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Summary Plan Description PPB Plan A,B & D PEIA Summary PlanPPBPlanA B D2019.pdf 1 5/20/19 8:59 AM Public Employees Summary Plan Description Insurance Agency 601 57th Street, SE / Suite 2 PPB Plan A,B & D Charleston, WV 25304-2345 Plan Year 2020 July 1, 2019-June 30, 2020 C M Y CM MY CY CMY K i Notice to PEIA Enrollees Concerning Election for Plan Exemption from Certain Federal Requirements Group health plans sponsored by state and local government employers must generally comply with federal law require- ments in the title XXVII of the Public Health Service Act. However, these employers are permitted to elect to exempt a plan from the requirements listed below for any part of the plan that is “self-funded” by the employer, rather than provided through a health insurance policy. PEIA has elected to exempt the PEIA PPB Plans from item two of the fol- lowing requirements: 1. Protection against limiting hospital stays in connection with the birth of a child to less than 48 hours for a vaginal delivery, and 96 hours for a cesarean section. 2. Protections against having benefits for mental health and substance-use disorders be subject to more restrictions than apply to medical and surgical benefits covered by the plan. 3. Certain requirements to provide benefits for breast reconstruction after a mastectomy. 4. Continued coverage for up to one year for a dependent child who is covered as a dependent under the plan solely based on student status, who takes a medically necessary leave of absence from a postsecondary educa- tional institution. The exemption from these federal requirements will be in effect for the 2020 plan year, beginning July 1, 2019 and end- ing June 30, 2020. The election may be renewed for subsequent plan years. Medicare Part D Notice If you (and/or your covered dependents) have Medicare or will become eligible for Medicare in the next 12 months, a Federal law gives you more choices about your prescription drug coverage. Please see page page 101 for details. Summary of Benefits and Coverage Want to compare all of the plans offered by PEIA? There’s an easy way! Go to www.wvpeia.com and click on Mem- bers, then Active Members, then scroll down to choose the “Summary of Benefits and Coverage” link. This link allows you to enter a bit of information and receive customized comparisons of the PEIA PPB Plans. If you don’t have internet access, you can call PEIA’s customer service unit at 1-888-680-7342 and we can generate the SBCs for you! PEIA PPB Plan C PEIA also offers an IRS-qualified High-Deductible Health Plan (HDHP) which we call PEIA PPB Plan C. For information about Plan C, download the Summary Plan Description (Plan C) at www.wvpeia.com or call 1-888-680-7342. ii Contents Introduction ...................................................................................................................................... 1 Who to Call with Questions.............................................................................................................. 2 Terms & Definitions .......................................................................................................................... 3 What PEIA Offers ............................................................................................................................. 9 Eligibility and Enrollment for Active Employees ............................................................................. 10 Eligibility and Enrollment for Retired Employees ........................................................................... 15 Eligibility and Enrollment for Surviving Dependents ...................................................................... 21 Special Eligibility Situations ........................................................................................................... 22 Leaves of Absence ......................................................................................................................... 24 Other Eligibility Details ................................................................................................................... 26 Qualifying Events ........................................................................................................................... 26 Your Responsibility to Make Changes ........................................................................................... 27 When Coverage Ends .................................................................................................................... 28 Options after Termination of Coverage .......................................................................................... 30 Paying for Benefits ......................................................................................................................... 32 Determining Monthly Premiums..................................................................................................... 33 Premium Conversion ...................................................................................................................... 37 Health Care Benefits ...................................................................................................................... 39 PEIA PPB Plans A, B and D ........................................................................................................... 39 Medical Deductible ........................................................................................................................ 41 Benefit Design ................................................................................................................................ 44 Benefit Maximums ......................................................................................................................... 48 Lifetime Maximum .......................................................................................................................... 49 PEIA PPB Plan Fee Schedules and Rates ..................................................................................... 49 Pre-Service Decisions.................................................................................................................... 49 Medical Case Management ........................................................................................................... 52 Transition of Care Program (New Participants Only) ..................................................................... 53 What Is Covered: Medically-Necessary Services ......................................................................... 54 Healthy Tomorrows ........................................................................................................................ 68 Face-to-Face (F2F) Diabetes Program .......................................................................................... 68 Weight Management Program ...................................................................................................... 68 Tobacco Cessation ........................................................................................................................ 69 What Is Not Covered ...................................................................................................................... 70 How to File a Claim ........................................................................................................................ 73 Appealing a Claim ...........................................................................................................................74 iii Prescription Drug Benefits ............................................................................................................. 76 What You Pay ................................................................................................................................. 76 West Virginia Preferred Drug List (WVPDL) ................................................................................... 77 Prior Authorization .......................................................................................................................... 80 Drugs with Special Limitations ...................................................................................................... 82 Quantity Limits (QL) ....................................................................................................................... 83 Maintenance Medications .............................................................................................................. 86 Specialty Drug Program ................................................................................................................ 86 Diabetes Management ................................................................................................................... 89 Drugs or Services That Are Not Covered ...................................................................................... 90 Other Important Features of Your Prescription Drug Program...................................................... 91 Filing a Prescription Drug Claim .................................................................................................... 93 Filing Claims for Court-ordered Dependents (COD) ..................................................................... 93 Appealing a Drug Claim ................................................................................................................. 94 How to Reach CVS Caremark ....................................................................................................... 95 Controlling Costs ..........................................................................................................................
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