Q. My claims are the result of an accident. Do you need special information to process my claims?
A. If you have an accident, we need to know how, when, and where the injury occurred. We also need to know if there is another insurance policy that might cover this claim, such as an auto, workers compensation, or homeowners policy. Complete the accident form (LG199) and fax it to our office at 309-346-8265.
Q. How do I file my claims?
A. Your doctor or hospital normally will submit your claims to us for you. You will not need to do anything as long as you have provided them with your health insurance identification card at the time you received the service.
Drug claims are submitted by using your drug card when you purchase prescriptions. Your participating pharmacist electronically files the claim with the drug card company. If you do not have your drug card with you when you purchase a drug, you will need to get your drug card information to the pharmacy where you purchased the medication within 7 days of purchasing the medication so that the claim can be filed.
Q. Do I need to pre-certify or receive prior approval for any services?
A. You are only required to pre-certify an overnight stay in a hospital. You can do this by calling MCM’s pre-certification line at 800-245-3005. You should pre-certify a scheduled stay at least 48 hours before admission to avoid a penalty and to confirm your stay is approved. For emergency admissions, you must call the pre-certification line within two business days after admission.
Calling the pre-certification number does not confirm health care coverage for your stay or that the provider is a PPO provider. It simply establishes if the length of the overnight stay in the hospital is medically appropriate.
You will need to receive prior approval before purchasing or renting any medical equipment. You can do this by contacting our case management nurse at 800-371-9622, Extension 2782. The nurse will refer you to a cost-effective vendor if the item is a covered expense under your health insurance policy.
You will also need prior approval for any injectable medications other than insulin. You should call 800-371-9622, Extension 2782, for a vendor for these items.
Q. How can I get my prescriptions filed with the drug card company since I didn’t have my card with me when I purchased my drugs?
A. If you did not have your drug card with you when you purchased a drug, you will need to get your drug card information to the pharmacy where you purchased the medication within 7 days of purchasing the medication so that the claim can be filed electronically. Any delay past 7 days may result in the medication not being covered.
Q. Why does my prescription cost less if I don’t use my drug card?
A. Your prescription drug card program provides the lowest cost available for the prescription. It should never cost less by not using your drug card. If the pharmacist has told you this, please call us at 800-371-9622, Extension 3281, and let us know so that we can educate the pharmacist on the proper way to submit your claim to the drug card company. The price you pay is always the lower of the drug card company contracted rate or the lowest price the medication is selling for in the pharmacy that day.
Q. Will my health insurance policy pay for a brand medication if there is a generic equivalent available?
A. Your health insurance policy will not pay for a brand medication if a generic equivalent is available. If you choose to purchase the brand medication, the difference in cost between the brand medication and the generic medication will not be covered. You will have to pay that amount out of your pocket in addition to any other deductible or copay amounts that would be due.
Q. Why would I want to purchase prescriptions through mail order instead of through a local pharmacy?
A. Your health insurance policy will only allow you to purchase the lesser of a 34-day supply or 100 unit doses at a time through a local pharmacy. If you need to purchase larger quantities than this, you will need to use mail order where you can purchase up to a 90-day supply. For most medications, mail order prices are less expensive than retail pharmacy prices. Some generics may not be less expensive. You can always get a price quote from mail order before ordering to confirm any savings.
Q. When can I get my medication refilled?
A. You can refill your medication at a local pharmacy after you have used 75% of the medication as prescribed. You can refill at mail order once 60% has been used as prescribed. You need to make sure you reorder a mail prescription early enough for it to get to you before your medication is all gone.
Q. Can I get my medication refilled early since I’m going on vacation?
A. Call us at 800-371-9622, Extension 3281, for a vacation override. You will need to provide us with the names of the drugs that need an early refill. We will perform the override, and you should be able to get the drugs refilled anytime within the next three days.
Q. How do I request an additional or replacement drug card?
A. Call us at 800-371-9622, Extension 3281, and we will order you a new card. The card will be mailed to you at your home.
Q. How can I find out the amount a prescription will cost?
A. This information is available through the website www.magellanrx.com under Members then Member Login. You can also call MagellanRx at 800-424-5828.
Q. Why am I being told I have to try a different medication than the one ordered by my doctor?
A. Your medication is on a list of medications that are part of the step therapy program. Step therapy requires you to try therapeutically equivalent but more cost-effective medications before the more expensive medication is approved. This saves both you and your employer premium dollars and out-of-pocket expense. If you have already tried the other recommended medication and it did not work for you, your physician can file a request for a medically necessary override. Your physician can call MagellanRx at 800-424-5828 to start the prior authorization process.
Q. What is an optimum dose amount?
A. This is the dosage amount that provides the same therapeutic effect in the least expensive format. Pills are usually priced on a per pill basis. Often, you can take one pill per day in a higher dosage amount, instead of two pills, with the same therapeutic result for half the cost. If one pill per day will work, your health insurance policy will not cover two pills.
Q. How can the drug card company tell me I can’t get my medication?
A. The drug card company is not telling you that you cannot get a medication. The drug card company is telling you that if you decide to obtain a medication that they will not approve, then you will have to pay for it out of your own pocket. It is your decision if you wish to purchase a medication that is not covered by your health insurance policy.
Medicare Supplement Insurance
Q: What is a Medicare Supplement plan?
A: Medicare Supplement insurance plans help cover the health care costs that are left unpaid after Medicare Parts A and B pay their portions of your health care costs. Medicare Supplement policies pay only for services Medicare considers medically necessary. Payments are generally based on the Medicare-approved charge. The policy might not fully cover all of your health care costs.
Medicare Supplement policies are available from private health insurance companies. While the costs of these policies may vary, individual health insurance companies must provide the same standardized benefits.
Q: What Medicare Supplement plans does Pekin Insurance offer?
A: Pekin Life Insurance Company offers Medicare Supplement Plans A, F, High Deductible F, and G. Plan offerings vary by state.
Wisconsin does not offer the standard alphabetized Medicare Supplement plan menu. The Wisconsin plan is a base plan with optional benefit riders that can be added.
Q: Am I eligible to purchase a Medicare Supplement plan?
A: If you’re enrolled in Medicare Part A and Part B, you’re probably eligible to buy a Medicare Supplement policy. During your Medicare Supplement Open Enrollment Period – for people 65 or older, that’s six months after you sign up for Medicare Part B – a health insurance company must allow you to buy any Medicare Supplement plan offered. In some states these plans may be available to those under age 65 who are in an Open Enrollment period.
Q: Do I have to use certain doctors with my Pekin Life Insurance Company Medicare Supplement Plan?
A: No. With a Medicare Supplement plan, you have the flexibility to choose any doctor or hospital that accepts Medicare.
Not connected with or endorsed by the U.S. government or the federal Medicare program. The purpose of this communication is the solicitation of insurance. Respondents will be contacted by a Pekin Life Insurance Company agent.
This policy has (exclusions) (limitations) (reductions of benefits) (terms under which the policy may be in force or discontinued). For cost and complete details of coverage, call (or write) your insurance agent or company (whichever is applicable).
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