frequently asked questions

 

 

Are Diabetes medications and supplies covered? How and by whom?

Supplies:
Supplies such as testing strips, syringes, needles, glucometers, etc. are covered in two different ways.

1. You can purchase these supplies at your local pharmacy and then send your bills to POMCO for reimbursement. The method of reimbursement will be to first check your yearly deductible. Once this is satisfied you will be reimbursed at 70% of reasonable and customary.

Or

2. Look for Ancillary Providers in the POMCO providers list. That section will list DURABLE MEDICAL EQUIPMENT. Many of the providers listed will indicate the counties they service. Call them and discuss your needs. They will deliver your supplies to you for a monthly co-pay.

Medications:
Insulin and other medications related to the treatment of diabetes are covered at your local pharmacy or by mail order using your prescription drug card.

 

 

If I have pre-certified for services prior to January 1, 2008, and I am still in treatment, do I have to pre-certify with POMCO?

A: Yes. After December 3, 2007, call POMCO for any service that you would have Pre-certified with Empire, if your treatment will continue in 2008.

 

 

DEDUCTIBLES - MEDICAL AND PHARMACEUTICAL

What are my individual and family DEDUCTIBLES for the Medical and Pharmaceutical programs? When do they begin and end?

MEDICAL - January 1 - December 31

$ 300 Individual, $900 Family

PRESCRIPTION DRUGS - July 1 - June 30

$ 85.00 Individual, $170.00 Family

OUT-OF-POCKET EXPENSES

$1,000 per person and/or family per calendar year, plus deductibles.
When you utilize out of network providers in our program, you often pay a portion of the bill. Once you and / or members of your family have spent $1,000 paying for those portions, you will then be reimbursed at 100% of Usual and Customary.

The potential out-of-pocket expenses incurred by an individual could be $1,300. This includes the annual deductible of $300 and the out-of-pocket maximum of $1000 if the individual used the services of a non-participating provider.

The potential out-of-pocket expenses incurred by a family could be $1,900. This includes the annual deductible of $900 and the out of pocket maximum of $1,000 if the family uses the services of a non-participating provider.

NOTE: This Out-of-Pocket provision does not include any co-payments to participating providers or co-payments for prescription drugs. Additionally, Outpatient psychiatric expenses do not apply to Out-of-Pocket maximum.