IBEW/Western Utilities Health and Welfare Trust Fund
Using the Benefits – Frequently Asked Questions and Answers
Can I refill my prescription online with SavRx?
What are CompuSys of Utah’s office hours?
Is vision therapy covered under the Plan?
Can employees receive a copy of the R&C schedule of benefits for every procedure?
How are injectable drugs reimbursed by SavRx and the medical Plan?
How are R&C (reasonable & customary) charges determined for dental benefits?
What is the medical background and credentials of people working at Dobson & Associates?
How often do the medical and dental networks update their provider lists?
Sealants are known to come off during a lifetime, so why are they covered only once?
What are the Plan benefits for speech therapy?
What is the number of hours required for full-time student status?
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Q If I’m prescribed a brand-name drug because the generic doesn’t work or if I’m not able to take the generic version, how will I be charged? Will my prescription be considered a generic, preferred or non-preferred?
A If you fill your prescription with a brand-name drug when there is a generic available, you will be charged 20% (minimum of $10) plus the difference in cost between the brand and generic drug. No special provisions apply.
Q My child is going to college in a location outside of our service territory (i.e., New Mexico, Texas, etc.) How will his/her claims be paid, as in-network or out-of-network?
A The claim will be considered out of area and reimbursed at the in-network reimbursement level (90%/10%).
Q Can I refill my prescription online with SavRx?
A Yes. SavRx has the capabilities of refilling your prescription via their Web site at www.savrx.com. SavRx must have the original script on file to process your refill request.
Q What are CompuSys of Utah’s office hours?
A CompuSys of Utah is open Monday through Friday from 7:00 a.m. to 4:00 p.m. PST. The office is closed between 11:00 a.m. and noon MST.
Q Is vision therapy covered under the Plan?
A Vision therapy is not a covered benefit under the Plan.
Q How are R&C (reasonable & customary) charges determined? Is it specific to zip code? If there is only one hospital in the area, how is R&C determined?
A R&C does not apply to hospital fees. The Plan pays the semi-private room rate. If rooms are billed as private, the Plan will apply the semi-private room rate for that facility and you will be responsible for the difference in cost. The Plan utilizes the MDR schedule at the 90th percentile for physician, lab, X-ray, etc. expenses.
Q Can employees receive a copy of the R&C schedule of benefits for every procedure?
A A printed copy of the R&C schedule cannot be sent to every employee. However, you may contact CompuSys of Utah with your provider’s zip code, procedure code and the amount that will be billed and CompuSys can tell you if the charge is within the allowable fee or if it’s over R&C.
Q If an employee and spouse are both covered by the Plan as employees, how does coordination of benefits work?
A When an employee and spouse are both covered under the Plan, internal coordination of benefits is done. No paperwork is required by the member or provider(s). The Plan pays as primary carrier on the employee and secondary carrier under the spouse. Example: Employee enrolled under the Basic Medical Plan with a spouse who is enrolled with employee and spouse coverage under the Premium Health Plan. If the employee, insured, who is enrolled in the Basic Medical Plan incurs $1,000 in eligible emergency room expenses at an in-network hospital, the PPO discount would be taken on the bill and the balance applied towards the Basic Medical Plan deductible of $1,500. The claim would then be processed under the spouse’s Premium Health Plan as a dependent. The PPO discount would be taken on the $1,000 emergency room expenses, a $100 co-payment would be applied, and the balance would be reimbursed at 90% of eligible expenses. Primary coverage for eligible dependent children is determined by the birthday rule. The parent whose birthday falls earliest in the calendar year (month and day) is the primary carrier. The parent whose birthday falls later in the year (month and day) is the secondary carrier.
Q How are injectable drugs reimbursed by SavRx and the medical Plan?
A Injectable drugs are reimbursed just as any other drug and according to Plan rules, based on the price paid locally, less the applicable copay. During the enrollment process, new members to the IBEW/Western Utilities Health and Welfare Trust Fund had very good questions to ask on how the benefits plan works and will be implemented. We have gathered those questions and provide the answers for the benefit of all.
Q How are R&C (reasonable & customary) charges determined for dental benefits?
A R&C dental fees are those that are usual, customary and reasonable, as those terms are defined below in a., b. and c.
a). A "usual" fee is that fee regularly charged and received for a given service by an individual dentist, i.e. his or her own usual fee. If more than one fee is charged for a given service, the fee determined to be usual shall not exceed the lowest fee, which is regularly charged, or is offered to patients.
b). A fee is "customary" when it is within the range of usual fees charged and received by dentists of similar training for the same service with the geographic area determined by the carrier to be relevant. A customary fee for a participating dentist is the fee allowed by the carrier in the Participating Dentist Agreement.
c). A fee is "reasonable" if it is "usual" and "customary" or if it falls above "usual" or "customary" or both, but is determined to be justifiable considering the special circumstances or extraordinary difficulty of the case in question.
Q What is the medical background and credentials of people working at Dobson & Associates?
A There are intake coordinators who assist with data entry and gathering of information. Clinical reviews for medical cases are reviewed by Registered Nurses. Psychiatric reviews are done by licensed clinical social workers. They also have a physician review panel with physicians from all specialties to review cases as needed.
Q What will happen if the call for precertification is not made 7 days in advance? Will all services be denied?
A A $200.00 penalty will be assessed if medically necessary services are not precertified. Claims for medical services or supplies that have not been precertified may be subject to retrospective review to determine if they are medically necessary. If the services or supplies are determined to not be medically necessary, no benefits will be provided by the Plan.
Q How often do the medical and dental networks update their provider lists?
A Delta Dental updates their Web site every week. Only when a provider’s office contacts them about a retired or deceased physician do they update that information. Each year they “clean-up” the Web site to keep the files as accurate as possible. First Health Network sends updates monthly to the Administrative Office.
Q Sealants are known to come off during a lifetime, so why are they covered only once?
A Sealant benefits do not include the repair or replacement of a sealant on any tooth within 3 years of its application.
Q If someone already has been referred for allergy services under another plan, do they need to get a physician referral again under this Plan?
A No referrals are required under this Plan. CompuSys of Utah advises members to utilize a PPO provider to maximize benefits.
Q If an individual is seeking assistance for fertility and a physician discovers endometriosis, which can be a severe medical problem, will the Plan cover this treatment since many types of infertility problems are health-related problems for a female?
A If the diagnosis is endometriosis, treatment for this condition would be eligible under the Plan. Any charges for infertility would be excluded per the Plan document.
Q When a surgical procedure is done on the spot during the examination due to concerns that the condition may be more complicated, am I expected to get preauthorization from my insurance before proceeding?
A In-office surgical procedures do not require preauthorization/precertification.
Q If I use mail order and pay the $10 copay for generic prescriptions, am I still subject to the deductible?
A Yes, the deductible of $75/individual, $150/family applies to brand-name or generic drugs, both retail and mail order.
Q What are the Plan benefits for speech therapy?
A Speech therapy is a benefit if the loss was due to an injury or illness. Refer to pages 39-40, R #5 of the Summary Plan Description. Speech therapy is not a benefit if services are not to restore loss.
Q What is the number of hours required for full-time student status?
A A student must be enrolled status for at least 12 credit hours of classes.