals, re-packaged powders, and pharmaceutical adjuvants are not covered. We encourage you to contact Anthem member services to discuss your specific situation. This applies to both plans. NOTE: For all other pharmacy-related questions, please refer to the Anthem Pharmacy quick link on the Reimagine Your Health website. Q. If I enroll in the WHC plan and have my HCA balance transferred to that plan, would it move back to the OneWoodward plan should I decide to switch back? If you switch back to the OneWoodward plan, your HCA (called HRA effective 1/1/2017) does not transfer back. The One Woodward plan would start with a new HRA account. As previously noted, there is no HRA affiliated with the WHC Plan. However, if you choose the new WHC Plan, and you have funds remaining in your HRA at the end of 2016, that balance will move with you to the new plan to use toward any out-of-pocket expenses until there is a zero balance. The account balance will automatically transfer to the WHC Plan on March 3, 2017, and no additional HRA funds will be added. Q. If my spouse is on Medicare, how will the new plan work? Generally, as an active covered member with a spouse over 65 (Medicare Eligible) the Woodward plan(s) will be primary and Medicare would be secondary. Anthem will coordinate benefits with Medicare as required by federal law. This is the same for both Woodward plans. Q. For college students who areaway and can t get to the WHC the first of year--could they do phone consultation for their initial visit and then be referred to local doctor in their area? No, the student would need to schedule an appointment with the WHC when they are in the area to establish care. To reiterate, once your child (ie. college student) has established at the WHC, his or her urgent and emergency care will be covered at the referred benefit level. In some instances services for chronic conditions (like diabetes) being treated by your dependents' WHC physician may be referred while they are temporarily away. It is important to work with your physician and care coordinator on details specific to your child's care. Q. If I go to the ER and am admitted, do I pay both copay s? Once admitted, are there co-pays for services such as MRI, CT scan, etc.? No, if you are admitted to the hospital from the ER, only the inpatient hospital co-pay would apply; no additional co-pays for other services during the hospital stay.
Q. Can I still go to Walgreens or CVS for my prescriptions, or are they all mail order with Express Scripts? Walgreens and CVS pharmacies are in-network, and you may continue to use them for your covered prescription drugs. Your retail prescription drug benefits will apply. Please note, you will need to use the home delivery/mail order program if you would like a 90-day supply of your medication, as is the current policy with the OneWoodward plan. Q. What is the definition of minor surgery within the WHC? Minor surgical procedures that are performed in the WHC are limited to the physician s discretion and may include small procedures such as lesion removals and limited skin biopsies. Q. Will the WHC clinic be able to treat an illness similar to other immediate care clinics? For example: if I go in for a sore throat, need a strep test and medication prescribed, will that be covered at the WHC? The WHC is a full functioning primary care clinic that will provide many services including those listed above. There will be a lab and x-ray department on-site to order necessary testing for members. We will also have a limited number of acute medications available for dispensing at the time of the visit. Q. Will preventive routine colonoscopy be covered at 100% both under WHC and OneWoodward? Or would the specialist copay, advanced radiology copay, or, under OneWoodward, 90% coverages apply? Yes, preventive routine colonoscopy will be covered at 100% under both plans when you use in-network providers. The OneWoodward plan also covers the preventive at 100% when you use in-network providers. Q. For allergy treatments, will a new referral need to be made before I can get ongoing allergy treatment? Yes, as with all current treatment plans once you select a WHC primary care physician they will talk with you about your pre-existing condition and the current specialist you are seeing. Your PCP will determine if the specialist is within the network. If so, and if the referral is for a chronic condition, the referral can be issued by your PCP for a timespan vs. needing to have a referral for each visit. Q. What are the mental health benefits and how will that care be coordinated? Does the PCP need to drive that? Mental health services are covered, including office visits, inpatient care, and outpatient care. Please refer to the plan summary for the mental health benefits. The WHC would need to be contacted for the referral for mental health services. Q. How is Physical Therapy covered under the WHC? Outpatient physical therapy is covered with a $30 Specialist Co-pay with a referral from the WHC. Q. If a member is pregnant and due in 2017 and her doctor has asked for full payment of the deductible at the time of diagnosis, how will this be transitioned to the WHC as now she has overpaid? We encourage you to discuss the situation with your doctor and ask if they will submit a new claim to your new plan in 2017.
Q. How are preventive drugs, such as diabetic supplies, covered under the WHC? Both plans have the same PreventiveRX coverage. You can find the plan summary when you select choose/plan comparison under the Reimagine Your Health website. Also, refer to the Anthem Pharmacy quick link for the list of covered preventive drugs and diabetic supplies. Q. Are all doctors within an in-network specialty clinic automatically part of the network? The answer depends on how that doctor bills their services and how they are contracted with Anthem. For example, some doctors may operate out of a clinic but bill their services to Anthem through a direct contract between the doctor and Anthem (instead of the clinic and Anthem). We encourage you to use the Find a Doctor or contact Anthem Member Services to confirm if the doctor or clinic is in-network. Q. How long will it take for referrals to be issued? Is there a time line? Typically, if a provider is seeing a patient in the office, and a referral is needed, it will usually be initiated that day. The commitment on the part of the WHC staff is to assist and simplify the entire referral process to make it as easy as possible. Q. What is covered under the outpatient surgical copay of $200? Is this similar to inpatient where the copayment covers the facility claim and then the ancillary fees for surgeon, pathology, assistant surgeon and radiology are covered at 100% with a referral? The $200 co-pay applies to the surgical facility claim. Claims for the surgeon, pathologist, assistant surgeon and radiology are covered at 100% with a referral. Q. How many Care Coordinators will be assigned to Woodward? Will there be a CC at each AFM location or is this a separate contact from each office? AFM has Care Coordinators at all of our locations that serve our entire population of patients. Q. Are any Mayo Clinic doctors in either of Woodward s networks? We encourage you to use the Anthem Find a Doctor feature. Instructions for the WHC Anthem Pathway Network and OneWoodward Anthem National Blue Card PPO Network are provided on the Reimagine Your Health website under the Choose tab. Q. How is pre-natal care covered through the Women s Clinic? Since this is generally a one-time charge for all visits, is it a separate $30 copayment for each visit? What if this charge is part of the full amount charged up front upon diagnosis? Prenatal care office visits at covered at 100% with a referral. If the OB/GYN global bills and charges the full amount for their services upon diagnosis, that is also covered at 100% with a referral.
Q: What will happen to my health club membership through the Blue Cross Blue Shield Fitness Program? And will there be a new Fitness Program available through Anthem Blue Cross Blue Shield? The Blue Cross Blue Shield Fitness Program will expire at midnight on December 31, 2016. The final withdrawal from your account will be in December. If your current deduction is withdrawn on the 20 th of December, you will have until January 20 th to still use the gym. We are still investigating the wellness programs that will be available in January, 2017. Q. What will happen to the Blue Points I have accumulated? A. Members should redeem their Blue Points prior to midnight on December 31, 2016. After midnight on the 31 st, members will no longer have access to Well on Target and will not be able to log into the portal to redeem. Note: The remaining FAQs (below) are those originally posted 8-30-16. Q. If we have college students out of state, how would coverage for them work if we wanted to utilize the WHC plan? If you enroll in the Woodward Health Center (WHC) plan, your dependents must select a Primary Care Provider (PCP) and obtain their primary care services from the WHC. If your dependent is not currently living with you (eg. college student) their urgent and emergency care will be covered at the referred benefit level. In some instances services for chronic conditions (like diabetes) being treated by your dependents' WHC physician may be referred while they are temporarily away. It is important to work with your physician and care coordinator on details specific to your child's care. Q. Can I enroll in one plan and enroll my dependents in another? No, enrollment is one plan per family. Q. Please clarify who UC Health is, Associates in Family Medicine (AFM) and how Anthem fits into it all. The eight WHN locations are all AFM locations and staffed by AFM physicians and clinical staff. UCHealth is providing occupational health services, lifestyle health services for chronic conditions, as well as referral and authorization assistance to the AFM primary care providers. The provider network is Anthem's Pathway Network, and Anthem is providing claims and customer service support to Woodward members. Q. Are there separate networks for the two health plans? Yes. If you select the WHC benefit plan, you would be using the Anthem Pathway provider network. If you select the One Woodward benefit plan, you would use the Anthem National PPO provider network. Q. How does The Women s Clinic fit into the UCHealth plan for Colorado? The Women s Clinic is part of the UCHealth/Anthem Pathway Provider Network panel, and Woodward members can access The Women s Clinic for annual, well-woman exams with no referrals or cost.
However, the Women s Clinic is not one of the designated WHCs. If you select the WHC plan, you will need to choose a primary care physician from one of the designated WHC locations. Then, if needed, your WHC primary care provider will refer you to The Women s Clinic provider and the appropriate benefit level will apply. (Refer to WHC Plan Summary for details). Q. If I go to my OBGYN for my annual physical and a mammogram is ordered how is that coordinated with the WHC? If your OBGYN is within the Anthem Pathway network, you would go for your annual physical and mammogram as you normally would and there will be no copay or financial responsibility for you as the member as these are preventive, routine services. If it is determined that additional care needs to be rendered, or further testing is required, you would need to coordinate the additional care with your WHC PCP. Q. What is the cost to have a baby within the WHC plan? On the Woodward Health Center plan, if the member obtains a referral from WHC to In-Network providers, the member coverage and cost-share for having a baby are as follows: -Prenatal and postnatal visits are covered at 100% -Inpatient hospital delivery - $300 copay per admission -Anesthesiologist services are covered at 100%. Q. If I go to an AFM clinic that is not listed as one of the WHC s, will services still be covered at 100%? The plan services delivered within one of the designated WHC locations are covered at 100%. If a Woodward member self-directs (meaning does not obtain a referral from the WHC) and goes outside for services (other than emergency services), the services delivered outside of the WHC will be covered based on the Non-Referred In-Network or Non-Referred Out-of-network level of benefits. Q. If I enroll in the new WHC plan do I have to see one of the Primary Care Physicians listed on the website? Yes, all 32 AFM primary care providers at the designated WHC s are available for selection by Woodward members and dependents under the WHC plan. As we get closer to Open Enrollment you will have the opportunity to select your Primary Care Physicians. Q. I live-in Windsor, CO and would have my PCP in Windsor. But I work in Fort Collins. Can I still use the WHC on Lemay Ave. if needed? Yes, the first step is to choose your primary care physician within one of the eight WHC locations. You may use any WHC primary care provider or location based upon where you are at the time of requiring services. Q. Can you use any of the providers at the AFM facilities on the list, or only those providers listed on your website? There are other PA-C providers at these sites; can you only use MD s at these locations?
The WHC plan requires selection of a primary care physician (eg, MD) within one of the eight AFM WHC locations. AFM has 32 primary care physicians as well as a supporting clinical team that you may access for your care, including physician assistants, nurse navigators, and health coaches. Q. Ultimately there is absolutely no cost to the member or dependents if they go to the WHC and rack up $10,000+ worth of services, correct? Correct. If you use the WHC exclusively you are covered 100%. However, there may be some "referred services" available at a WHC location. Your care coordinator will help you determine if there are out-ofpocket expenses associated with such services. Q. Please explain in more detail the term Non-Referred In Network (Anthem) / Out of Network. If you need medical services that cannot be provided within the WHC, you will need to contact the care coordinator to obtain a referral in order for that claim to be covered at the "referred" level of benefits. If you choose to self-direct (not obtain a referral), then the "non-referred" level of benefits will apply. Examples of services that need a referral include: office visits to specialist providers such as physical therapy and speech therapy, inpatient hospitalization, outpatient surgery, durable medical equipment, lab services, X-rays, imaging services (MRI, CT, MRA), prosthetics, private duty nursing, and home health care. Q. What is covered under the inpatient hospital (per admission) copay of $300? The inpatient hospital copay covers the inpatient facility claim. Ancillary fees from surgeon, pathology, assistant surgeon and radiology are covered at 100% with a referral. Q. Can we get allergy shots at the new Woodward Health Center? If we can, do we need to make an appointment. Allergy shots are not done at the WHC; your PCP will provide you with a referral to an allergist. If your provider does not bill an office visit with the allergy shot, then you will not have a $30 copay. However, if the provider bills both an office visit and allergy shot, then the $30 copay will apply to the office visit (if you have a referral to that provider). The referral can be issued by your PCP for a timespan vs. needing to have one for each visit. The care coordinator can assist with determining how your specialist will bill for ongoing injections administered by a nurse. Q. If we have a pre-existing condition that we are already seeing a specialist for on a regular basis do we need to get a referral from the Woodward Health Center for each visit? Once you select a WHC primary care physician they will talk with you about your pre-existing condition and the current specialist you are seeing. Your PCP will determine if the specialist is within the network. If so, and if the referral is for a chronic condition, the referral can be issued by your PCP for a timespan vs. needing to have a referral for each visit. Q. Will Anthem offer a fitness program discount like Blue Cross Blue Shield of IL (where we pay $25 per month and get access to several gyms around town)?
The Fitness Program is specific to BCBSIL and not offered through Anthem. However, as an Anthem member, you will have access to the SpecialOffers@Anthem program, which includes discounts on fitness centers. You will be able to register and login to your Anthem secure portal for more information on this discount program. Q. How are chiropractic visits covered? You do not need a referral for chiropractic services with the WHC plan. The copay is $15 per visit as long as you remain in-network. Q. My child s pediatrician is in the UCHealth network, but not with the Youth Clinic or with AFM. Can I get a referral for my child to continue seeing them since they ve been going there for their entire life? The WHN plan requires that your child's care be rendered either within one of the eight WHC locations or by the Youth Clinic. If you choose to remain with your child's current pediatrician, those services would be covered at the non-referred WHN benefit level. Q. When being referred to a specialist, will I be able to choose the doctor or am I limited to the doctor you refer me to? You are encouraged to discuss your preference with your WHC primary care provider. If the specialist you prefer is within the Anthem Pathway network, your WHN primary care provider will ensure that is where you are directed for specialty care. Q. Does the WHC plan cover services when travelling/vacations? Emergency and urgent care are covered and do not require a referral. (See Benefit Plan Summary) Q. Will there be more Woodward Health Centers to go to in the future? We will closely monitor the needs of the Woodward member population in terms of WHC locations and will regularly evaluate expansion opportunities to ensure we are providing comprehensive coverage through our locations. Q. Are you making changes to the Woodward 401(k) matching contribution or Woodward Stock contribution as part of this change? No, we are not making any changes to the Woodward 401(k) matching contribution or Woodward stock contribution. We see both of these components key to Woodard s overall total rewards strategy for members.