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 Empire Blue Cross Blue Shield 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 your Empire Blue Cross Blue Shield Directory. 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.

 

 

ANESTHESIA

I use a participating doctor and a participating hospital. Why am I receiving separate bills from an anesthesia provider?

Prior to January 1, 1997, most anesthesia bills were covered as part of your hospital charges. Changes took place after this date when the State deregulated the hospitals. Many providers such as anesthesiologists privatized. They continue to provide for the hospital, but chose not to participate with insurance companies. Therefore, they send you a separate bill using their own corporate stationary. If this happens to you, send the bill to SWSCHP / Empire Blue Cross Blue Shield and you will be reimbursed based upon the satisfaction of your yearly deductible and then at 70% of reasonable and customary. This arrangement will end December 31, 2007 when POMCO becomes the hospital and medical claims administrator because POMCO participates with these anesthesia providers.

 

 

What should I do if I am presently involved in an active course of treatment with an Empire provider that may continue past December 31, 2007?

A: Check with your provider to see if he/she participates with the POMCO/MULTIPLAN/PHCS ALLIED NETWORKS.

If the provider participates, be sure to give your new cards to the office staff so services received on and after January 1, 2008 will be billed to POMCO. You will be only responsible for the $20.00 co-pay and subject to applicable plan benefits.

If the provider does not participate click Recruit a Provider, fill out the form and send it to:

POMCO
2425 James Street,
Syracuse, NY 13206

POMCO will contact your provider and invite your provider to join the network. You also can ask your provider to call POMCO Provider Services Department, 800-766-2687. Should that not be successful, you will continue to receive an in-network level of benefits for a limited period of time. Contact us for additional information if necessary. Thereafter, it will be necessary to find a participating provider or continue with your present provider with the understanding that your claims will be paid as out-of-network. Claims out-of-network will be subject to the annual $300 deductible and thereafter paid at 70% of UCR (usual, customary and reasonable).

 

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.