Directory of Offices - Office of Benefits - Medical and Prescription Insurance

This information is only a summary of typical questions and does not replace the binding plan documents.
Please contact the Benefits Office with any benefit related questions.

Medical Insurance | Prescription Insurance

Medical Insurance

Anthem Blue Cross Blue Shield PPO
1-800-324-6086
www.anthem.com

Eligibility:
You must be an active full-time employee, regularly scheduled to work 30 hours or more per week, and forty weeks a year.

Medical Plan Q&A:

What is the name of the health insurance plan?
The name of the plan is Anthem Blue Cross Blue Shield.

What type of health insurance plan is the Diocese of Gary Health Care Plan?
It is a self-insured PPO (Preferred Provider Organization) plan.

What is a self-insured health insurance plan?
Self-insured means that the Diocese of Gary assumes the financial risk for eligible member’s claims. We also purchase stop-loss coverage from an insurer who agrees to bear the risk for those expenses exceeding a predetermined amount.

What does PPO health insurance plan mean?
It means that participants of this plan may seek care from any provider. However, the participants will be responsible for a far greater part of the cost of their services when they see providers that are not network of preferred providers.

What is the network of preferred providers for the health insurance plan?
The Diocese of Gary Health Care Plan uses the Anthem Access Blue PPO network.

How do I find out what providers are part of the Anthem network?
You may check online at www.anthem.com  (click on Blue Access PPO) or call: 1-800-810-2583.
It is your responsibility to be certain of the network status of any provider prior to scheduling an appointment for services.

When does my health insurance coverage begin as a new enrollee?
Your coverage starts on the first date of your employment as long as you properly complete your enrollment forms within 31 days from your start date. If you wait and complete the forms beyond the 31-day period, your coverage will not start until the date the forms are completed at midnight.

Can I cover dependent children and/or my spouse on the health insurance plan?
Yes, you may cover dependents. The term dependent typically means your spouse and/or children. Please see the plan document for a detailed explanation regarding dependent eligibility. You are responsible for the monthly premium for the dependents by payroll deduction.

Until what age are my dependent children eligible to remain on the health insurance plan?
Eligible dependent children may remain on the Diocese of Gary Health Care Plan until they reach twenty six years old.

Both the Diocese of Gary Health Care plan and my spouse’s plan cover my dependent. How do I know which plan pays first, and which plan pays second?
The Diocese of Gary follows the birthday rule. With a few exceptions for separated parents and joint custody decrees, the primary plan (pays first) is the plan with the parent whose birthday is earlier in the year.

Can I add my dependent and I to the health insurance plan?
Yes, you may add an eligible dependent to the plan during open enrollment by completing a Change of Status Form and a Payroll Deduction Authorization Form.  If there is a status change (i.e. loss of other coverage, marriage, birth/adoption), you may add coverage for you and your dependents within 31 days of the status change.   You are responsible for the premium for your dependent through a payroll deduction.

Can I delete myself and/or my dependent from the health insurance plan?
Yes, you may delete you and/or a dependent at any time by calling the Benefits Office for the proper form.  Remember, you may only re-enroll the dependent during a subsequent open enrollment period.

May I waive my health insurance coverage?
The Diocese of Gary Health Care Plan is a contributory plan, and therefore you may waive your health insurance coverage.   A waiver form must be signed and provided to the Benefits Office.  However, it is very important to note that eligibility for retiree medical coverage is based on the years of continuous coverage, not on years of service. Therefore, if you waive coverage you may be forfeiting your eligibility for retiree medical coverage.

What is a premium?
A premium is the monthly amount paid for coverage by a participant in the plan and the employer.

What is a deductible?
This is the amount that you are personally responsible to pay each calendar year before the plan begins to pay any benefits. There are different deductible amounts depending upon your choice of an in-network or out-of-network provider. Please check the current plan document for the most current deductibles, or call the Benefits Office at (219) 769-9292. You should submit all claims, so that they may be applied to your deductible.

What is the total amount of deductibles I pay each calendar year if I see both in-network and out-of-network providers?
Your maximum deductible for a calendar year is the same amount as the out-of-network deductible. It is not a combination of both the in-network and out-of-network deductible.

What is the out-of-pocket limit?
The out-of-pocket limit is the maximum amount of co-payments you are responsible for in a calendar year. It does not include co-payments for prescriptions.

What is a co-payment?
This is the amount that you are responsible to pay for each claim, after you meet your deductible for the calendar year. For example, if you met your deductible, and you have an in-network claim for $100.00, the plan pays 90% of the claim minus any discounts, and you are responsible for the balance as your co-payment.

What is an Explanation of Benefits (EOB)?
This is a form the third party administrator (Anthem) sends to you explaining the payment of your claim. If you require help understanding the form, you should call the member services number on your I. D. card. You may also access your EOB’s through Anthem’s web site at www.anthem.com.   An EOB is not a bill, or request for payment.

Is the procedure my doctor ordered covered by the health insurance plan?
If you are not sure if a particular procedure is covered, you or your doctor’s office should call Anthem Member Services at 1-800-324-6086 prior to scheduling the procedure.  

Has my health insurance claim been paid or was it paid correctly?
Call Anthem Member Services at 1-800-324-6086 or access Anthem’s website at www.anthem.com.

How do I get a new I.D. card to replace my lost card?
You may request a replacement card as well as print a temporary card online at www.anthem.com or contact Anthem Member Services at 1-800-324-6086.

When do I need to call to pre-certify for a health insurance benefit?
You must pre-certify for all admissions by calling Anthem at 1-877-814-4803.   The Benefits Office cannot pre-certify any procedure or hospital admission.

What is open enrollment?
There is an annual Open Enrollment period every late spring (date subject to change).  The Benefits Office mails open enrollment materials to all eligible employees.

  • Open Enrollment permits those who previously declined coverage under the Plan to elect coverage - effective July 1.
  • For employees currently participating in the plan, Open Enrollment is also a time when dependents not previously enrolled in the plan can be added.

What address do I send a health insurance claim to?
Anthem Blue Cross Blue Shield
P.O. Box 105187
Atlanta, GA 30348

Does my health insurance cover me while traveling out of the country?
Yes, you or the out of country medical provider can call Anthem’s Travel Coverage department at 1-800-810-2583.   As many foreign providers do not accept a health insurance card, you may need to pay the bill and submit a claim for reimbursement. Please understand that translating bills and converting currencies takes additional time as opposed to processing a domestic claim. 

When does my health insurance coverage end?
Coverage ends on the last day of the month in which your employment terminates. For contracted teachers, your last day of coverage is detailed in your contract.

Is COBRA coverage available so I can continue my health insurance benefits?
No, because not-for-profit religious organizations (such as church plans) are not required to provide COBRA coverage.

Am I eligible for health insurance when I am retired?
Below are the various situations in which you may or may not continue with the Diocese of Gary health insurance benefit.
Please note that eligibility is not based on years of service but rather on years of continuous health insurance coverage.

  • If you are age 65 or older and have 25 years or more of continuous coverage prior to January 1, 2006, retiree medical coverage is available and the premium is paid by your employer.
  • If you are age 65 or older and have at least 15 years of continuous coverage, retiree medical coverage is available and the premium is paid by you.
  • If you are younger than 65 years old and have 25 years or more of continuous coverage prior to January 1, 2006, retiree medical coverage is available with the premium paid by you – the employee – at the active employee premium rate until you reach age 65 and are covered my Medicare.   At that time, your employer will pay the premium.
  • If you are younger than age 65 years old and have at least 15 years of continuous coverage, medical coverage is available, and the premium is paid by you.
  • At any age with less than 15 years of continuous health insurance coverage, there is no coverage available.

May I continue my health insurance under the Diocese of Gary Health Plan when I terminate my employment?
See the above answer.

Resources and Forms:

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Prescription Insurance

Express-Scripts (formerly Medco)
1-800-987-8680
www.express-scripts.com          

Eligibility:
You must be an active full-time employee, regularly scheduled to work 30 hours or more per week, and forty weeks a year.

Prescription Plan Q&A:

What is the co-payment for my prescriptions?
The co-payment depends on the type and pricing tier of the medication (i.e. generic, preferred brand name, non-preferred brand name) so you can either call Member Services at 1-800-987-8680 or visit their website at www.express-scripts.com.  
If possible, always ask for a generic brand as that will be the greatest cost savings to you.

How do I order maintenance prescriptions through the mail?
You can call Member Services at 1-800-987-8680 or visit their website at www.express-scripts.com.

  • Policy Number is 610014
  • Group Number is DOFGARY

Members must use the mail order plan for all maintenance medications.   Maintenance medications are prescriptions that require more than 3 refills.   Members are 100% responsible for the cost of maintenance medications purchased through a retail pharmacy after the 3rd refill.

Resources and Forms:

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