i
Plan Year 2018
July 1, 2017-June 30, 2018
Public Employees
Insurance Agency
601 57th Street, SE / Suite 2
Charleston, WV 25304-2345
PAID
Summary Plan Description
PPB Plans A, B and D
PEIA 2017-2018 SPD ABD-REV.indd 1 7/13/17 9:15 AM
ii
Notice to PEIA Enrollees Concerning Election for Plan
Exemption from Certain Federal Requirements
Group health plans sponsored by state and local governmental employers must generally comply with federal law
requirements 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
following 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 benets for mental health and substance-use disorders be subject to more restrictions
than apply to medical and surgical benets covered by the plan.
3. Certain requirements to provide benets 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.
e exemption from these federal requirements will be in eect for the 2018 plan year, beginning July 1, 2017 and end-
ing June 30, 2018. e 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 102 for details.
Summary of Benefits and Coverage
Want to compare all of the plans oered by PEIA? ere’s an easy way! Go to www.wvpeia.com and click on Preferred
Provider Benet Plans, then choose the “Summary of Benets and Coverage” link. is 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!
NOTE: PEIA also oers PPB Plan C, which is an IRS-qualied High-Deductible Health Plan (HDHP). For
more information about Plan C, download the Summary Plan Description (Plan C) at www.wvpeia.com or call
1-888-680-7342.
PEIA 2017-2018 SPD ABD-REV.indd 2 7/13/17 9:15 AM
iii
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 ......................................................................................................................... 31
PEIA PPB Plans A & B ................................................................................................................... 39
PEIA PPB Plan D............................................................................................................................ 40
Medical Deductible ........................................................................................................................ 40
Benefit Maximums ......................................................................................................................... 48
Lifetime Maximum .......................................................................................................................... 49
PEIA PPB Plan Fee Schedules and Rates ..................................................................................... 49
Pre-Service Decisions.................................................................................................................... 52
Medical Case Management........................................................................................................... 55
Transition of Care Program (New Participants Only) ..................................................................... 55
What Is Covered: Medically-Necessary Services ......................................................................... 56
Healthy Tomorrows ........................................................................................................................ 70
Face-to-Face (F2F) Diabetes Program .......................................................................................... 70
Hemophilia Disease Management Program .................................................................................. 71
Weight Management Program....................................................................................................... 71
Tobacco Cessation ........................................................................................................................ 72
What Is Not Covered...................................................................................................................... 73
How to File a Claim ........................................................................................................................ 76
Appealing a Claim .......................................................................................................................... 77
Prescription Drug Benefits ............................................................................................................. 79
What You Pay................................................................................................................................. 79
PEIA 2017-2018 SPD ABD-REV.indd 3 7/13/17 9:15 AM
iv
West Virginia Preferred Drug List (WVPDL) ................................................................................... 80
Prior Authorization .......................................................................................................................... 83
Drugs with Special Limitations ...................................................................................................... 84
Quantity Limits (QL) ....................................................................................................................... 85
Maintenance Medications .............................................................................................................. 87
Common Specialty Medications ................................................................................................... 88
Diabetes Management ................................................................................................................... 89
Tobacco Cessation Program ......................................................................................................... 90
Drugs or Services That Are Not Covered ...................................................................................... 90
Other Important Features of Your Prescription Drug Program...................................................... 91
How to File a Claim ........................................................................................................................ 93
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 ........................................................................................................................... 95
Coordination of Benefits ................................................................................................................ 97
Medicare ...................................................................................................................................... 100
Recovery of Incorrect Payments ................................................................................................. 103
Amending the Benefit Plan .......................................................................................................... 104
HIPAA Notice of Privacy Practices .............................................................................................. 105
PEIA Adult Annual Routine Physica and Screening Examination ............................................... 109
Health Tomorrows Reporting Form ..............................................................................................111
PEIA 2017-2018 SPD ABD-REV.indd 4 7/13/17 9:15 AM
1
Introduction
Welcome to your PEIA Summary Plan Description. is booklet describes the benets provided for PEIA insureds in the
PEIA PPB Plans A, B and D for Plan Year 2018 (July 1, 2017 June 30, 2018). It includes important information for all
public employees who have ANY coverage through PEIA. PEIA also oers PPB Plan C, which is an IRS-qualied High-
Deductible Health Plan (HDHP). For more information about Plan C, download the Summary Plan Description (Plan
C) at www.peia.com or call 1-888-680-7342.
Managed Care Members
For those who are enrolled in managed care plans, this booklet provides all of the eligibility and enrollment information
regarding your benets. If you need or want to change your benets, please refer to the information in the beginning of
this booklet for details of your rights, responsibilities, and the time frames for making eligibility changes. Information in
this booklet regarding managed care plan benets and guidelines is limited. erefore, you should refer to your managed
care Evidence of Coverage for benet details if you are covered by one of the managed care plans oered by PEIA.
PPB Plan Participants
For those enrolled in the PEIA PPB Plans A, B and D, this booklet includes many details of the Preferred Provider Benet
(PPB) Plans. It is important to review this information closely so that you may familiarize yourself with all aspects of PEIA’s
PPB Plans. Please keep this booklet close at hand and refer to it often if you have questions about your health care benets.
is Summary Plan Description (SPD) provides PEIA PPB Plan participants with an easy-to-read description of benets
available through the Plan and instructions on how to use these benets. e SPD is a summarized version of a portion of
PEI A’s Plan Document. e Plan Document describes, in detail, all aspects of the operations of the Agency, and is on le
with the Secretary of State.
PEIA contracts with third party administrators (TPAs) to process health and drug claims for the PEIA PPB Plans. If you
have a question about a specic claim or benet, the fastest way to obtain information is to contact the TPA directly at one
of the numbers listed on the next page.
PEIA PPB Plan A is PEI A’s most popular plan. PEIA PPB Plan B is similar to the s
tandard PPB Plan A, but oers lower
premiums with higher deductibles, higher out-of-pocket maximums, and higher copayments for prescription drugs. e
medical coverage is the same as in PPB Plan A. PEIA PPB Plan C is PEI A’s IRS-qualied High Deductible Health Plan,
and the details of Plan C are covered in the Summary Plan Description – Plan C, which is available at www.wvpeia.com
or by calling 1-888-680-7342. Plan D is the West Virginia ONLY plan whose benets mirror those of Plan A, but with
no out-of-state benets except for medical emergencies and a few services that are not available within W V.
Medicare-primary Members
For most Medicare-eligible retired employees and Medicare-eligible dependents of retired employees, PEIA has a con-
tract with Humana to provide medical and prescription drug benets. Information in this booklet regarding benets for
Medicare retirees is very limited. You should refer to your Humana Evidence of Coverage booklet for benet details. Each
eligible member has received detailed information about the plan from Humana. If you have questions please use the num-
bers on the back of your ID card to obtain answers.
Life Insurance Only
For employees who carry only life insurance with the PEIA, your eligibility and enrollment details are in this booklet.
Details of the life insurance coverage are in the Life Insurance Booklet. For questions about life insurance or to le a life
insurance claim, call Minnesota Life at 1-800-203-9515.
Subject to Change
e benet information in this Summary Plan Description is subject to change during the plan year, if circumstances arise
which require adjustment. Plan changes will be communicated to participants. e changes will be included in PEI A’s
Plan Document, which is on le with the Secretary of State, and will be incorporated into the next edition of the Sum-
mary Plan Description.
PEIA 2017-2018 SPD ABD-REV.indd 1 7/13/17 9:15 AM
2
Who to Call with Questions
Health Claims and Benefits, Precertification, Pre-authorization, Prior Approval of Out-of-
State Care and Utilization Management
HealthSmart at 1-304-353-7820 or 1-888-440-7342 (toll-free) or on the web at www.healthsmart.com.
Provider Network Administration
HealthSmart with Aetna Signature Administrators at 1-304-353-7820 or 1-888-440-7342 (toll-free).
Prescription Drug Benefits and Claims
CVS Caremark at 1-844-260-5894 (toll-free) or on the web at www.caremark.com.
Common Specialty Medications
HealthSmart Specialty Drug Program at 1-888-440-7342 (toll-free).
Sleep Testing, Equipment, and Supplies
Sleep Management Services at 1-888-497-5337
Subrogation and Recovery
Beacon Recovery Group at 1-800-874-0500 (toll-free).
PEIA
Answers to questions about eligibility and third-level claim appeals WV Public Employees Insurance Agency at
1-304-558-7850 or 1-888-680-7342 (toll-free) or on the web at www.wvpeia.com.
Humana
Medical and prescription drug benets for Medicare-primary members. Answers to questions about eligibility, health
claims, benets, and claim appeals. Call Humana at 1-800-783-4599.
Minnesota Life
Answers to questions about life insurance or to le a life insurance claim. Call Minnesota Life at 1-800-203-9515.
Mountaineer Flexible Benefits
Dental, vision, and disability insurance and exible spending accounts. FBMC Benets Management at
1-844-559-8248 (toll-free) or on the web at www.myf bmc.com.
PEIA Face-to-Face Diabetes Management Program
For information call 1-888-680-7342 or visit www.peiaf2f.com.
PEIA Weight Management Program
For information or to enroll in the program, call 1-866 -688-7493.
The Health Plan HMOs & PPO
1-800-624-6961 (toll-free), 1-740-695-3585 or on the web at www.healthplan.org.
PEIA 2017-2018 SPD ABD-REV.indd 2 7/13/17 9:15 AM
3
Terms & Denitions
Aetna® Signature Administrators (ASA) PPO: PEIA’s out-of-state Preferred Provider Network. Not all providers in
the ASA PPO network may participate with PEIA. Kings Daughters Medical Center and Our Lady of Bellefonte hospi-
tals in Kentucky remain out-of-network for PEIA, regardless of their network status with the ASA PPO network. Also,
PEIA does not use the ASA PPO network in Washington County or Cuyahoga County, Ohio, or in Boyd County,
Kentucky. PEIA reserves the right to remove providers from the network, so not all providers listed in the network may
be available to you.
Aordable Care Act (ACA) Out-of-Pocket Maximum: e Aordable Care Act places a limit on how much you
must spend for healthcare in any plan year before your plan starts to pay 100% for covered essential health benets.
is limit includes deductibles (medical and prescription), coinsurance, copayments, or similar charges and any other
expenditure required of an individual which is a qualied medical expense for the essential health benets. is limit
does not include premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing,
or spending for non-essential health benets.
e maximum out-of-pocket cost for Plan Year 2018 can be no more than the rates set by the federal government for in-
dividual and family plans. Because PEIA’s plans have out-of-pocket maximums that are substantially lower than the ACA
required limits, the ACA out-of-pocket maximum should never come into play for most PEIA PPB Plan members.
Allowed Amounts: For each PEIA-covered service, the allowed amount is the lesser of the actual charge amount or the
maximum fee for that service as set by the PEIA.
Alternate Facility: A facility other than an acute care hospital.
Annual Deductible: e amount you must pay each plan year before the plan pays its portion of the cost. Under the
PPB Plans A & B, oce visits are not subject to the deductible. Only the Allowed Amounts for covered expenses will
be applied to your deductible. e family deductible is divided up among the family members. No one member of the
family will pay more than the individual (or Employee Only) deductible.
Beacon Recovery Group: e subrogation and recovery vendor for PEIA. Beacon pursues recovery of money paid for
claims that were not the responsibility of the PEIA PPB Plan. For more information, read the “Recovery of Incorrect
Payments” section.
Beneciary: e person who receives the proceeds of your PEIA life insurance policy.
Claims Administrator: HealthSmart Benet Solutions.
Coinsurance: e percentage of eligible expenses that you are required to pay after the deductible has been met. is
is the amount applied to your out-of-pocket maximum. You are responsible for paying the coinsurance and deductible
amounts directly to the provider of services.
Comprehensive Care Partnership (CCP ) Program: is program promotes the use of health services to keep the pa-
tient well, identify health problems early, maintain control of chronic conditions and to promote ecient utilization of
healthcare resources. e CCP provider is responsible for providing preventative services, routine sick care, and coordi-
nation of care with specialists when needed. Members who enroll in the CCP program pay reduced or no copayments,
deductible or coinsurance for specied services at their CCP provider. Any time a CCP member uses any provider
outside the CCP, including another primary care provider, the copayment for the oce visit will be $40.
Coordination of Benets: A practice insurance companies use to avoid double or duplicate payments or coverage of
services when a person is covered by more than one policy.
PEIA 2017-2018 SPD ABD-REV.indd 3 7/13/17 9:15 AM
4
Copayment: is is the set dollar amount that you pay when you use the services—like the at dollar amount you pay
for an oce visit in PEIA PPB Plans A, B & D. Copayments do not count toward your annual out-of-pocket maxi-
mum or your annual deductible.
Deductible: e amount of eligible expenses you are required to pay before the plan begins to pay benets. e de-
ductible does not apply to charges for oce visits. See Annual Deductible above.
Dependent: An eligible person, under PEIA guidelines, who the policyholder has properly enrolled for coverage under
the Plan.
Durable Medical Equipment: Medical equipment that is prescribed by a physician which can withstand repeated use,
is not disposable, is used for a medical purpose, and is generally not useful to a person who is not sick or injured.
Eligible Expense: A necessary, reasonable and customary item of expense for health care when the item of expense is
covered at least in part by one or more plans covering the person for whom the claim is made. Allowable expenses un-
der this plan are calculated according to PEIA fee schedules, rates and payment policies in eect at the time of service.
Emergency: A condition that manifests itself by acute symptoms of sucient severity including severe pain such that
the absence of immediate medical attention could reasonably be expected to result in serious jeopardy to the individu-
al’s health or with respect to a pregnant woman the health of the unborn child, serious impairment to bodily functions
or serious dysfunction of a bodily part or organ.
Employers: PEIA oers its benets through these West Virginia employers:
• State government and its agencies;
• State-related colleges and universities;
• County boards of education;
• County and municipal governments; and
• Other employers as specied in W. Va. Code §5-16-2.
Under West Virginia law, dierent types of employers may oer their employees dierent benets. erefore, the
benets for which you are eligible may vary. If you have any questions about your benets, contact the benet
coordinator at your payroll location or call the PEIA.
Exclusions: Services, treatments, supplies, conditions, or circumstances that are not covered under the PEIA PPB Plans.
Experimental, Investigational, or Unproven Procedures: Medical, surgical, diagnostic, psychiatric, substance abuse or
other health care technologies, supplies, treatments, procedures, drug therapies or devices that are determined by t
he plan
(at the time it makes a determination regarding coverage in a particular case) to be: (1) not approved by the U.S. Food and
Drug Administration (FDA) to be lawfully marketed for the proposed use and not identied in the American Medical As-
sociation Drug Evaluations as appropriate for the proposed use; or (2) subject to review and approval by any Institutional
Review Board for the proposed use; or (3) the subject of an ongoing clinical trial that meets the denition of Phase 1, 2, 3
Clinical Trial set forth in the FDA regulations, regardless of whether the trial is actually subject to FDA oversight; or (4)
not demonstrated through prevailing peer-reviewed medical literature to be safe and eective for treating or diagnosing the
condition or illness for which its use is proposed. Phase 2 and 3 Clinical Trials for terminal cancer and other life-threaten-
ing conditions and which meet certain statutory criteria will be covered despite being experimental.
Explanation of Benets (EOB): A form sent to the policyholder after a claim for payment has been evaluated or pro-
cessed by the Claims Administrator which explains the action taken on the claim. is explanation might include the
amount paid, benets available, reasons for denying payment, etc.
CVS Caremark: PEIA’s prescription drug benet administrator. CVS Caremark processes and pays prescription drug
claims and helps manage the prescription drug benet.
PEIA 2017-2018 SPD ABD-REV.indd 4 7/13/17 9:15 AM
5
Handicap: A medical or physical impairment which substantially limits one or more of a person’s major life activities.
e term “major life activities” includes functions such as care for oneself, performing manual tasks, walking, seeing,
hearing, speaking, breathing, learning or working. “Substantially limits” means interferes with or aects over a substan-
tial period of time. Minor, temporary ailments or injuries shall not be considered physical or mental impairments which
substantially limit a person’s major life activities. “Physical or mental impairment” includes such diseases and conditions
as orthopedic, visual, speech and hearing impairments; cerebral palsy; epilepsy; muscular dystrophy; autism; multiple
sclerosis and diabetes. e term “handicap” does not include excessive use or abuse of alcohol, tobacco or drugs.
Health Maintenance Organization (HMO): A managed care organization that provides a wide range of compre-
hensive health care services for a xed periodic payment. PEIA contracts with HMOs to provide health coverage for
policyholders and their dependents that choose this coverage. HMO participants receive general information about the
plans in PEIA’s Shopper’s Guide, and specic information in the Evidence of Coverage (EOC) provided by their HMO.
Health Savings Account (HSA): A health savings account (HSA) is a tax-exempt trust or custodial account that mem-
bers of PEIA PPB Plan C may set up with a qualied HSA trustee to pay or reimburse certain medical expenses. e
HSA works in conjunction with a High Deductible Health Plan. For more information about PEI A’s HDHP, down-
load the Summary Plan Description (Plan C) at www.wvpeia.com or call 1-888-680-7342.
HealthSmart: e third party administrator that handles medical claim processing, management of specialty medica-
tions, case management, utilization management, precertication, prior approval and customer service for the PEIA
PPB Plans.
Healthy Tomorrows: A coordinated lifestyle and disease management program for all PEIA PPB Plan members.
Inpatient: Someone admitted to the hospital as a bed patient for medical services.
Insured: Someone who is eligible for and enrolled in the PEIA PPB Plans, a managed care plan, or life insurance only.
Insured refers to anyone who has coverage under any plan oered by PEIA.
Legal Guardianship: A legal relationship created when a person or institution is named by the Court to take care of
minor children. Eligibility for guardianship requires an Order from a Court of Record. Notarized documents signed by
parents assigning “guardianship” are not sucient to establish eligibility. e term “guardian” may also refer to some-
one who is Court-appointed to care for and/or handle the aairs of a person who is incompetent or incapable of admin-
istering his/her aairs. Sometimes a separate person is appointed to handle the nancial matters of the child(ren) or the
adult and that relationship is called a conservatorship.
Medical Case Management: A process by which HealthSmart Care Management assures appropriate available re-
sources for the care of serious long-term illness or injury. HealthSmart Care Management can assist in providing alter-
native care plans.
Medical Home: A West Virginia provider who is a general practice doctor, family practice doctor, internist, pediatri-
cian, or geriatrician, who has enrolled with HealthSmart as a medical home provider, and who is listed in PEIA’s Medi-
cal Home directory.
Medicare: e federal program of health benets for retirees and other qualied individuals as established by Title XVII
of the Social Security Act of 1965, as amended. Parts A and B provide medical coverage to Medicare Beneciaries.
Retired, qualied Medicare Beneciaries covered by PEIA are REQUIRED to enroll for both Medicare Part A and
Part B. Medicare Part D (drug coverage) IS NOT required for members of the PEIA Plans.
Medicare Advantage and Prescription Drug (MAPD) Plan: A type of Medicare benets that combines Medicare
Parts A, B and D into one comprehensive benet package. PEIA provides benets to Medicare-eligible retired employ-
ees and Medicare-eligible dependents of retired employees almost exclusively through the Humana MAPD plan oered
by PEIA.
PEIA 2017-2018 SPD ABD-REV.indd 5 7/13/17 9:15 AM
6
Medicare Beneciary: Individual eligible for Medicare as established by Title XVII of the Social Security Act of 1965,
as amended.
Non-Resident PPB Plan Participants: A PEIA PPB Plan participant who resides outside WV and beyond the
bordering counties.
Notication: e required process for reporting an inpatient stay to HealthSmart Care Management. is process is
performed to screen for care planning, discharge planning, follow-up care and ancillary service requirements.
Outpatient: Someone who receives services in a hospital, alternative care facility, freestanding facility, or physician’s of-
ce but who is not admitted as a bed patient.
OOSINNA: Out-of-state (beyond the contiguous counties), in-network, not approved. Services of an out-of-state,
in-network provider, not approved in advance by HealthSmart are covered at the lower benet level. e patient is also
responsible for double the in-network deductible and double the in-network out-of-pocket maximum. OOSINNA does
not apply to non-resident PPB Plan participants.
Participant: A policyholder or dependent enrolled in one of the PEIA PPB Plans.
PEIA PPB Plan A: e most expensive PEIA PPB Plan oered to all eligible active employees and non-Medicare retirees.
PEIA PPB Plan B: A lower-cost PEIA PPB Plan oered to all eligible active employees and most non-Medicare retir-
ees. Plan B oers lower premiums with higher deductibles, higher out-of-pocket maximums, and higher copayments for
prescription drugs. e medical coverage is the same in Plans A, B and D. e dierences in deductibles, out-of-pocket
maximums and drug copayments are noted in the benet tables in the “Medical Benets” section and the “Prescription
Drug Benet” section of this book.
PEIA PPB Plan C: e IRS-qualied High Deductible Health Plan (HDHP) oered by PEIA to all eligible active em-
ployees. e plan oers lower premiums, but a high deductible that must be met before the plan begins to pay. e plan
is designed to work with either a Health Savings Account (HSA) or a Health Reimbursement Arrangement (HR A).
For more information about PEI A’s H DHP, download the Summary Plan Description (Plan C) at www.wvpeia.com
or call 1-888-680-7342.
PEIA PPB Plan D: PEIA PPB Plan D is the West Virginia ONLY plan. Members enrolling in this plan must be West
Virginia residents, and all care provided under this plan must be provided in West Virginia. e benets (copayments,
coinsurance, deductible and out-of-pocket maximum) of Plan D are i
dentical to PEIA PPB Plan A, and the premiums
are much lower than Plan A. e dierence is that the only care allowed outside the State of West Virginia will be
emergency care to stabilize the patient, and a limited number of procedures that are not available from any health care
provider inside West Virginia.
For policyholders who are West Virginia residents but who have dependents who reside outside West Virginia (such as
students attending college out-of-state), PEIA PPB Plan D will cover those out-of-state dependents for emergency care
to stabilize the patient, and a limited number of procedures that are not available from any health care provider inside
West Virginia. All other services must be provided within West Virginia.
PEIA PPO: e PEIA PPO is the network of providers from whom PEIA PPB Plan participants can receive care to get
the highest level of benet. is network consists of all properly licensed WV providers who provide health care services
or supplies to any PEIA participant, as well as most out-of-state providers in Aetna Signature Administrators Preferred
Provider Organization. For services provided outside of the State, contact HealthSmart to nd a network provider.
Pharmacy Benets Manager (PBM): A company with which PEIA has a contract to administer the prescription drug
benet component of PEIA PPB plans. e PBM processes and pays prescription drug claims and helps manage the
prescription drug benet.
PEIA 2017-2018 SPD ABD-REV.indd 6 7/13/17 9:15 AM
7
Plan: e plan of benets oered by the Public Employees Insurance Agency, including the PEIA PPB Plans, managed
care plans and life insurance coverages.
Plan Year: A 12-month period beginning July 1 and ending June 30 for active PEIA participants. January 1 to Decem-
ber 31 for participants in the Special Medicare Plan.
Policyholder: e employee, retired employee, surviving dependent or COBR A participant in whose name the PEIA
provides any health or life insurance coverage.
Preauthorization: A voluntary program that allows you to contact HealthSmart Care Management in advance of a
procedure to verify that the service is a covered benet and medically necessary.
Precertication: e required process of reporting any out-of-state inpatient admission, any mental health inpatient
admission, in-state admissions for certain procedures and certain outpatient procedures in advance to HealthSmart
Care Management to obtain approval for the admission or service.
Premium: e payment required to keep coverage in force.
Primary Care Provider: A general practice doctor, family practice doctor, internist, pediatrician, geriatrician, OB/
GYN, nurse practitioner or physician assistant working in collaboration with such a physician, who, generally, provides
basic diagnosis and non-surgical treatment of common illnesses and medical conditions.
Prior Approval: e required process of obtaining approval from HealthSmart Care Management for out-of-state or
out-of-network care under the PEIA PPB Plans.
Prior Authorization: e required process of obtaining authorization from the Rational Drug erapy Program for
coverage for some prescription medications under the PEIA PPB Plans.
Provider Discount: A previously determined percentage that is deducted from a provider’s charge or payment amount
and is not billable to the insured when PEIA is the primary payer and the service is provided in West Virginia or by a
PPO network provider.
Qualifying Event: A qualifying event is a personal change in status which may allow you to change your benet elec-
tions. Examples of qualifying events include, but are not limited to, the following:
1. Change in legal marital status – marriage, or divorce, of policyholder or dependent
2. Change in number of dependents – birth, death, adoption, placement for adoption, award of legal guardianship
3. Change in employment status of the employee’s spouse or employee’s dependent – switching from part-time to
full-time employment status or from full-time to part-time, termination or commencement of employment, a
strike or lockout, commencement of or return f
rom an unpaid leave of absence which results in employee/de-
pendent becoming ineligible for coverage
4. Dependent satises or ceases to satisfy eligibility requirements
If you experience a qualifying event, you have the month in which the event occurs and the two following calendar
months to act upon that qualifying event and change your coverage. If you do not act within that timeframe, you can-
not make the change until the next open enrollment. Qualifying events which end eligibility (such as divorce) must be
reported immediately. For purposes of eligibility, the term “immediately” shall mean as soon as practically possible and,
in no case, greater than thirty (30) days from the date of the event, e.g. divorce.
Rational Drug erapy Program (RDT): e Rational Drug erapy Program of the WVU School of Pharmacy
provides clinical review of requests for drugs that require prior authorization under the PEIA PPB Plans.
Reasonable and Customary: e prevailing range of charges and fees charged by providers of similar training and
experience, located in the same area, taking into consideration any unusual circumstances of the patient’s condition that
might require additional time, skill or experience to treat successfully.
PEIA 2017-2018 SPD ABD-REV.indd 7 7/13/17 9:15 AM
8
Resident PPB Plan Participants: PEIA PPB Plan participants who live in West Virginia or a bordering county of a
surrounding state.
Secondary Payer: e plan or coverage whose benets are determined after the primary plan has paid. Order of pay-
ment is determined by rules described under “Which Plan Pays First” on page 98.
Special Medicare Plan: e plan created by PEIA to provide benets to retirees unable to access providers in the
Medicare Advantage plan and those retirees who become eligible for Medicare benets during a plan year. Medical
claims under this plan are paid by Medicare rst, then by HealthSmart and prescription claims are paid by CVS Care-
mark. e medical benets are identical to those provided to members of the Humana MAPD plan, including a plan
year that runs from January through December.
Specialty Medications: Specialty medications are high-cost injectable, infused, oral or inhaled drugs that generally re-
quire close supervision and monitoring of the patient’s drug therapy. Some specialty medications are covered under the
medical benet and some are covered under the prescription drug benet. ose covered under the prescription drug
benet, have a two-tier copay; after meeting your deductible, preferred specialty drugs have a $100 copay, non-preferred
specialty drugs have $150 copay. Under the PEIA PPB Plans, all specialty medications require precertication from
HealthSmart Specialty Drug Program.
ird Party Administrator (TPA): A company with which PEIA has contracted to provide services such as customer
service, utilization management and claims processing to PEIA PPB Plan participants.
Utilization Management: A process by which PEIA controls health care costs. Components of utilization man-
agement include pre-admission and concurrent review of all inpatient stays, known as precertication; prior review
of certain outpatient surgeries and services; and medical case management. Utilization management is handled by
HealthSmart Care Management.
Waiver of Premium: If you become disabled before age 60, and while insured, your basic life insurance coverage will
continue as long as you are disabled without further payment of premium. To be considered disabled, you must be
unable to do any work for pay or prot. Application for a waiver of premium must be provided to PEI A’s life insurance
carrier within 12 months of your last day worked. Contact your benet coordinator or PEIA to obtain an application.
PEIA 2017-2018 SPD ABD-REV.indd 8 7/13/17 9:15 AM
9
What PEIA Offers
Health Coverage
PEIA oers four PEIA PPB Plans. Read on to see who is eligible to enroll in each plan. Plan A is the most expensive
plan available to all eligible enrollees, including active employees and non-Medicare retirees. Plan B oers lower pre-
miums with higher deductibles, higher out-of-pocket maximums, and higher copayments for prescription drugs. e
medical coverage is identical in PPB Plans A and B. Plan B is available to all active employees and to non-Medicare
retirees whose dependents do not have Medicare.
Plan C is an IRS-qualied High-Deductible Health Plan (HDHP). For more information about PEIA’s HDH P, down-
load the Summary Plan Description (Plan C) at www.wvpeia.com or call 1-888-680-7342. Plan C is available to
active employees only.
Plan D is the West Virginia ONLY plan. Insureds enrolling in this plan must be West Virginia residents, and all care
provided under this plan must be provided in West Virginia. e only care allowed outside the State of West Virginia
will be emergency care to stabilize the patient, and a limited number of procedures that are not available from any
health care provider inside West Virginia. e benets (copayments, coinsurance, deductible and out-of-pocket maxi-
mum) of Plan D are identical to PEIA PPB Plans A, but there is no out-of-network coverage, except as noted above.
Plan D is available to active employees only.
If you live in an area where PEIA oers a managed care plan, you may be eligible to enroll in a managed care plan or in
the PEIA PPB Plan. You must live in the managed care plan’s enrollment area to be eligible to enroll in a plan. Please
consult your Shopper’s Guide for information about the managed care plans oered in your area.
e PEIA PPB Plans use a coordination of benets provision that determines how they will pay if you have other health
insurance available to you. See page 97 for a complete description of this provision. e PEIA PPB Plans may be of
little or no value to you as secondary insurance on your dependents.
Life Insurance
As an active or retired employee, you may be eligible for Basic decreasing term life insurance. is policy includes acci-
dental death and dismemberment (AD&D) benets for active employees only. If you enroll for health benets as an ac-
tive employee, you must also enroll for Basic life insurance. If you choose not to enroll for health benets, you may still
enroll for basic life insurance. You must enroll for basic life insurance before you elect any of the optional life insurance
coverages. Eligibility and enrollment details for the life insurance plans are included in this booklet. For a complete
description of the life insurance benets, please see the Life Insurance Booklet.
Mountaineer Flexible Benefits
Mountaineer Flexible Benets is a “cafeteria plan” which oers additional optional benets. is plan is available to ac-
tive employees of all State agencies, colleges, universities, and those county boards of education and non-State agencies
which elect to participate. If you’re not sure whether you’re eligible, contact your benet coordinator.
Active employees may choose from among several options for dental, vision, hearing and short- and long-term disability
insurance, as well as medical care and dependent care exible spending accounts, and pay for these benets on a pre-tax
basis. A Legal Plan is also available as a post-tax benet option.
Retired employees are eligible for dental, hearing, and vision coverage and the group legal plan on a post-tax basis. En-
rollment materials are mailed to all eligible retired employees prior to the April enrollment period. If you have questions
about these benets, contact Fringe Benets Management Company at 1-844-559-8248.
PEIA 2017-2018 SPD ABD-REV.indd 9 7/13/17 9:15 AM
10
Open Enrollment for Mountaineer Flexible Benets is held each Spring for ALL active and retired employees. e cur-
rent information about these benets and associated premiums is included in the enrollment materials mailed prior to
the annual Open Enrollment.
If you have questions about Mountaineer Flexible Benets, contact Fringe Benets Management Company at
1-844-559-8248.
Mountaineer Flexible Benefits At-A-Glance
Benefit Options
Dental Benets¹ Coverage for routine dental care. Deductibles, copayments and benets vary
Vision Benets¹ Coverage for vision exams and corrective lenses
Disability Insurance Replacement of a portion of your pay if you are disabled
Hearing Benets Coverage for hearing examination, diagnostic testing and hearing aids
Medical Flexible Spending Account Deposit up to $2,500 for tax-free reimbursement of eligible medical expenses
Dependent Care Flexible Spending Account Deposit up to $5,000 for tax-free reimbursement of eligible expenses
*Legal Plan Coverage for legal matters
1. These benets are available to retirees on a post-tax basis.
* This is a post-tax benet.
For a more complete description of benets, see the Mountaineer Flexible Benets Plan booklet.
Eligibility and Enrollment for Active Employees
Who Is Eligible?
As a public employee, you are eligible to be covered under the plans oered by your employer if you are:
• a full-time employee (working regularly at least 20 hours per week);
• an elected ocial who works full-time in the elected position;
• a member of the West Virginia Legislature (must pay 100% of the premium);
• a member of the West Virginia Board of Education (must pay 100% of the premium);
• a permanent full-time substitute teacher working on a contract of 90-days or more per school year;
• an elected member of a county board of education (must pay 100% of the premium); or
• a school service employee eligible under W. Va. Code, Chapter 18A.
Dependents: If you elect PEIA coverage, you may also enroll the following dependents with proper documentation:
• your legal spouse;
• your biological children, adopted children, or stepchildren under age 26;
• other children for whom you are the court-appointed guardian to age 18.
A child may not be enrolled for health coverage as both a policyholder (as a public employee in his or her own right)
and as a dependent child. Dependent biological children, adopted children, or stepchildren may be covered under the
plan to age 26, regardless of their residency, marital status, or the availability of other insurance coverage. e de-
PEIA 2017-2018 SPD ABD-REV.indd 10 7/13/17 9:15 AM
11
pendent child’s marriage is a qualifying event for the policyholder to remove the dependent child from coverage. e
policyholder MAY remove the child, but is not required to do so.
From time to time PEIA may conduct eligibility audits to verify that policyholders and dependents in the plan qualify
for coverage. If you are audited, you will have to produce documentation for the dependent in question. If you can-
not prove that the dependent qualies for coverage, coverage will be terminated retroactively to the date the dependent
would otherwise have been terminated, and PEIA will pursue reimbursement of any medical or prescription drug
claims paid during the time the dependent was ineligible.
How to Enroll or Make Changes
You may enroll for or make changes to PEIA health and life benets using PEI A’s online enrollment site, “Manage
My Benets,” or by completing enrollment forms at your place of employment or, in the case of retirees or surviving
dependents, by contacting PEIA. You will select the types of coverage you want and enroll the eligible dependents
you wish to cover.
Participation in PEIA benet plans is not automatic; you must enroll yourself and your dependents. Enrollment will autho-
rize your employer or retirement system to deduct the premiums for the coverages you select from your salary or annuity.
ere are restrictions on how and when you may enroll and make changes in your coverage. Please read all parts
of the “Eligibility” section of this booklet carefully before you enroll so that you will fully understand your op-
tions and responsibilities.
New Employees
You may enroll for health coverage, basic life insurance, dependent life insurance, and up to $500,000 of optional life
insurance coverage during the calendar month in which you are hired and the following two calendar months. is
is your “initial enrollment period.” To enroll your dependents, you will need to provide documentation substantiating
their eligibility for benets. e chart on page 26 shows the documentation required.
As an active employee, if you enroll for health insurance, you must enroll for basic life insurance, as well. If you enroll
for basic life insurance, then you may enroll for optional life insurance, if you so choose. No medical information is
required for up to $100,000 of optional life insurance elected during this initial enrollment period. Medical informa-
tion is always required for optional life insurance in excess of $100,000. You may also enroll for optional life insurance
for your dependents of up to $20,000. Dependent life insurance in excess of $20,000 requires medical information.
Health and life insurance coverage will become eective the rst day of the calendar month following the date of
enrollment. If you enroll and begin work on the rst day of a month, your coverage will not be eective until the rst
day of the following calendar month. If you enroll before you actually start work, coverage will begin the rst day of
the month following your rst day of active employment. Your health care plan selection will remain in eect for a full
plan year unless you move outside the service area of your plan or have a qualifying event that enables you to change or
cancel coverage.
If you choose not to enroll for life insurance during this initial enrollment period, but want life coverage later (basic,
optional or dependent) for you or your dependents, you may apply for that coverage at any time, but you will have to
submit medical information and be approved by PEI A’s life insurance carrier. Coverage will become eective the rst
day of the calendar month following approval.
If you choose not to enroll for health coverage as a new employee, you may do so later during an open enrollment pe-
riod or if you have a qualifying event, in accordance with guidelines in eect at the time you choose to enroll. To enroll
as a result of a qualifying event, you must do so during the month of the event or the following two calendar months or
you will have to wait until the next open enrollment period.
PEIA 2017-2018 SPD ABD-REV.indd 11 7/13/17 9:15 AM
12
Employees hired on and after July 1, 2010, will not receive any plan subsidy of their health insurance premiums at
retirement. ese employees may continue coverage in the plan at retirement, but must pay the unsubsidized premium
for the coverage of their choice. Two exceptions will be made to this rule:
1. Active employees hired before July 1, 2010, who separate from public service but return within two years of
their separation may be restored to their original (pre-July1, 2010) hire date.
2. Retired employees who had an original hire date prior to July 1, 2010, may return to active employment and
retain their pre-July 1, 2010, original hire date for purposes of determining their eligibility for premium subsidy.
Employees of non-state agencies that join the PEIA Plan after July 1, 2010, will be assigned a “hire date” in the PEIA
systems that is the same as their eective date of coverage under the PEIA Plan. Upon retirement, these employees will
be treated as those hired on or after July 1, 2010, and will be required to pay the full cost of coverage as noted above.
Actively At Work
For health coverage to be eective, you must be actively at work. To be considered “actively at work,” you must:
• perform the normal tasks for your job on a full-time basis on the day your coverage is to begin; and
• perform such tasks at one of your normal places of business or at a location to which you must travel to do your
job; and
• not be absent from work because of leave of absence or temporary layo.
If you do not meet these requirements, coverage for you and your dependents will begin on the next day on which you
do meet these requirements.
Pre-existing Medical Conditions
PEIA has no pre-existing condition limitation. PEIA will provide coverage for all eligible medical conditions from the
eective date of coverage. Managed care plans also do not apply pre-existing condition limitations on their members.
Life Insurance Coverage
For life insurance coverage (or an increase in the amount of optional life insurance) to go into eect, you must meet the
following requirements on the eective date of coverage:
• have completed a full day of active work on that date; and
• have completed a full day of active work on y
our last regularly scheduled work day and be able to work on the
date you become eligible.
If you do not meet the requirements of a) and b) above, coverage will become eective on the date you return to active
work. Active work and actively at work mean performing regular duties for a full work day for the policyholder.
Existing Employees
Existing employees may make changes in their coverage as follows:
Health Coverage
Existing employees who choose not to take health coverage at the time of employment may enroll for health coverage
by using PEI A’s online enrollment site, “Manage My Benets” or completing a Health Insurance Enrollment Form,
provided that they have experienced one of the qualifying events shown in the chart on page 26.
To enroll as a result of a qualifying event, you must do so during the month of the event or the following two calendar
months or you will have to wait until the next open enrollment. Coverage will be eective on the rst day of the month
following enrollment. In the absence of a qualifying event, coverage may be added for the employee and/or eligible
dependents, only during PEIA’s annual Open Enrollment period.
PEIA 2017-2018 SPD ABD-REV.indd 12 7/13/17 9:15 AM
13
Life Insurance
Existing employees may add or increase the amount of life insurance at any time by using PEIA’s online enrollment site,
“Manage My Benets” or completing an Optional Life Insurance Enrollment Form, submitting medical informa-
tion, and being approved by PEIA’s life insurance carrier. Coverage will become eective on the rst day of the month
following approval by the life insurance carrier. You must meet the following requirements on the eective date of
coverage:
a) have completed a full day of active work on that date; and
b) have completed a full day of active work on your last regularly scheduled work day and be able to work on the
date you become eligible.
If you do not meet the requirements of a) and b) above, coverage will become eective on the date you return to active
work. Active work and actively at work mean performing regular duties for a full work day for the policyholder.
Dependents
You may enroll eligible dependents for health and life coverage during your initial enrollment period, and if you do,
their coverage begins the same day as yours. To enroll dependents, you must provide documentation substantiating
their eligibility for benets. See page 26 for details. You may enroll dependents for health coverage outside your ini-
tial enrollment period only if you experience a qualifying event. If you enroll them at a later date, their coverage will
become eective the rst day of the month following enrollment. In the absence of a qualifying event, you may only
enroll dependents for health coverage during Open Enrollment. Coverage will be eective on the rst day of the follow-
ing plan year. To add a dependent to your coverage, you must submit documentation to prove the dependent’s eligibil-
ity. See page 26 for details.
If you are adding a dependent to your existing dependent life insurance policy at a date later than the calendar month
following an enrollment event, coverage will not become eective until medical information has been submitted to, and
approved by, PEIA’s life insurance carrier. To add a dependent to your coverage, you must submit documentation to
prove that this is an eligible dependent. See page 26 for details.
To enroll or add dependents, you must use PEIA’s online enrollment site, “Manage My Benets” or complete paper
forms available f
rom your benet coordinator. Coverage is not automatic, even if you have an existing family plan.
Dependents may be removed from coverage only during open enrollment or at the time of a qualifying event. To make
a change as a result of a qualifying event, you must do so during the month of the event or the following two calendar
months or you will have to wait until the next open enrollment. Qualifying events which end eligibility (such as di-
vorce) must be reported immediately. e policyholder must provide documentation supporting the qualifying event to
remove dependents. Coverage of removed dependents will terminate at the end of the month in which the policyholder
removes them from coverage. For purposes of eligibility, the term “immediately” shall mean as soon as practically pos-
sible and, in no case, greater than thirty (30) days from the date of the event, e.g. divorce.
Medicare for Active Employees
For PEIA PPB Plan active employees or dependents of active employees who are age 65 or older and eligible for Medi-
care, as long as you are an active employee, PEIA will be your primary insurer, except in a few rare cases. As long as you
are an active employee, neither you nor your Medicare-eligible dependent need to sign up for Medicare Part B and pay
the premium. When you prepare to retire, you and your Medicare-eligible dependent must enroll for Medicare Part B.
If you do not enroll in Medicare Parts A & B, you will not be eligible for PEIA’s Medicare Advantage plan, and your
PEIA coverage may be terminated.
For PEIA PPB Plan active employees who are also eligible for Medicare, and Medicare is the primary payor, PEIA will
use the traditional method of coordinating benets.
PEIA 2017-2018 SPD ABD-REV.indd 13 7/13/17 9:15 AM
14
If you become eligible for Medicare prior to age 65, you must send a copy of your Medicare card to PEIA. is notica-
tion will make the claims payment process go much more smoothly.
Newly Eligible Active Employees
Employees who become eligible to enroll for health coverage due to a qualifying event may enroll for coverage during
the calendar month of that qualifying event or the two following calendar months. Coverage will become eective the
rst day of the month following enrollment. Newly eligible employees may enroll in one of the PEIA PPB Plans or a
managed care plan. ey may make another plan selection during the next open enrollment period.
Special Rules for Newborn or Adopted Children
Newborn Child
When you have a child you must:
• provide documentation;
• PEIA will accept the Certicate of Live Birth from the hospital as documentation to enroll the child initially,
but you must provide the Birth Certicate as soon as you have it or PEIA will suspend the child’s coverage until
we receive it;
• you do not need a Social Security Number to enroll your newborn, but when you get the baby a Social Security
Number, please provide it to your benet coordinator or to PEIA.
To enroll the child for health coverage you must:
• enroll your biological newborn child for health coverage during the calendar month of birth or the two follow-
ing calendar months;
• coverage will be made eective retroactive to the date of birth;
• any premium increase associated with the addition of this child will also be retroactive to the month of birth;
and
• if you do not enroll your newborn within this time frame, you cannot add the newborn child until the next
open enrollment period.
To enroll the child for life insurance coverage you must:
• add a biological newborn child to your existing dependent life insurance policy during the calendar month of
or the two calendar months following the date of birth;
• coverage will be made eective retroactive to the date of birth;
• any premium increase associated with the addition of this child will also be retroactive to the month of birth;
• if you add the child later, you will have to submit medical information and be approved to obtain dependent
life insurance coverage for your child.
Adopted C
hild
When you adopt a child you must:
• provide documentation;
• PEIA requires a copy of the adoption papers to enroll the child;
• in the case of a foreign adoption, PEIA requires adoption papers in English, and may require entry visa and/or
statement from the U.S. consulate in the country of origin recognizing the adoption.
To enroll the child for health coverage you must:
• enroll an adopted child during the calendar month the child is placed in your home or the two following calen-
dar months;
PEIA 2017-2018 SPD ABD-REV.indd 14 7/13/17 9:15 AM
15
• coverage will be made eective retroactive to the date of placement;
• any premium increase associated with the addition of this child will also be retroactive to the date of placement;
• coverage for an adopted infant will become eective the day the adoptive parents are legally and nancially
responsible for the medical expenses if bona de legal documentation is presented to PEIA;
• if you do not enroll your child within this timeframe, the adopted child cannot be added to your coverage until
the next open enrollment period.
To enroll the child for life insurance coverage you must:
• add an adopted child to your existing dependent life insurance policy during the calendar month of or the two
calendar months following the date of placement in your home;
• coverage can be made eective retroactive to the date of placement;
• any premium increase associated with the addition of this child will also be retroactive to the date of placement;
• if you add the child later, you will have to submit medical information and be approved to obtain dependent
life insurance coverage for your adopted child.
Eligibility and Enrollment for Retired Employees
Who Is Eligible?
Retired public employees are eligible for health and life benets through PEIA, provided:
1. you meet the minimum eligibility requirements of the applicable State retirement system or a PEIA-approved
retirement system; and
2. your last employer immediately prior to retirement is a participating employer in the PEIA Plan and under the
State retirement system or a PEIA-approved retirement system.
Members who participate in a non-State retirement system must, in the case of education employees (such as
TIA ACREF, TDC or similar plans), meet the minimum eligibility requirements of the State Teachers Retirement
System, and in other cases, meet the minimum eligibility requirements of the Public Employees Retirement System.
If you have questions about your retirement, contact the Consolidated Public Retirement Board (CPRB) toll-free at
1-800-654-4406.
If you have PEIA coverage as an active employee, you may continue coverage into retirement without interruption. To
do so, you must complete Retired Employee Enrollment Forms during the calendar month of retirement or the two fol-
lowing calendar months. e retiring employee and all enrolled dependents must re-enroll to continue health benets
into retirement.
PEIA oers non-Medicare retirees coverage through PEIA PPB Plan A or B or an HMO. Non-Medicare retirees must
continue coverage in the plan in which they were covered as active employees until the next open enrollment, when
they can choose any plan for which they are eligible. Retiring employees enrolled in PEIA PPB Plans C or D must
choose either PEIA PPB Plan A or B upon retirement, since Plans C and D are not oered to retirees. Medicare-eligible
PPB Plan members who retire after the beginning of a plan year, and retired employees who become eligible for Medi-
care during the plan year are transferred to PEI A’s Special Medicare Plan until the beginning of the next Medicare plan
year. Members enrolled in an HMO when they become Medicare-eligible will be transferred to the Special Medicare
Plan. Medicare’s Plan Year runs from January through December; PEIA follows that plan year for Medicare Retirees.
Open Enrollment for Medicare members is held during the month of October with benets eective on January 1.
Under the Special Medicare plan, the member must enroll for traditional Medicare Parts A and B, and their second-
ary medical and prescription claims are paid by HealthSmart and CVS Caremark, respectively. Medical benets under
PEIA 2017-2018 SPD ABD-REV.indd 15 7/13/17 9:15 AM
16
the Special Medicare Plan are generally the same as those provided under PEIA’s Medicare Advantage plan. Members
remain in the Special Medicare Plan until the beginning of the next Medicare Plan Year (January 1), when they are
transferred to PEIA’s Medicare Advantage Plan.
ese members can request to be transferred immediately to the Humana/PEIA Plan 1. ere are two main benet dif-
ferences between the PEIA Special Medicare Plan and the Humana/PEIA Plan 1:
1. e Special Medicare Plan does not oer the SilverSneakers® tness benet that includes a free tness center
membership. is is only available from Humana.
2. e cost of non-preferred brand name medications is dierent.
a. Under the Humana/PEIA Plan1, the copay for a 30-day supply of a non-preferred drug is $50 and
maintenance medications in this category are eligible for the maintenance medication discount.
b. Under the Special Medicare plan, a 30-day supply of a non-preferred drug will cost you 75% of the
cost of the drug, and maintenance medications in this category are NOT eligible for the maintenance
medication discount.
Continuous coverage and employment are necessary if you wish to use your accrued sick and/or annual leave for
extended employer-paid PEIA coverage. You cannot defer your sick and/or annual leave. See page 34 for more informa-
tion on extending employer paid insurance upon retirement.
If you were not covered under a PEIA Plan as an active employee or if you allow your coverage to lapse, you may choose
to enroll for health coverage at the time of your retirement if your last employer immediately prior to retirement is a
participating employer in the PEIA Plan and under the State retirement system and as long as you meet the minimum
retirement qualications as determined by CPRB. Coverage will be eective on the rst day of the month following
enrollment.
Return to Active Employment
If you retire, then return to active employment with a participating agency, you will lose your right to use your sick
and/ or annual leave for extended employer-paid PEIA coverage. When you return to active employment, you have
PEIA benets as an active employee, which makes your new eective date of coverage in the PEIA plan after July 1,
2001, and therefore you are ineligible for the sick/annual leave benet. e only exception to this rule is provided for
those who participated in the plan prior to July 1, 2001, and who become reemployed with an employer participating
in the plan within two years following separation from employment (retirement). In this case, the employee would be
permitted to apply any sick and/or annual leave earned after re-employment, toward health premiums at retirement.
Employees hired on and after July 1, 2010, will not receive any plan subsidy of their premiums at retirement. ese
employees may continue coverage in the plan at retirement, but must pay the unsubsidized premium for the coverage of
their choice. Two exceptions will be made to this rule:
1. Active employees hired before July 1, 2010, who separate from public service but return within two years of
their separation may be restored to their original (pre-July 1, 2010) hire date.
2. Retired employees who had an original hire date prior to July 1, 2010, may return to active employment and
retain their pre-July 1, 2010, original hire date for purposes of determining their eligibility for premium subsidy.
Deferred Retirement
If you separate from employment before your retirement from a participating employer under the State retirement plan,
you may not enroll in PEIA as a retiree if you have other (private sector) employment just prior to retirement. To be eli-
gible to enroll in PEIA, your last employer immediately prior to retirement must have been a public entity that partici-
pates in the State retirement system or a PEIA-approved retirement system, and in the PEIA Plan.
PEIA 2017-2018 SPD ABD-REV.indd 16 7/13/17 9:15 AM
17
Separated Pre-retirement Employees with 20 Years’ Service
Employees with 20 or more years of service, who separate from public employment but who have not retired, may en-
roll in PEIA health benets for up to two (2) years following separation. Employees in this category will be required to
pay 105% of the total unsubsidized premium for the coverage they choose. Enrollees in this category are not eligible for
PEI A’s retiree premium assistance program or retiree premium subsidy until such time as they meet CPRB and PEI A’s
eligibility requirements as a full retiree.
Disability Retirement
A member who is granted disability retirement by a state retirement system or who receives Social Security disability
benets is eligible to continue coverage in the PEIA Plan as a retired employee, provided that the member meets the
minimum years of service requirement of the applicable state retirement system. Members in this category pay the
same premiums as those with 25 or more years of service. If you receive Social Security Disability benets, please send
a copy of your Disability Award letter to PEIA. Generally, those awarded Social Security disability benets will receive
Medicare benets after a two-year waiting period. When you receive your Medicare ID card, you must provide a copy
of that card to PEIA immediately. Disability retirees may be eligible for a life insurance waiver of premium. See page 36
for details.
Non-State Agency Retirees
Employees who retire from non-state entities which employer joined the PEIA Plan after July 1, 2010, will be assigned
a “hire date” in the PEIA systems that is the same as their eective date of coverage under the PEIA Plan. Upon retire-
ment, these employees will be treated as those hired on or after July 1, 2010, and will be required to pay the full cost of
their coverage.
Deputy Sheriffs
Deputy sheris have the right to retire prior to attaining age 55 and continue their health benets by paying the pre-
miums designated for them in the Shopper’s Guide each year. At the time of retirement, these retirees must continue
coverage in the plan in which they were covered as active employees until the next open enrollment, when they can
choose any plan for which they are eligible. Retiring employees enrolled in PEIA PPB Plans C or D must choose either
PEIA PPB Plan A or B upon retirement, since Plans C and D are not oered to retirees.
Medicare
As a retired employee or a dependent of a retired employee, when you become an eligible beneciary of Medicare, you
must:
1. enroll in Medicare Part A and Medicare Part B; and
2. send a copy of your Medicare ID card to PEIA.
Your Medicare Health Insurance Claim (HIC) number is required for coverage in PEI A’s Medicare Advantage Plan or
the Special Medicare Plan.
Most Medicare-eligible retired employees and Medicare-eligible dependents of retired employees have coverage through
PEI A’s Medicare Advantage plans.
• To be eligible for PEI A’s Medicare Advantage plans, the member must enroll for Medicare Parts A and B.
• If you do not enroll in Medicare Parts A & B and pay the monthly premium, you will not be eligible for PEI A’s
Medicare Advantage plans, which is the only coverage oered to most retired, Medicare-eligible members.
e Medicare Advantage Plans provide dierent benet options from which Medicare-eligible retirees can choose.
Open Enrollment for Medicare retirees is held each October, with benets eective on January 1. Medicare retirees’
PEIA 2017-2018 SPD ABD-REV.indd 17 7/13/17 9:15 AM
18
plan year runs from January through December. Benets for non-Medicare dependents covered by PEIA will run on
PEI A’s plan year from July through June.
If you become eligible for Medicare prior to age 65, please send a copy of your Medicare card and any disability award
letter to PEIA. is notication may allow PEIA to reduce your premiums, and will make the claims payment process
go much more smoothly.
Medicare oers prescription drug coverage through a program called Medicare Part D. Please be aware that you should
NOT purchase Medicare Part D coverage. You DO NOT need to enroll in a separate Medicare Part D plan, since
PEIA will provide prescription drug coverage for retirees with Medicare. If you enroll in a separate Medicare Part D
plan, you will be disenrolled from all medical and prescription benets from PEIA. You will have only original Medi-
care Parts A, B and D with no secondary coverage.
Dependents
If you elect PEIA coverage, you may also enroll the following dependents:
• your legal spouse;
• your biological children, adopted children, or stepchildren under age 26; or
• other children for whom you are the court-appointed guardian to age 18.
A child may not be enrolled for health coverage as both a policyholder (as a public employee in his or her own right)
and as a dependent child.
From time to time PEIA may conduct eligibility audits to verify that policyholders and dependents in the plan qualify
for coverage. If you are audited, you will have to produce documentation for the dependent in question. If you can-
not prove that the dependent qualies for coverage, coverage will be terminated retroactively to the date the dependent
would otherwise have been terminated, and PEIA will pursue reimbursement of any medical or prescription drug
claims paid during the time the dependent was ineligible.
How to Enroll
You may enroll for PEIA health and life benets by completing enrollment forms available from your benet coordinator
or the PEIA. On these forms, you will select the types of coverage you want and enroll the eligible dependents you wish to
cover. When you have completed the forms, return them to your benet coordinator (if initially retiring) or to the PEIA (if
already retired). Participation in PEIA benet plans is not automatic upon retirement; you must complete the proper en-
rollment forms. Enrollment authorizes PEIA to deduct the premiums from your annuity for the coverages you select. ere
are restrictions on how and when you may enroll and make changes in your coverage. Please read all parts of the “Eligibil-
ity” section of this booklet carefully before you enroll, so that you will fully understand your options and responsibilities.
At present, you cannot initially enroll for retirement benets on PEI A’s online enrollment website, but once you are
retired, you may make changes in your information by going to www.wvpeia.com and clicking on “Manage My
Benets”.
PEIA PPB Plan/PEIA’s Medicare Advantage Plan
You may enroll for PEIA retiree benets regardless of age, as long as you meet the eligibility requirements. Non-Medi-
care retirees have benets through the PEIA PPB Plan A or B or the managed care plan of their choice. Most Medi-
care eligible retirees receive their benets from PEIA’s Medicare Advantage plan, although some are enrolled in PEI A’s
Special Medicare Plan.
Managed Care Plans
As a retired employee, you may enroll in a managed care plan if you are not yet eligible for Medicare. If you or any
enrolled dependents have Medicare as your primary health coverage (or will at any time during the plan year), you may
PEIA 2017-2018 SPD ABD-REV.indd 18 7/13/17 9:15 AM
19
not join an HMO. Generally, Medicare or an MAPD plan is primary when the policyholder is retired. If you have
more questions about when Medicare is primary, call PEI A’s Customer Service Unit at 1-888-680-7342.
Life Insurance
You may continue your basic, optional and dependent life insurance at the time of retirement. If you wish to elect new
or increased life insurance as a retired employee, you must enroll and submit medical information during the calendar
month of retirement or the two following calendar months. Coverage will be eective upon approval of PEIA’s life
insurance carrier. You may not elect or increase life insurance after this period.
Enrolling Your Dependents
You may enroll dependents for health coverage when you enroll as a retiree, and if you do, their coverage begins the
same day as yours. You may enroll dependents for health coverage outside your initial enrollment period only if you
experience a qualifying event. To make a change as a result of a qualifying event, you must do so during the month of
the event or the following two calendar months or you will have to wait until the next open enrollment. If you enroll
them at a later date, their coverage will become eective the rst day of the month following enrollment. In the absence
of a qualifying event, you may only enroll dependents for health coverage during Open Enrollment; coverage will be
eective on the rst day of the following plan year. To add a dependent to your coverage, you must submit documenta-
tion to prove that this is an eligible dependent. See page 26 for details.
If you are adding a dependent to your existing dependent life insurance policy at a date later than the two calendar
months following a qualifying event, coverage will not become eective until medical information has been submitted
to, and approved by, PEI A’s life insurance carrier. To add a dependent to your coverage, you must submit documenta-
tion to prove that this is an eligible dependent. See page 26 for details.
Dependents may be removed from coverage during open enrollment or at the time of a qualifying event. To make a
change as a result of a qualifying event, you must do so during the month of the event or the following two calendar
months or you will have to wait until the next open enrollment. Qualifying events which end eligibility (such as di-
vorce) must be reported immediately. e policyholder must provide documentation supporting the qualifying event to
remove dependents. Coverage of removed dependents will terminate at the end of the month in which the policyholder
removes them from coverage. For purposes of eligibility, the term “immediately” shall mean as soon as practically pos-
sible and, in no case, greater than thirty (30) days from the date of the event, e.g. divorce.
PEIA PPB Plan/Special Medicare Plan/PEIA’s Medicare Advantage Plan
For the PPB Plan, the Special Medicare Plan or PEI A’s Medicare Advantage Plan, you must enroll new dependents
during the calendar month of, or the two calendar months following, the date of the qualifying event that makes them
eligible (i.e., date of marriage, date of birth or adoption) even if you already have family coverage. To add a dependent
to your coverage, you must submit documentation to prove that this is an eligible dependent. See page 26 for details.
In the absence of a qualifying event, coverage may be added for the employee and/or eligible dependents, only during
PEI A’s annual Open Enrollment period.
Life Insurance
Add new dependents to your existing dependent life insurance policy during the calendar month of or the two calendar
months following the date they become eligible (i.e., date of marriage, date of birth or adoption). Otherwise, you will
have to submit medical information and be approved to obtain dependent life insurance coverage.
PEIA 2017-2018 SPD ABD-REV.indd 19 7/13/17 9:15 AM
20
Special Rules for Newborn or Adopted Children
Newborn Child
When you have a child you must:
• provide documentation;
• PEIA will accept the Certicate of Live Birth from the hospital as documentation to enroll the child initially,
but you must provide the Birth Certicate as soon as you have it or PEIA will suspend the child’s coverage until
we receive it;
• you do not need a Social Security Number to enroll your newborn, but when you get the baby a Social Security
Number, please provide it to your benet coordinator or to PEIA.
To enroll the child for health coverage you must:
• enroll your biological newborn child for health coverage during the calendar month of birth or the two follow-
ing calendar months;
• coverage will be made eective retroactive to the date of birth;
• any premium increase associated with the addition of this child will also be retroactive to the month of birth; and
• if you do not enroll your newborn within this time frame, you cannot add the newborn child until the next
open enrollment period.
To enroll the child for life insurance coverage you must:
• add a biological newborn child to your existing dependent life insurance policy during the calendar month of
or the two calendar months following the date of birth;
• coverage will be made eective retroactive to the date of birth;
• any premium increase associated with the addition of this child will also be retroactive to the month of birth;
• if you add the child later, you will have to submit medical information and be approved to obtain dependent
life insurance coverage for your child.
Adopted Child
When you adopt a child you must:
• provide documentation;
• PEIA requires a copy of the adoption papers to enroll the child;
• in the case of a foreign adoption, PEIA requires adoption papers in English, and may require entry visa and/or
statement from the U.S. consulate in the country of origin recognizing the adoption.
To enroll the child for health coverage you must:
• enroll an adopted child during the calendar month the child is placed in your home or the two following calen-
dar months;
• coverage will be made eective retroactive to the date of placement; and
• any premium increase associated with the addition of this child will a
lso be retroactive to the date of placement;
• coverage for an adopted infant will become eective the day the adoptive parents are legally and nancially
responsible for the medical expenses if bona de legal documentation is presented to PEIA;
• if you do not enroll your child within this timeframe, the adopted child cannot be added to your coverage until
the next open enrollment period.
PEIA 2017-2018 SPD ABD-REV.indd 20 7/13/17 9:15 AM
21
To enroll the child for life insurance coverage you must:
• add an adopted child to your existing dependent life insurance policy during the calendar month of or the two
calendar months following the date of placement in your home;
• coverage can be made eective retroactive to the date of placement;
• any premium increase associated with the addition of this child will also be retroactive to the date of placement;
• If you add the child later, you will have to submit medical information and be approved to obtain dependent
life insurance coverage for your adopted child.
Eligibility and Enrollment for Surviving Dependents
Who Is Eligible
e surviving spouse or dependent of an active or retired public employee who was insured as a spouse or dependent
under the policyholder’s coverage by PEIA at the time of the policyholder’s death, may elect to continue health coverage
as a policyholder in his or her own right under the health plan using a Surviving Dependent enrollment form available
from PEIA.
If you are such a surviving spouse and you choose not to enroll immediately for coverage, you may elect PEIA health
coverage during a future Open Enrollment Period, if you have not remarried. e surviving spouse’s eligibility for PEIA
coverage terminates upon remarriage. If a divorce occurs after the remarriage, re-enrollment as a surviving dependent is
not allowed.
Dependent Children
• Surviving dependent children are eligible to continue health coverage, if they were enrolled in the health cover-
age at the time of the policyholder’s death, subject to the same age restrictions as other dependent children in
the PEIA plan.
• e deceased policyholder’s biological or adopted children or stepchildren may continue coverage to age 26
• other children for whom the deceased policyholder was the court-appointed guardian to may continue coverage
to age 18
• Surviving dependent biological children, adopted children, or stepchildren may be covered under the plan to
age 26, regardless of their residency, marital status, or the availability of other insurance coverage. e depen-
dent child’s marriage is a qualifying event to cancel PEIA coverage. A married surviving dependent child may
not enroll his or her spouse for PEIA coverage.
From time to time PEIA may conduct eligibility audits to verify that policyholders and dependents in the plan qualify
for coverage. If you are audited, you will have to produce documentation for the dependent in question. If you can-
not prove that the dependent qualies for coverage, coverage will be terminated retroactively to the date the dependent
would otherwise have been terminated, and PEIA will pursue reimbursement of any medical or prescription drug
claims paid during the time the dependent was ineligible.
How to Enroll
To continue health coverage without interruption, surviving dependents must complete enrollment forms in the calen-
dar month death occurs or the two following calendar months. In this case, surviving dependents must enroll in the
same plan in which they were covered at the time of the policyholder’s death. During open enrollment, you may select
any plan for which you are eligible. Surviving dependents are not eligible for life insurance.
PEIA 2017-2018 SPD ABD-REV.indd 21 7/13/17 9:15 AM
22
In the event of the death of the employee spouse who is the policyholder in the PEIA Plan, when the surviving depen-
dent is also an active or retired public employee who is benet-eligible in his or her own right, the surviving dependent
has a choice to make. He or she must choose whether to enroll in the PEIA plan as a surviving dependent of the policy-
holder, or as an active or retired employee.
If you enroll as a surviving dependent before July 1, 2015, premiums will be based on the Medicare or non-Medicare
(depending on the survivor’s age) retiree premium with 25 or more years of service, but the surviving dependent is not
eligible for life insurance.
If you enroll as a surviving dependent on or after July 1, 2015, premiums will be based on the Medicare or non-Medi-
care (depending on the survivor’s age) retiree premium and the years of service earned by the deceased policyholder, but
the surviving dependent is not eligible for life insurance.
If enrolled as an active or retired employee, premiums will be based on the appropriate active employee premium chart
or if retired, the surviving employee’s own years of service, and he or she will be eligible for life insurance.
If you need help evaluating which would be better, please contact PEIA’s customer service unit at 1-888-680-7342.
Special Eligibility Situations
If You and Your Spouse are Both Public Employees
Two public employees who are married to each other and who are both eligible for benets under PEIA may elect to
enroll as follows:
1. as Family with Employee Spouse in any plan;
2. as “Employee Only” and “Employee and Child(ren)” in two dierent plans;
3. as “Employee Only” and “Employee and Child(ren)” in the same plan.
All children must be enrolled under the same policyholder. If no children are to be covered, you may enroll as “Family
with Employee Spouse” or as separate “Employee Only” plans. Both employees are eligible to enroll for the basic life
policy, as well as optional and dependent life insurance.
To qualify for the Family with Employee Spouse premium, both employees MUST have basic life insurance. For active
employees, the premium for Family with Employee Spouse coverage is based on the average of the two employees’ sala-
ries. e Family with Employee Spouse discount is also oered when the ‘employee spouse’ is a retired public employee;
the premium for this coverage is based on the active employee’s salary.
Generally, since both spouses, as policyholders, are eligible to make independent benet elections, both spouses receive
the Shopper’s Guide, Summary Plan Description, and other relevant benet information.
If the employee spouse on an active employee’s plan is retired and Medicare-eligible, that employee spouse may want to
consider becoming a “policyholder only” in PEI A’s Medicare Advantage plan. Doing so could reduce your total pre-
mium and cost-sharing, depending on your situation.
In the event of the death of the employee spouse who is the policyholder in the PEIA Plan, when the surviving depen-
dent is also an active or retired public employee who is benet-eligible in his or her own right, the surviving dependent
has a choice to make. He or she must choose whether to enroll in the PEIA plan as a surviving dependent of the policy-
holder, or as an active or retired employee.
PEIA 2017-2018 SPD ABD-REV.indd 22 7/13/17 9:15 AM
23
If you enroll as a surviving dependent before July 1, 2015, premiums will be based on the Medicare or non-Medicare
(depending on the survivor’s age) retiree premium with 25 or more years of service, but the surviving dependent is not
eligible for life insurance.
If you enroll as a surviving dependent on or after July 1, 2015, premiums will be based on the Medicare or non-Medi-
care (depending on the survivor’s age) retiree premium and the years of service earned by the deceased policyholder, but
the surviving dependent is not eligible for life insurance.
If enrolled as an active or retired employee, premiums will be based on the appropriate active employee premium chart
or if retired, the surviving employee’s own years of service, and he or she will be eligible for life insurance.
If you need help evaluating which would be better, please contact PEIA’s customer service unit at 1-888-680-7342.
Transfer from One Participating Agency to Another
If you transfer from one participating agency to another in the middle of a plan year without a lapse in coverage, that
transfer does not constitute a qualifying event to change coverage. You can only change plans if the transfer moves you
out of the enrollment area of a plan so that accessing care is unreasonable. Since the PEIA PPB Plans A, B and C have an
unlimited enrollment area, you will not be permitted to transfer out of them during the plan year, even if you move. PEIA
PPB Plan D is available only to WV residents, so if you move outside the state you will be required to change plans.
When an employee transfers from one participating State agency to another, PEIA will collect updated salary informa-
tion, and the premium at the new agency will be based on the salary at the new agency, whether it is a salary increase or a
decrease. In this case, a plan change may be permitted, if the transfer creates a qualifying change in family status under the
Premium Conversion Plan. Other transfers may permit a change in coverage based on documented nancial hardship.
Disabled Child
Your dependent child may continue to be covered after reaching age 26 if he or she is incapable of self-support because
of mental or physical disability. To be eligible:
• the disabling condition must have begun before age 26;
• the child must have been covered by PEIA upon reaching age 26; and
• the child must be incapable of self-sustaining employment and chiey dependent on you for support and
maintenance. To continue this coverage, the WV PEIA Disabled Dependent Disability Application must be
obtained from PEIA, completed by a licensed physician, and returned to PEIA with all supporting medical
records, between 2-3 months prior to the dependent’s 26th birthday, to prevent a potential lapse in coverage.
Court-Ordered Dependent (COD)
If a PEIA policyholder and his or her spouse divorce, and the policyholder is not the custodial parent for the depen-
dent child(ren), the employee may continue to provide medical benets for the child(ren) through the PEIA plan. If
the noncustodial parent is ordered by the court to provide medical benets for the child(ren), the custodial parent may
submit medical claims for the court-ordered dependent(s), and benets may be paid directly to the custodial parent.
Special claim forms are required. e custodial parent will also receive Explanations of Benets (EOBs) for the CODs
as claims are processed. Contact PEIA to discuss this benet.
Medicare and Active Employees
If an active employee or the dependent of an active employee becomes eligible for Medicare and has no other insurance,
the PEIA PPB Plan remains the primary insurer, except if the policyholder or dependent attains Medicare eligibility
due to End Stage Renal Disease (ESRD). As long as you are an active employee, you and your Medicare-eligible de-
pendents are not required to sign up for Medicare Part B and pay the premium. When you prepare to retire, you and
PEIA 2017-2018 SPD ABD-REV.indd 23 7/13/17 9:15 AM
24
your Medicare-eligible dependents must enroll for Medicare Part B. If you do not enroll in Medicare Parts A & B, your
coverage may be terminated.
For PEIA PPB Plan active employees who are also eligible for Medicare, and Medicare is the primary payor (as in the
case of ESRD), PEIA will use the traditional method of coordinating benets, which means that once Medicare has
paid, PEIA will pay the balance up to 100% of Medicare’s allowed amount.
When you or your dependent become eligible for Medicare, you must send a copy of the Medicare card to PEIA.
Medicare-eligible Members Who Reside Outside the U.S.
Medicare-eligible retirees who reside outside the United States will have benets through PEI A’s Special Medicare Plan.
Medical claims will be processed by HealthSmart, and PEIA will pay only the amount we would have paid if Medicare
had processed your claim and made a payment. Prescription drug claims will be processed by CVS Caremark.
Leaves of Absence
It is the employer’s responsibility to make the determination regarding an employee’s eligibility for a leave of absence.
It is important to note that a leave of absence is intended for an employee who is expected to return to work and for
whom the employer maintains an open position. It is not intended to extend medical benets for individuals who are
not eligible to retire and not able to return to work, or for whom a position is not being held open. Such a person is not
an employee and it is improper to continue his or her health coverage as if he or she were still an employee. Employers
are reminded that under State law it is a felony to misrepresent any material fact to obtain PEIA benets to which a
person is not entitled (W. Va. Code §5-16-12).
Return from a leave of absence does not constitute a qualifying event which would allow the member to change plans
during the plan year.
Medical Leave (Non-Workers’ Compensation)
Any employee who is on a medical leave of absence due to an injury or illness that is not covered by Workers’ Compen-
sation is eligible to continue coverage subject to the following:
• the medical leave must be approved by the employer;
• the employee and employer must continue to pay their respective proportionate shares of the premium cost. If
the employee fails to pay his or her premium, the employer may terminate coverage;
• the employer is obligated to pay its share only for a period of one year, after which the employee may be re-
quired to pay the full cost of coverage. If the employee fails to pay his or her premium, the employer may
terminate coverage; and
• each month the employee must submit to the employer a physician’s statement certifying that the employee is
unable to return to work. e employer must retain these statements in the employee’s personnel le.
Medical Leave (Workers’ Compensation)
Any employee who is on a leave of absence and is receiving temporary total disability benets from Workers’ Compen-
sation is entitled to continue PEIA coverage until he or she returns to work. e employer and employee must continue
to pay their respective proportionate shares of the premium cost for as long as the employee receives temporary total
disability benets. If the employee fails to pay his or her premium, the employer may terminate coverage.
Personal Leave
An employee may continue insurance coverage while on a personal leave of absence approved by the employer. e
monthly premium will be paid according to the policy or agreement established by the employer. If the employee fails
to pay his or her premium, the employer may terminate coverage.
PEIA 2017-2018 SPD ABD-REV.indd 24 7/13/17 9:15 AM
25
Family Leave
An employee may continue insurance coverage during an approved family leave. If the employee fails to pay his or her
premium, the employer may terminate coverage. Contact your benet coordinator for further details regarding the
federal Family and Medical Leave Act (FMLA).
Military Leave
For an employee on military leave with pay, health and life insurance benets will generally continue without interrup-
tion, as long as the employee is on the payroll.
An employee who is on an approved military leave of absence without pay, due to an active call of duty from the Presi-
dent, is entitled to continue health and life benet coverage for as long as premium payments are made. e employee
is responsible for paying the employee share of the premium costs for each month during the military leave of absence,
and Governor Wise’s Executive Order No. 19-01 requires the employer to pay its share. Upon return from a military
leave, if there has been a lapse in coverage, the employee may generally reinstate the same health and/or life insurance
benets without penalty.
Leaves of Absence for Teachers and Service Personnel
Any teacher or school service employee who is returning from an approved leave of absence of one year or less shall be
restored to the same benets which he or she had at the time of the approved leave of absence.
PEIA 2017-2018 SPD ABD-REV.indd 25 7/13/17 9:15 AM
26
Other Eligibility Details
Qualifying Events
A qualifying event is a personal change in status which may allow you to change your benet elections, whether you or
your employer participate in an IRS Section 125 plan, or not. Qualifying events which end eligibility (such as divorce)
must be reported immediately. For purposes of eligibility, the term “immediately” shall mean as soon as practically pos-
sible and, in no case, greater than thirty (30) days from the date of the event, e.g. divorce.
All qualifying events require substantiating documentation, which must be provided in English, as detailed in the
chart below:
Qualifying Event Documentation Required
Divorce Copy of the divorce decree showing that the divorce is nal
Marriage (of policyholder or dependent) Copy of valid marriage license or certicate — the dependent child’s
marriage is a qualifying event for the policyholder to remove the
dependent child from coverage. The policyholder MAY remove the
child, but is not required to do so.
Birth of Child Copy of child’s birth certicate
Adoption Copy of adoption papers
Adding coverage for a dependent child Copy of child’s birth certicate
Adding coverage for any other child who resides with policyholder Copy of court-ordered guardianship papers
Open Enrollment under spouse’s or dependent’s employer’s benet
plan
Copy of printed material showing open enrollment dates and the
employer’s name
Death of spouse or dependent Copy of death certicate
Beginning of spouse’s or dependent’s employment Letter from the spouse’s employer stating the hire date, effective date
of insurance, what coverage was added, and what dependents are
covered
End of spouse’s or dependent’s employment Letter from the employer stating the termination or retirement date,
what coverage was lost, and dependents that were covered
Signicant change in health coverage due to spouse’s or dependent’s
employment
Letter from the insurance carrier indicating the change in insurance
coverage, the effective date of that change and dependents covered
Unpaid leave of absence by employee, spouse or dependent Letter from your or your spouse’s or your dependent’s personnel
ofce stating the date the covered person went on unpaid leave or
returned from unpaid leave
Change from full-time to part-time employment or vice versa for
policyholder, spouse or dependent
Letter from the employer stating the previous hours worked and the
new hours worked and the effective date of the change
All documents used in support of eligibility transactions: birth certicates, adoption papers, marriage certicates,
divorce decrees, and citizenship documents (Visas, permits, residency documents, etc.), must be in English or have a
certied English translation.
If you experience a qualifying event, you have the month of the event and the two following calendar months to act
upon that qualifying event and change your coverage. If you do not act within that timeframe, you cannot make the
change until the next open enrollment. Qualifying events which end eligibility (such as divorce) must be reported im-
mediately. For purposes of eligibility, the term “immediately” shall mean as soon as practically possible and, in no case,
greater than thirty (30) days from the date of the event, e.g. divorce.
PEIA 2017-2018 SPD ABD-REV.indd 26 7/13/17 9:15 AM
27
Annual Open Enrollment
Each Spring PEIA holds an open enrollment period for active employees and non-Medicare retirees for health cover-
age. e period is typically the month of April. During Open Enrollment, current active employee and non-Medicare
retiree participants may move between plans and make eligibility changes, such as adding or removing dependents or
adding or dropping coverage. Choices made during the open enrollment period are eective on July 1 of that year.
During Open Enrollment, eligible policyholders who have not taken advantage of any health coverage from PEIA also
have the opportunity to enroll in the PEIA PPB Plan or any managed care plan, subject to the deadlines and rules in
force for that enrollment period. Selections made during Open Enrollment are eective on July 1 of that year, and
remain in eect for a full plan year unless the member moves outside the service area of his or her plan. A physician’s
withdrawal from a managed care plan does not qualify a member to change plans in the middle of a plan year.
At the beginning of Open Enrollment, PEIA mails a Shopper’s Guide to all active and non-Medicare retired poli-
cyholders. e Shopper’s Guide provides a side-by-side comparison of the general attributes of all plans oered. It is
intended as a general guide to the available plans. Members requiring further information about a specic plan should
contact that plan directly.
Medical Identification Cards
Each plan mails ID cards to its members. Managed care plans issue ID cards each year. PEIA issues cards upon enroll-
ment in the plan, and subsequently when there are changes in the plan that warrant it.
Your PEIA PPB Plan ID card veries that you have medical and prescription drug coverage through PEIA. On the
back, we’ve listed important phone numbers you may need. Members enrolled in the Comprehensive Care Partnership
will receive individualized cards with provider information. All others will receive one card for individual coverage, and
two cards for family coverage in the policyholder’s name. If you want additional cards, or if you need to replace a lost
card, please contact HealthSmart at 1-888-440-7342.
If you enroll in a managed care plan or if you are in PEI A’s MAPD plan, you will receive an identication card from
that plan, not from PEIA. For additional or replacement cards, call your plan.
Your Responsibility to Make Changes
It is your responsibility to keep your PEIA enrollment records up to date. You must notify your benet coordinator or
PEIA immediately of any changes in your participation status or in your family situation, and make the appropriate
change to keep your PEIA coverage up to date. Examples of such changes include retirement or disability retirement, a
change of address, a change in your marital status, or a dependent child no longer qualifying for coverage.
You must do this whether you belong to the PEIA PPB Plan, the Special Medicare Plan, PEIA’s Medicare Advantage
plan, a managed care plan or if you’ve elected only life insurance coverage. If you fail to notify your benet coordina-
tor or PEIA promptly of changes in your family status, your employing agency may look to you for reimbursement of
premiums your employer paid in error, and your plan may adjust claims paid for ineligible enrollees.
You can update your enrollment records at any time by logging on to the PEIA website at www.wvpeia.com and
clicking on the green “Manage My Benets” button. If you do not have internet access, you may update your re-
cords using a form available from your benet coordinator or by calling PEIA. Completed forms should be returned
to your benet coordinator.
PEIA 2017-2018 SPD ABD-REV.indd 27 7/13/17 9:15 AM
28
When Coverage Ends
Coverage for a policyholder and/or dependents will end at the end of the month in which the individual is no longer
enrolled for or eligible for coverage. In most cases when your coverage ends you have the option to extend health cover-
age under the federal COBR A law, or convert your life insurance benets into a private policy. All of these options are
at your expense and require you to act within a specied time. Please see the section on “Options After Termination of
Coverage” on page 30.
Voluntary Termination of Employment
PEIA coverage for an active policyholder and any covered dependents terminates at the end of the month in which
the employee voluntarily ceases employment. For employees on delayed payroll, coverage will terminate at the end
of the month in which their employment terminates, although they may continue to receive paychecks due to their
delayed payroll status.
Involuntary Termination of Employment
A policyholder who is terminated from employment involuntarily or through a reduction of work force may continue
coverage for three additional months after the end of the month in which employment ends. e employer must con-
tinue to pay the employer’s share of the premium during these three months. e policyholder will be responsible for
paying the employee’s share of the premium during these three months.
Termination for Misconduct
If an employee is discharged for misconduct and chooses to contest the charge, he or she may extend coverage for up
to 3 months while available administrative remedies are pursued. If the discharge is upheld, the former employee must
reimburse the employer’s share of the premium cost for the extended coverage to the former employer.
Voluntary Termination of Benefits
PEIA coverage for an active policyholder and any covered dependents terminates at the end of the month in which the
employee voluntarily terminates the coverage; provided that the employee has experienced a qualifying event that allows
such termination. Qualifying events which end eligibility (such as divorce) must be reported immediately. For purposes
of eligibility, the term “immediately” shall mean as soon as practically possible and, in no case, greater than thirty (30)
days from the date of the event, e.g. divorce. In the absence of a qualifying event, coverage cannot be terminated until
the next Open Enrollment period.
Retired/Retiring Employees
Coverage for an employee who has already retired will terminate at the end of the calendar month in which the retiree
elects no longer to participate, provided that the retired employee has experienced a qualifying event that allows such ter-
mination. In the absence of a qualifying event, coverage cannot be terminated until the next Open Enrollment period.
For retiring employees, coverage will terminate at the end of the month in which the employee ceases active employ-
ment, unless forms have been completed to continue coverage. If you are not yet eligible for Medicare, then your retire-
ment does not qualify you to change health care plans. If you are enrolled in a managed care plan as an active employ-
ee, then you must remain in that managed care plan upon retirement until the next open enrollment, when you may
choose any plan for which you are eligible. If Medicare becomes the primary coverage for you or your dependents while
enrolled in a managed care plan, you must transfer to PEI A’s Medicare Advantage plan or the Special Medicare Plan.
PEIA 2017-2018 SPD ABD-REV.indd 28 7/13/17 9:15 AM
29
Dependents/Surviving Dependents
Coverage for dependents terminates at the end of the calendar month in which one of the following occurs:
• policyholder (active or retired) terminates or loses coverage;
• dependent spouse is divorced from employee;
• dependent child reaches his/her 26th birthday;
• surviving spouse remarries;
• child for which policyholder is legal guardian reaches his/her 18th birthday;
• disabled dependent no longer meets disability guidelines; or
• policyholder voluntarily removes dependent from coverage.
e policyholder is required to report these events online at www.wvpeia.com using the “Manage My Benets” but-
ton, or by completing the appropriate forms to remove ineligible dependents. Qualifying events which end eligibility
(such as divorce) must be reported immediately. If a policyholder fails to remove ineligible dependents (divorced spouse,
etc.) the Plan may pursue reimbursement of any claims paid for the ineligible dependent from the employee. For pur-
poses of eligibility, the term “immediately” shall mean as soon as practically possible and, in no case, greater than thirty
(30) days from the date of the event, e.g. divorce.
e policyholder may voluntarily terminate coverage for dependents when there has been a qualifying event to allow
such a change. To make a change as a result of a qualifying event, you must do so during the month of the event or
the following two calendar months or you will have to wait until the next open enrollment. Qualifying events which
end eligibility (such as divorce) must be reported immediately. For purposes of eligibility, the term “immediately” shall
mean as soon as practically possible and, in no case, greater than thirty (30) days from the date of the event, e.g. di-
vorce. Go to www.wvpeia.com and use the “Manage My Benets” button, or complete the appropriate forms. If cov-
erage is terminated, it cannot be reinstated until the next Open Enrollment period, unless there is a qualifying event.
Failure to Pay Premium
Your coverage as an active or retired policyholder, and coverage of your dependents, will be terminated if you fail to
pay your premium contributions when due. Premiums are due by the fth day of the month following the month for
which the premium was invoiced. Example: May premium is due June 5. If payment is not received by PEIA within
30 days following the due date, all coverage may be suspended. If payment is not received within 45 days following the
due date, coverage will be cancelled, and all claims incurred will be your personal responsibility. PEIA will also submit
premiums over-due by 45 days to a collection agency.
Direct Pay
For non-Medicare policyholders who pay premiums directly to PEIA, if payment is not received by PEIA within 30
days following the due date, a termination notice containing the termination date will be mailed to the policyholder.
All claims incurred following the termination date will be the policyholder’s personal responsibility. e policyholder
has the right to appeal the termination in writing within 60 days following the termination date.
• If the terminated policyholder appeals the termination in writing within 60 days from the date of termination,
he or she may pay the past-due premiums, apply to pay premiums by direct draft from a bank account, and
may be granted uninterrupted coverage at PEI A’s discretion.
• If the terminated policyholder appeals the termination in writing more than 60 days following the date of
termination, PEIA may only allow re-enrollment if the policyholder enrolls as a new enrollee and agrees to pay
premiums by direct draft from a bank account. Two terminations for failure to pay within a 12-month period
may result in permanent disqualication from coverage under the PEIA plan.
PEIA 2017-2018 SPD ABD-REV.indd 29 7/13/17 9:15 AM
30
If extenuating circumstances prevent the policyholder from appealing within 60 days of the termination, the policy-
holder may appeal for and the PEIA director may, at his or her discretion, grant a waiver of the 60-day requirement.
For Medicare policyholders who pay premiums directly to PEIA, failure to pay premiums will result in termination
from the plan consistent with applicable Medicare rules.
Non-State Agency Employer Withdrawal from the Plan
By its agreement to participate in the PEIA plan, a non-State entity is required by PEIA to stay in the plan for a mini-
mum of three years. If a participating county or municipal government or other employer withdraws or is terminated
from the PEIA plan, coverage for all aected insureds ends on the eective date of that employer’s withdrawal/termina-
tion. PEIA requires a written 30-day notice of a Non-State Agency’s intent to terminate its contract with PEIA.
Eligible retirees may continue participation in PEIA. e withdrawn agency is billed a non-participating agency premi-
um for these retirees. Retirees not eligible to participate in PEIA must look to their former employer for retiree coverage.
Options after Ter minat ion of Coverage
If your PEIA coverage terminates, you may have a right to continue health and life coverage. Your options are ex-
plained below.
Continuing Health Coverage under COBRA
You and your enrolled dependents may have the right to continue your current health coverage for a limited time under
the federal Consolidated Omnibus Budget Reconciliation Act (COBR A). PEIA’s COBRA program is administered by
HealthSmart, and all COBRA eligibility is maintained by HealthSmart. New enrollees in any PEIA-sponsored health
plan will receive a detailed notice of their COBRA rights from HealthSmart.
You and/or your dependents may elect to continue coverage for up to 18 months due to termination of your employ-
ment (other than by reason of gross misconduct) or reduction in work hours.
Your dependents are eligible to continue coverage in their own right for a maximum of 36 months under COBRA in
the case of:
• divorce or legal separation;
• loss of eligibility of dependent children; or
• death of employee.
An election to continue coverage under COBRA must be made within 60 days of the end of the coverage. If you elect
to continue coverage under COBRA, you will be responsible for paying the full premium plus a 2% administrative fee.
Please note that COBRA premiums are billed directly to you.
To enroll for COBRA benets, contact HealthSmart at 1-888-440-7342.
If 18 months of COBRA coverage is provided due to termination or reduction in hours of employment, and if any CO-
BRA beneciary is determined to be disabled under the Social Security Act at any time during the rst 60 days of this
COBRA coverage, then the 18-month continuation period may be extended to 29 months for all individuals who are
qualied beneciaries. e disabled person can be a covered employee or a dependent. e disability determination must
be reported to PEIA within 60 days of the determination and before the end of the original 18-month coverage period.
Under COBRA, PEIA will charge 150% of the applicable premium for coverage during the 11-month disability exten-
sion. If a second qualifying event occurs during the 11-month extension, entitling a qualied beneciary to 36 months
of coverage (an additional 7 months of coverage), then PEIA will charge 150% of the applicable premium until the end
PEIA 2017-2018 SPD ABD-REV.indd 30 7/13/17 9:15 AM
31
of the 36-month continuation coverage period. Coverage under COBRA will cease under these circumstances (“you”
refers to the person who elected COBRA):
• you become covered under another group plan (unless it contains a pre-existing condition exclusion that re-
duces your benets);
• you become entitled to Medicare;
• you fail to pay the premium;
• the policyholder’s former employer withdraws or is terminated from the PEIA plan; or
• the PEIA PPB Plan ends.
If you are covered by another health plan or Medicare before the COBRA election is made, you may make a COBRA
election. In other words, your employer may end the right to COBRA continuation coverage based upon other group
health plan coverage or entitlement to Medicare benets only if the qualied beneciary rst becomes covered under the
other group health plan coverage or entitled to (covered for) the Medicare benets after the date of the COBRA election.
Converting Life Insurance to an Individual Policy
When employment ends, you may convert all or part of the life insurance coverage into an individual policy. Depen-
dents who lose eligibility for life insurance coverage may convert optional dependent life insurance to an individual
policy. is provision does not apply to retired employees or their dependents.
You must submit an application and remit the rst premium within 31 days after the termination of the life insurance
coverage. Coverage under the individual policy will become eective the day after the group life insurance coverage ends.
To obtain a Life Insurance Conversion Application Form, call Minnesota Life at 1-800-203-9515. e individual life
insurance policy is issued by PEIA’s life insurance carrier, Minnesota Life. Once you have completed the application
form, mail it to the address printed on the application form. Premiums for individual policies are generally higher than
rates for a group plan.
Paying for Benets
Each year the PEIA Finance Board sets premium rates for the PEIA PPB Plans. Premiums are set at a level that ensures
that the premiums collected from employers and employees will pay the anticipated claims for that year. Managed care
plan premiums are also set annually prior to Open Enrollment.
Your coverage as an active or retired policyholder, and coverage of your dependents, will be terminated if you fail to
pay your premium contributions when due. Premiums are due by the fth day of the month following the month for
which the premium was invoiced. Example: May premium is due June 5. If payment is not received by PEIA within
30 days following the due date, all coverage may be suspended. If payment is not received within 45 days following the
due date, coverage will be cancelled, and all claims incurred will be your personal responsibility. PEIA will also submit
premiums overdue by 45 days to a collection agency.
Direct Pay
For non-Medicare policyholders who pay premiums directly to PEIA, if payment is not received by PEIA within 30
days following the due date, a termination notice containing the termination date will be mailed to the policyholder.
All claims incurred following the termination date will be the policyholder’s personal responsibility. e policyholder
has the right to appeal the termination in writing within 60 days following the termination date.
PEIA 2017-2018 SPD ABD-REV.indd 31 7/13/17 9:15 AM
32
If the terminated policyholder appeals the termination in writing within 60 days from the date of termination, he or
she may pay the past-due premiums, apply to pay premiums by direct draft from a bank account, and may be granted
uninterrupted coverage at PEIA’s discretion.
If the terminated policyholder appeals the termination in writing more than 60 days following the date of termination,
PEIA may only allow re-enrollment if the policyholder enrolls as a new enrollee and agrees to pay premiums by direct
draft from a bank account. Two terminations for failure to pay within a 12-month period may result in permanent
disqualication from coverage under the PEIA plan.
If extenuating circumstances prevent the policyholder from appealing within 60 days of the termination, the policy-
holder may appeal for and the PEIA director may, at his or her discretion, grant a waiver of the 60-day requirement.
For Medicare policyholders who pay premiums directly to PEIA, failure to pay premiums will result in termination
from the plan consistent with applicable Medicare rules.
Tobacco-free Premium Discount
All health and optional life insurance premiums are based on the tobacco-use status of insureds. Tobac co-free insureds
receive the preferred monthly premium rate. Insureds must have been tobacco-free for 6 months prior to the beginning
of the Plan Year to qualify for the discount for the entire plan year. From time to time, the tobacco-free waiting period
may be adjusted and members will be notied in writing.
If your doctor certies on a form provided by the PEIA, that it is unreasonably dicult due to a medical condition
for you to become tobacco-free or it is medically inadvisable for you to become tobacco free, PEIA will work with you
for an alternative way to qualify for the tobacco-free discount. Send all such doctors’ certications and requests for
alternative ways to receive the discount to: PEIA Discount Alternatives, 601 57th St., SE, Suite 2, Charleston, WV
25304-2345.
For family health coverage, all enrolled family members must be tobacco-free to qualify the family for the reduced rate.
PEIA reserves the right to review medical records to check for tobacco use. PEIA oers a tobacco cessation benet. See
“Tobac co Cessation” on page 72 for details.
Once a member has submitted a tobacco adavit, PEIA will rely upon that adavit from year to year, unless t
he mem-
ber submits a replacement. It is not necessary for members to submit a tobacco adavit each year, although PEIA may,
periodically, require policyholders to update their tobacco status during Open Enrollment. Instructions for updating
tobacco status, if required, will be provided in the Shopper’s Guide.
Members who become tobacco-free during a plan year may apply for the discount when they have been tobacco-free
for at least six months. Apply online at www.wvpeia.com; click on the green “Manage My Benets” button at the
top right of the page. Adavits completed online are processed immediately, and the discount becomes eective on the
rst day of the following month. When using a paper adavit, PEIA has sixty days from receipt of the tobacco adavit
to process the request and implement the discount. e tobacco-free discount will apply only to future premiums, and
WILL NOT be applied retroactively. No refunds will be granted based on tobacco status.
Newly hired insureds must have been tobacco-free for 6 months prior to their eective date of coverage to qualify for
the discount, and must complete the tobacco adavit online or on paper to receive the discount.
Advance Directive/Living Will Discount
PEIA no longer oers the Advance Directive/Living Will discount. We encourage members to have an Advance Di-
rective/ Living Will and to discuss it with their family and health care providers, but the premium discount has been
discontinued.
PEIA 2017-2018 SPD ABD-REV.indd 32 7/13/17 9:15 AM
33
Determining Monthly Premiums
Active Employees
If you are an active employee of a State agency, college, university or county board of education, most of your health
insurance premium is paid by your employer. e amount of your contribution is determined by your salary, the type
of coverage you choose, and your tobacco-use status.
If you are an active employee of a local government agency, your employer will set your health insurance premium con-
tribution level. You may pay anywhere from 0% to 100% of the premium that PEIA charges to your employer.
If you are a member of the West Virginia Legislature, a member of the West Virginia Board of Education , or an elected
member of a county board of education, you must pay 100% of the premium for any coverage you elect.
Retired Employees
Premiums for retired employees are determined based on a number of factors, including retirement date. See more
information below. Premiums for most retired employees are deducted from their annuity on a monthly basis. Some re-
tired employees pay premiums directly to PEIA each month, and for them, premiums are due by the fth of the month
following the month for which the premium was invoiced. Example: May premium is due June 5.
Retired Employees Who Retired Before July 1, 1997
Retired employees who retired prior to July 1, 1997, pay premiums based on the plan they choose, their tobacco-use sta-
tus, and eligibility for Medicare, but NOT their years of service. ese retirees are not subject to the “years of service”
policy. For premium purposes, employees who retired prior to July 1, 1997, fall into the “25 or more” years of service
category on PEI A’s premium charts. Eligible retired employees may use sick and/or annual leave to extend employer-
paid health coverage.
Employees Who Retire On or After July 1, 1997
Employees who retire on or after July 1, 1997, pay premiums for their health coverage based on the plan they choose,
their eligibility for Medicare, their tobacco-use status, and their credited years of service as reported by the Consolidat-
ed Public Retirement Board (CPRB), or for those in the Teachers Dened Contribution Plan or a non-State retirement
plan, the years of service reported by the employing agency or the non-State plan. ese premiums may be adjusted an-
nually for medical ination. If you are using accrued sick and/or annual leave or years of service to extend your employ-
er-paid insurance, all or a portion of the premium will be covered by your accrued leave. e amount of sick and/or
annual leave accrued by the retiring employee will be reported by the benet coordinator at the agency from which the
employee is retiring. Disability retiree premiums are assessed on twenty-ve (25) years of service.
Employees Hired On or After July 1, 2010
Employees hired on and after July 1, 2010, will not receive any plan subsidy of their health insurance premiums at
retirement. ese employees may continue coverage in the plan at retirement, but must pay the unsubsidized premium
for the coverage of their choice. Two exceptions are made to this rule:
Active employees hired before July 1, 2010, who separate from public service but return within two years of their sepa-
ration may be restored to their original (pre-July1, 2010) hire date.
Retired employees who had an original hire date prior to July 1, 2010, may return to active employment and retain
their pre-July 1, 2010, original hire date for purposes of determining their eligibility for premium subsidy.
PEIA 2017-2018 SPD ABD-REV.indd 33 7/13/17 9:15 AM
34
Retirees from non-state entities which employers joined the PEIA Plan on or after July 1, 2010, will also receive no
premium subsidy and must pay the full cost of their participation in the plan. Such non-state retirees will be assigned a
“hire date” in the PEIA systems which is the same as the date they enroll in PEIA as an active employee.
Surviving Dependents
Surviving dependents of public employees pay premiums for their health coverage based on the plan they choose, their
eligibility for Medicare, and their tobacco-use status. ese premiums may be adjusted annually for medical ination.
Premiums charged to surviving dependents are determined by when the surviving dependent enrolls:
• For surviving dependents enrolled before July 1, 2015, premiums are based on the Medicare or non-Medicare
(depending on the survivor’s age) retiree premium for “25 or more years of service.”
• For surviving dependents enrolled on or after July 1, 2015, premiums are based on the Medicare or non-
Medicare (depending on the survivor’s age) retiree premium and the years of service earned by the deceased
policyholder.
Premiums for surviving dependents are deducted from their annuity on a monthly basis or are paid directly to PEIA.
Extending Employer-Paid Insurance upon Retirement
You may be eligible to extend your employer-paid insurance upon retirement, but how you do that depends upon your
employer. To take advantage of this benet, you must move directly from active public employment into your respective
retirement system. You must use your leave at the time of retirement. You may not save the leave for use later. If you choose
to separate from employment and defer your retirement, you cannot defer your sick and/or annual leave or years of teach-
ing service for use later. Elected public ocials are not eligible for this benet. is benet terminates when the policyhold-
er dies; it cannot be used by surviving dependents, who may continue coverage by paying the monthly premium.
Using Accrued Sick and Annual Leave to Extend Coverage
If you are an employee of a PEIA-participating employer (State agency, county board of education, local agency, college
or university) with coverage through PEIA and have accrued sick and/or annual leave when you retire, you may use that
accrued leave to extend your employer-paid insurance coverage. You must be enrolled in a PEIA PPB plan or a PEIA-
sponsored managed care plan or the group life insurance plan oered by PEIA prior to your retirement to qualif y. is
extended coverage must be for full months, and the leave must be used immediately at the time of retirement. Employ-
ees hired on or after July 1, 2001, are not eligible for this benet.
If the policyholder dies, the accrued leave benet terminates, even if the surviving dependent continues coverage.
If you and your spouse are both public employees eligible for extended employer-paid insurance coverage, you may
combine your accrued leave to extend your family coverage provided each of your respective employers agrees. Certain
restrictions apply. See your benet coordinator for details.
You may also have the option to use your accrued leave to increase your retirement benets from your retirement sys-
tem. You must choose between additional retirement benets and extended employer-paid insurance coverage. You may
not use some of your accrued leave to increase your retirement benet and the rest to extend your employer-paid insur-
ance coverage. Once this election is made, you may not revoke the selection.
PEIA 2017-2018 SPD ABD-REV.indd 34 7/13/17 9:15 AM
35
Calculating Your Benefit
e amount of this benet depends on when you were hired and came into the PEIA plan as follows:
Before July 1, 1988 :
If you elected to participate in the plan before July 1, 1988, and have been continuously covered by PEIA since that
time, then your extended employer-paid coverage is calculated as follows:
• 2 days of accrued leave = 100% of the premium for one month of single coverage
• 3 days of accrued leave = 100% of the premium for one month of family coverage
Between July 1, 1988 and June 30, 2001:
If you elected to participate in the plan after July 1, 1988 and before July 1, 2001, or if you had a lapse in coverage dur-
ing this period then your extended employer-paid coverage is calculated as follows:
• 2 days of accrued leave = 50% of the premium for one month of single coverage
• 3 days of accrued leave = 50% of the premium for one month of family coverage
On or after July 1, 2001:
If you elected to participate in the plan on or after July 1, 2001, or if you had a lapse in coverage during this period, you
are not eligible for extended employer-paid insurance upon retirement.
Extending Coverage for Higher Education Faculty
If you are a full-time faculty member employed on an annual contract basis for a period other than 12 months, you may
extend your employer-paid insurance coverage based on your years of teaching service. Your benet is calculated as follows:
• 3 1/3 years of teaching service = 1 year of single coverage
• 5 years of teaching service = 1 year of family coverage
is benet is not available to faculty hired on or after July 1, 2009.
PEIA 2017-2018 SPD ABD-REV.indd 35 7/13/17 9:15 AM
36
Retired Employee Assistance Programs
Retired employees whose total annual income is less than 250% of the federal poverty level (FPL) may receive assistance
in paying a portion of their PEIA monthly health premium based on years of active service, through a grant provided
by the PEIA called the Retired Employee Premium Assistance program. Applicants must be enrolled in the PEIA PPB
Plan, the Special Medicare Plan or PEI A’s Medicare Advantage plan. Managed care plan members are not eligible for
this program. Retired employees using accrued sick and/or annual leave to pay their premiums are not eligible for this
program until their accrued leave is exhausted. Applications are mailed to all retired employees with health coverage
each spring. Medicare-eligible retirees with 15 or more years of service who qualify for Premium Assistance may also
qualify for Benet Assistance. Benet Assistance reduces the medical and prescription out of pocket maximums and
most copayments. It is described in detail in the Evidence of Coverage provided by PEIA’s Medicare Advantage Plan.
For additional detail or for a copy of the application, call PEIA’s customer service unit.
e amount of assistance for which you are eligible is based on years of active service and percentage of FPL. For sur-
viving dependents, it will be based on years of service earned by the deceased policyholder. Disabled retirees are consid-
ered to have twenty (20) years of service.
Following is a chart that shows the premium reductions provided under the Retired Employee Premium Assistance
program.
Policyholder Only Monthly Premium Reduction
This amount will be deducted from your monthly premium for Medicare or non-Medicare coverage. If the amount of the reduction is greater
than the premium due, then the premium due will be $0.
Years of Service <100% of FPL 100-150% of FPL 150-200% of FPL 200-250% of FPL
5-14 $51 $34 $19 $13
15-24 $65 $50 $31 $19
25+ $88 $74 $46 $24
Policyholder With Dependents Monthly Premium Reduction
This amount will be deducted from your monthly premium for Medicare or non-Medicare coverage. If the amount of the reduction is greater
than the premium due, then the premium due will be $0.
Years of Service <100% of FPL 100-150% of FPL 150-200% of FPL 200-250% of FPL
5-14 $76.50 $51 $28.50 $19.50
15-24 $97.50 $75 $46.50 $28.50
25+ $132 $111 $69 $36
Life Insurance Premiums
Life insurance premiums for all participants are set by PEI A’s life insurance carrier. For active employees of State agen-
cies, colleges, universities and county boards of education, basic life insurance premiums are paid by your employer. For
active employees of a local government agency, your employer will determine what, if any, portion of the life insurance
premium will be paid for you. Retired employees must pay the basic life insurance premium to keep coverage in force.
Optional life insurance premiums are paid by the employee and are based on age and amount of coverage. See your Life
Insurance Booklet for further details of the options available to you.
Life Insurance Waiver of Premium
If you are an active employee with basic life insurance, and you become totally disabled before you reach age 60, your
basic life insurance may be continued at no cost to you while you remain totally disabled. To qualify for this waiver of
premium, you must furnish proof of total disability within one year after the date of disability. e date of disability is
considered the last day you were actively at work. You must furnish proof of total disability after you have been disabled
PEIA 2017-2018 SPD ABD-REV.indd 36 7/13/17 9:15 AM
37
for nine (9) months, but not later than twelve (12) months after your last day of active work. To qualify for the waiver
of premium, you must have been covered under basic life insurance when your disability began.
“Tota l Disability” exists when you are completely unable, due to sickness or injury or both, to engage in any gainful
occupation for which you are reasonably tted by education, training or experience. You will not be considered totally
disabled while working at any gainful occupation.
To apply for a disability waiver of premium, contact your benet coordinator. Proof of continuing disability will be
required three months before each anniversary of the initial date of disability. You may be asked by PEI A’s life insur-
ance carrier to submit periodic medical exams. AD&D coverage does not continue under the waiver of premium. If
your waiver of premium is approved, your basic life insurance will remain at $10,000 at no premium cost to you. At age
65, your basic life coverage decreases to $5,000, and further reduces to $2,500 at age 67. is coverage will end at the
earliest of these events:
• the end of disability;
• the failure to provide proof of continued disability; or
• the failure to submit to a physical examination when required by PEI A’s life insurance carrier.
See your Life Insurance Booklet for more details.
Managed Care Plan Premium
If you enroll in a managed care plan oered by the PEIA for your health coverage, your premium contribution is set
by the managed care plan. Premiums are published in the Shopper’s Guide each year prior to Open Enrollment. e
published premiums are set for one year. Local government agencies will determine their contribution for managed
care plans. To nd the amount of your premium contribution, check the Shopper’s Guide for the current plan year, or
contact your benet coordinator.
e managed care plans being oered by your employer are part of the PEIA benets package and you may enroll for any
plan in which you meet the eligibility guidelines. Your plan choice is binding for one year unless you move outside the
service area of the plan you have chosen. Your physician’s withdrawal from a plan does not qualify you to change plans.
Premium Conversion
Paying Premiums with Pre-Tax Dollars
e PEIA Premium Conversion Plan is an IRS Section 125 plan which allows active, participating employees to save
tax dollars when paying health and life insurance premiums. Your participation in the premium conversion plan is
automatic if you are an active employee of one of the following:
• State government and its agencies;
• State-related colleges and universities; or
• a participating county board of education.
Federal law does not allow retired employees to participate in premium conversion.
With premium conversion, your premiums are deducted from your salary before federal, state and Social Security taxes
are calculated. is reduces the amount of your income subject to tax. You must agree to pay the premiums through
this plan for a full plan year, unless you have a change in family status that allows you to change your benets. e
following example demonstrates how premium conversion can reduce your taxes and increase your take-home pay. is
example does not include State income tax, and assumes a 15% federal income tax bracket.
PEIA 2017-2018 SPD ABD-REV.indd 37 7/13/17 9:15 AM
38
Without Premium Conversion Plan With Premium Conversion Plan
Amount Description Amount Description
$1,500 Monthly Income (Taxable Income) $1,500 Monthly Income
-$340 Taxes -$121 Insurance Premium
$1,160 After-tax Salary $1,379 Taxable Income
-$121 Insurance Premium -$313 Taxes
$1,039 Take-home Pay $1,066 Take-home Pay
$27 Additional Take-home Income
How to Participate
If your employer oers the premium conversion plan your premiums automatically will be deducted on a pre-tax
basis. If you do not wish to participate in the premium conversion plan, you must indicate this in writing to your
benet coordinator.
Decisions regarding premium conversion must be made when you initially enroll for PEIA coverage or during the an-
nual open enrollment period each spring.
Limits on Benefit Changes
Under the IRS rules, you must pay the same amount of premium each month during the year, unless you have a quali-
fying change in family status. Qualifying changes in family status include:
• marriage or divorce of the employee;
• death of the employee’s spouse or dependent;
• birth or adoption of the employee’s child;
• commencement or termination of employment of the employee’s spouse or dependent;
• a change from full-time to part-time employment status, or vice versa, by the employee or his or her spouse;
• an unpaid leave of absence taken by the employee or spouse;
• a signicant change in the health coverage of the employee or spouse attributable to the spouse’s employment;
• annulment;
• change in the residence or work site of the employer, spouse, or dependent;
• a dependent loses eligibility due to age; or
• employment change due to strike or lock-out.
You may make a change in your plan when your spouse or dependent changes coverage during Open Enrollment under
his/her plan if:
• the other employer’s plan permits mid-year changes under this event; and
• the other employer’s plan year is dierent from PEIA.
For life insurance, the IRS allows you to pay pre-tax premiums on up to $50,000 of life insurance. is includes
the $10,000 basic plan and up to $40,000 of optional life insurance. Since you’re paying pre-tax premiums on only
$40,000 of optional life insurance, you may terminate any life insurance you have in excess of $40,000 at any time
during the plan year, but you can terminate your basic or the rst $40,000 of optional life insurance only during the
premium conversion plan open enrollment each spring.
To make a change in your coverage, use PEI A’s online enrollment site, “Manage My Benets” or get a Change-in-
Status form from your benet coordinator. ALL changes require additional documentation.
PEIA 2017-2018 SPD ABD-REV.indd 38 7/13/17 9:15 AM
39
Health Care Benets
Active employees may get health care benets through PEIA from a managed care plan or from one of the PEIA PPB
Plans. Non-Medicare retirees and surviving dependents may get health care benets through PEIA from a managed
care plan or from PEIA PPB Plan A or B, although Plan B is only available when all enrolled dependents are non-
Medicare. Medicare-eligible members of the Special Medicare Plan also receive their benets through PEIA. PEIA PPB
Plans C and D are not oered to retirees. PPB Plan C is an IRS-qualied, High-Deductible Health Plan (HDHP).
For more information about Plan C, download Summary Plan Description (Plan C) at www.wvpeia.com or call
1-888-680-7342.
Most Medicare-eligible retired employees and Medicare-eligible dependents of retired employees are covered by PEI A’s
Medicare Advantage plan, so the benets described here do not apply to them.
If you choose to receive your benets from a managed care plan, you must enroll with PEIA and choose a plan. Refer to
the information provided by the managed care plan for details of your benets.
If you choose the PEIA PPB Plan A, B or D, your benets are described on the following pages. PEIA PPB Plan C is an
IRS-qualied, High-Deductible Health Plan (HDHP). For more information about Plan C, download Summary Plan
Description (Plan C) at www.wvpeia.com or call 1-888-680-7342.
PEIA PPB Plans A, B and D
e PEIA PPB Plans A, B and D pay for a wide range of health care services for employees and their dependents. ese
benets include hospital services, medical services, surgery, durable medical equipment and supplies, and prescription
drugs. e medical benets in the PEIA PPB Plans A, B and D are identical. e dierence is in the deductibles and
out-of-pocket maximums, and in Plan D’s provider network.
Under the plans, certain costs are your responsibility. In addition, to receive maximum benets for some services, pre-
certication is required or your benets will be reduced. Please read the health care benets section carefully so that you
will have a clear understanding of your coverage under the plan.
If you have any questions about coverage or payment for health care services, please call:
Medical claims and benets – HealthSmart Benet Solutions at 1-888-440-7342
Precertication, pre-authorizations, case management or prior approval for out-of-state care a
nd maternity management
-- HealthSmart Care Management at 1-888-440-7342
Prescription drug claims and benets-- CVS Caremark at 1-84 4-260-5894
Common Specialty Medication claims and benets – HealthSmart Specialty Drug Program at 1-888-440-7342
PEIA’s Networks
PEIA PPB Plans A & B
e PEIA PPB Plans provide care through several networks of providers, and the benet level depends on whether
the care is provided inside West Virginia, or out, and on whether the out-of-state care is approved in advance by
HealthSmart, if necessary. In West Virginia, any properly licensed health care provider who provides health care ser-
vices or supplies to a PEIA participant is automatically considered a member of our network. Outside West Virginia,
PEIA uses the Aetna® Signature Administrators PPO to provide care for members of PEIA PPB Plans A, B and C. e
PEIA 2017-2018 SPD ABD-REV.indd 39 7/13/17 9:15 AM
40
Aetna® Signature Administrators PPO contracts with some out-of-state providers to serve PEIA PPB Plans A, B and C
participants only. To locate a network provider, call HealthSmart at 1-888-440-7342 or 304-353-7820.
Care provided outside West Virginia, even by network providers, costs more. Outside West Virginia, even with the dis-
count contracts we have with network providers, PEIA cannot control its costs as it can inside West Virginia. erefore,
your out-of-pocket costs will be higher if you use in-network providers outside the state of West Virginia.
Not all providers in the Aetna Signature Administrators PPO network may participate with PEIA. Kings Daughters
Medical Center and Our Lady of Bellefonte hospitals in Kentucky remain out-of-network for PEIA, regardless of their
network status with the ASA PPO network. Also, PEIA does not use the ASA PPO network in Washington County
(including Marietta Memorial Hospital) or Cuyahoga County, Ohio, or in Boyd County, Kentucky. PEIA reserves the
right to remove providers from the network, so not all providers listed in the network may be available to you.
PEIA PPB Plan D
PEIA PPB Plan D members have access to WV providers ONLY. For PEIA PPB Plan D, the only care allowed outside
the State of West Virginia will be emergency care to stabilize the patient for transport back to a WV facility, and a lim-
ited number of procedures that are not available from any health care provider inside West Virginia. Plan D members
must contact HealthSmart Care Management when it appears that out-of-state care may be necessary. HealthSmart
Care Management will direct the patient to the appropriate facility to provide care – either in WV or out-of-state. Non-
emergency care provided outside WV without approval from HealthSmart Care Management IS NOT COVERED.
Sanctioned Providers
Providers, both in and out of state, who are under sanction by Medicare, Medicaid or both are excluded from PEIA’s net-
work for the duration of their sanction. Additionally, providers may be excluded from PEI A’s network based upon adverse
audit ndings. If you have questions about a specic network provider, please contact HealthSmart at 1-888-440-7342.
Resident PPB Plan A & B Participants
PEIA PPB Plans A & B participants who live in West Virginia or a bordering county of a surrounding state may access
care from any of the following providers without receiving prior approval:
• any West Virginia health care provider who provides health care services or supplies to a PEIA participant; or
• any network provider located in those bordering counties.
All services, except emergency care, provided outside of West Virginia beyond the bordering counties require prior approval.
Non-Resident PPB Plan A & B Participants
For PEIA PPB Plans A & B participants who reside outside the State of West Virginia (beyond the bordering counties
of surrounding states), PEIA has made special arrangements. Participants who live more than one county outside the
State may seek care from any network provider without obtaining prior approval. Care from network providers will be
covered at the in-network benet level (typically 70%). Precertication of inpatient stays and certain outpatient proce-
dures is still required. See page 52 for details.
Non-Network Providers
Care provided by non-network providers is not covered except for the initial care in an emergency, or if those services
are not available from a network provider.
What You Pay With the PEIA PPB Plans A, B & D
Medical Deductible
During any plan year, if you or your eligible dependents incur expenses for covered medical services (other than oce
visits), you must meet a deductible before the plan begins to pay.
PEIA 2017-2018 SPD ABD-REV.indd 40 7/13/17 9:15 AM
41
Medical deductibles are determined based on your salary, tier of coverage (i.e., individual or family), and whether you
get your services within the PEIA network, or, if out-of-state beyond the bordering counties, whether you have prior
approval from HealthSmart.
e family deductible is shared among the family members. No one member of the family will pay more than the
individual deductible (see Employee Only in the chart). Once one person has met the individual deductible, the plan
will begin paying on that person. When another member of the family meets the balance of the family deductible, then
the plan will begin paying on the entire family. Alternatively, all members of the family may contribute to the family
deductible with no one person meeting the individual deductible; once the family deductible is met, the plan pays on all
members of the family.
e deductibles are listed on the following chart according to income level and coverage tier. Deductibles for Family
with Employee Spouse coverage are based on the average of the two employees’ salaries. is provision does not apply
to local government agency employees or retired employees.
Annual Deductibles
Annual Salary Employee
Only
Employee &
Child(ren)
Family Family with
Employee Spouse*
PEIA PPB Plans A & D
(state agencies, colleges, universities
and county boards of education)
$ 0 - 20,000 $325 $650 $650 $650
$20,001 30,000 $375 $750 $750 $750
$30,001 36,000 $425 $850 $850 $850
$36,001 42,000 $450 $900 $900 $900
$42,001 50,000 $475 $950 $950 $950
$50,001 62,500 $600 $1,200 $1,200 $1,200
$62,501 75,000 $625 $1,250 $1,250 $1,250
$75,001 100,000 $650 $1,300 $1,300 $1,300
$100,001 125,000 $725 $1,450 $1,450 $1,450
$125,001 + $825 $1,650 $1,650 $1,650
PEIA PPB Plan B
(state agencies, colleges, universities
and county boards of education)
$ 0 42,000 $725 $1,450 $1,450 $1,450
$42,001 + $1,225 $1,950* $1,950* $1,950*
Non-State Plan A Not applicable $450 $900 $900 N/A
Non-State Plan B Not applicable $725 $1,450 $1,450 N/A
Non-Medicare Retirees Plan A Not applicable $525 N/A $1,050 N/A
Non-Medicare Retirees Plan B Not applicable $925 N/A $1,850 N/A
Deputy Sheriff’s Early Retirement
Plan A
Not applicable $450 N/A $900 N/A
Deputy Sheriff’s Early Retirement
Plan B
Not applicable $725 N/A $1,450 N/A
State-funded Elected Ofcials Plans
A and D
Not applicable $450 $900 $900 N/A
State-funded Elected Ofcials Plan B Not applicable $725 $1,450 $1,450 N/A
* One family member may have to meet the ‘employee only’ deductible, which is $1,025. See Medical Deductible beginning above the chart.
PEIA 2017-2018 SPD ABD-REV.indd 41 7/13/17 9:15 AM
42
OOSINNA: For in-network out-of-state care beyond the bordering counties, if not approved in advance, the deductible
and out-of-pocket maximum amounts are doubled, and the plan pays only 60% of the allowed amount.
For inpatient admissions that span two plan years, the facility charges are paid based on the rst plan year, but physi-
cian charges are paid based on the date of service, which could be in the rst plan year, new plan year or both plan
years. For example, if you go into the hospital on June 28 and are released on July 6, the hospital bill is paid based on
the date of admission, so it would fall under the old plan year’s deductible. Physician charges are paid based on the
date of service, so if you have surgery on July 2, the surgeon’s bill will be processed based on the new plan year, and the
deductible for the new plan year will apply to the surgeon’s bill.
e OOSINNA deductible applies to the in-network deductible, but the in-network deductible does not satisfy the
OOSINNA deductible. Please note that the amounts listed in the chart are for in-network deductibles. OOSINNA
deductibles are twice the amount of the in-network deductibles listed above.
Prescription drug benets are subject to a separate deductible. See the “Prescription Drug Benet” section for details.
Coinsurance for In-Network and Out-of-Network Benefits for PEIA PPB Plans
If you live in WV, you will pay: If you live in a bordering
county of a surrounding
state, you will pay:
If you live out-of-state
(beyond bordering counties),
you will pay:
Access care in WV Plan A: 20% coinsurance
Plan B: 30% coinsurance
Plan D: 20% coinsurance
Plan A: 20% coinsurance
Plan B: 30% coinsurance
Plan A: 20% coinsurance
Plan B: 30% coinsurance
Access care in a bordering
county of a surrounding
state using PPO providers*
Plan A: 30% coinsurance
Plan B: 35% coinsurance
Plan D: not covered
Plan A: 30% coinsurance
Plan B: 35% coinsurance
Plan A: 30% coinsurance
Plan B: 35% coinsurance
Access care outside WV
(beyond bordering coun-
ties) using PPO providers
with prior approval*
Plan A: 30% coinsurance
Plan B: 35% coinsurance
Plan D: not covered
Plan A: 30% coinsurance
Plan B: 35% coinsurance
Plan A: 30% coinsurance
Plan B: 35% coinsurance
Access care outside WV
(beyond bordering coun-
ties) using non-PPO provid-
ers with prior approval*
Plan A: 30% coinsurance + amounts
that exceed the Reasonable and
Customary amount.
Plan B: 35% coinsurance
+ amounts that exceed the Reason-
able and Customary amount.
Plan A: 30% coinsurance +
amounts that exceed the Reason-
able and Customary amount.
Plan B: 35% coinsurance
+ amounts that exceed the Rea-
sonable and Customary amount.
Plan A: 30% coinsurance +
amounts that exceed the Reason-
able and Customary amount.
Plan B: 35% coinsurance
+ amounts that exceed the Rea-
sonable and Customary amount.
Access care outside WV
(beyond bordering coun-
ties) using PPO providers
without prior approval*
(OOSINNA)
Plan A: 40% coinsurance + up to a
$500 copayment
for unapproved out-of-state care.
Plan B: 50% coinsurance + up to
a $500 copayment for unapproved
out-of-state care.
Plan A: 40% coinsurance + up to
a $500 copayment for unapproved
out-of-state care.
Plan B: 50% coinsurance + up to
a $500 copayment for unapproved
out-of-state care.
Plan A: 30% coinsurance +
amounts that exceed the Reason-
able and Customary amount.
Plan B: 35% coinsurance
+ amounts that exceed the Rea-
sonable and Customary amount.
Access care outside WV
using non-PPO providers
without prior approval*
Not covered. You are responsible
for 100% of the provider’s charges,
except if the care is the result of a
medical emergency.
Not covered. You are responsible
for 100% of the provider’s charges,
except if the care is the result of a
medical emergency.
Not covered. You are responsible
for 100% of the provider’s charges,
except if the care is the result of a
medical emergency.
* PEIA PPB Plan D has NO coverage for out-of state services. Plan D members cannot receive services outside WV, except in a medical emergency or when
HealthSmart Care Management determines that a needed service is not available within WV. In these cases, out-of-state care is covered as in-network care.
* Prior approval is generally only provided if services are not available in West Virginia.
e PEIA PPB Plans A, B & D are designed to provide as much care as possible within the State of West Virginia. e
PEIA Preferred Provider Organization (PPO) is made up of West Virginia health care providers who provide health
PEIA 2017-2018 SPD ABD-REV.indd 42 7/13/17 9:15 AM
43
care services or supplies to PEIA participants. For services provided outside of the State, PEIA uses Aetna Signature
Administrators Preferred Provider Organization.
Resident PPB Plan Participants
PEIA PPB Plan A & B participants who live in West Virginia or a bordering county of a surrounding state may access
care from any West Virginia health care provider who provides health care services or supplies to a PEIA participant,
or any network provider located in those bordering counties without prior approval. All services provided outside of
West Virginia beyond the bordering counties require prior approval to be paid at the highest benet level. For services
of network providers, the plan will pay its portion of the contracted payment rate, and you will be responsible for any
copayments, deductible, coinsurance, and non-covered services.
For services of out-of-state (beyond the contiguous counties) in-network providers without approval in advance from
HealthSmart, the plan will pay of its portion of PEI A’s maximum allowance; you will be responsible for any deductible,
a $500 copayment for unapproved out-of-state care, and coinsurance. ese are OOSINNA services.
For services of out-of-state, non-network providers without prior approval, the plan will pay nothing, unless the ser-
vices are provided as a result of a medical emergency or because the necessary care is not available from an in-network
provider, in which case the services will be paid at the in-network benet level. For non-emergent services of out-of-state
non-network providers without prior approval, you will be responsible for 100% of billed charges, and those amounts
are considered non-covered services, so they do not count toward the deductible or out-of-pocket maximum.
PEIA PPB Plan D members must be WV residents and may use ONLY WV providers. PEIA PPB Plan D participants
may access care from any West Virginia health care provider who provides health care services or supplies to a PEIA
participant, without prior approval. Services provided outside of West Virginia are not covered, except if provided as a
result of a medical emergency to stabilize the patient for transport back to W V, or if provided outside the state because
necessary care is not available within W V. For services of WV providers, the plan will pay its portion of the contracted
payment rate, and you will be responsible for any copayments, deductible, coinsurance, and non-covered services.
PPB Plan participants traveling out-of-state have coverage for urgent and emergency care. In an emergency, seek treat-
ment at the nearest facility that is able to provide the needed care, and that care will be paid at the in-network benet
level as an emergency. For non-emergency, urgent care, call HealthSmart Care Management for a referral to a network
provider, or for approval to see an out-of-network provider where you are.
Non-resident PPB Plan Participants (PEIA PPB Plans A and B only)
PEIA PPB Plan A & B participants who reside outside West Virginia and beyond the bordering counties may access
care using any network provider without prior approval, and the claims will be paid at the higher level of benet (see
chart on page 47) based on the contracted payment rate. You will be responsible for any copayment, deductible, coin-
surance, and non-covered services. PEIA PPB Plan D participants must be WV residents.
Care provided by non-network providers must be provided as a result of a medical emergency or have prior approval to
be covered. Emergency or approved services of non-network providers will be paid at the in-network benet level. Other
out-of-state non-network services ARE NOT COVERED. Precertication requirements apply for inpatient stays and
certain outpatient procedures. PEIA PPB Plans A & B members please consult the preceding chart to determine your level
of coinsurance based on where you reside, where you receive your services, and whether or not you obtain prior approval.
Charges for non-covered services and applicable plan penalties, such as precertication penalties are your responsibility.
PEIA 2017-2018 SPD ABD-REV.indd 43 7/13/17 9:15 AM
44
Benet Design
Covered in Full
e following services are covered in full if in-network for all PEIA PPB Plans:
Type of Service Frequency
Covered Preventive Services for Adults *AWV=Annual Wellness Visit
Abdominal Aortic Aneurysm one-time screening for men aged 65-75 who have ever smoked Once per lifetime
Alcohol Misuse screening and counseling Included in AWV
Aspirin use for men and women of certain ages (requires a prescription; covered under prescription drug plan) As Needed
Blood Pressure screening for all adults Included in AWV
Cholesterol screening for men age 35 and older and women age 45 and older or others at higher risk Included in AWV
Colorectal Cancer screening for adults over 50 See Colorectal Cancer
Screening, page 58
Depression screening for adults Included in AWV
Type 2 Diabetes screening for adults with high blood pressure Included in AWV
Diet counseling for adults at higher risk for chronic disease Included in AWV
Hepatitis B screening for people at high risk As Needed
Hepatitis C screening for everyone born between 1945-1965 and people at high risk As Specied
HIV screening for all adults at higher risk Annually
Immunization vaccines for adults--doses, recommended ages, and recommended populations vary:
Hepatitis A Hepatitis B
Herpes Zoster Human Papillomavirus
Inuenza (Flu Shot) Measles, Mumps, Rubella
Meningococcal Pneumococcal
Tetanus, Diphtheria, Pertussis Varicella
As Recommended by the
American Academy of
Family Physicians
Obesity screening and counseling for all adults Included in AWV
Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk Included in AWV
Tobacco Use screening for all adults and cessation interventions for tobacco users (tobacco cessation products
covered under prescription drug plan; see Tobacco Cessation)
See Tobacco Cessation,
page 72
Syphilis screening for all adults at higher risk Annually
Covered Preventive Services for Women, Including Pregnant Women
Anemia screening on a routine basis for pregnant women As Needed
Bacteriuria urinary tract or other infection screening for pregnant women As Needed
BRCA counseling about genetic testing for women at higher risk As Needed
Breast Cancer Mammography screenings every 1-2 years for women over 40 Every 1-2 years
Breast Cancer Chemoprevention counseling for women at higher risk Once per lifetime
Breastfeeding comprehensive support and counseling from trained providers, as well as access to breastfeed-
ing supplies, for pregnant and nursing women
As Needed
Cervical Cancer screening for sexually active women Annually
Chlamydia Infection screening for younger women and other women at higher risk Annually
Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures,
and patient education and counseling (generic oral contraceptives require a prescription; covered under the
prescription drug plan)
As Needed
PEIA 2017-2018 SPD ABD-REV.indd 44 7/13/17 9:15 AM
45
Domestic and interpersonal violence screening and counseling for all women Included in AWV
Folic Acid supplements for women who may become pregnant (requires a prescription; covered under prescrip-
tion drug plan)
As Needed
Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gesta-
tional diabetes
Once per pregnancy
Gonorrhea screening for all women at higher risk Annually
Hepatitis B screening for pregnant women at their rst prenatal visit Once per pregnancy
Human Immunodeciency Virus (HIV) screening and counseling for sexually active women Annually
Human Papillomavirus (HPV) DNA Test: high risk HPV DNA testing every three years for women with normal
cytology results who are 30 or older
Every 3 years
Osteoporosis screening for women over age 60 depending on risk factors Annually after age 60
Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk As Needed
Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users
(tobacco cessation products covered under prescription drug plan; see Tobacco Cessation)
See Tobacco Cessation,
page 72
Sexually Transmitted Infections (STI) counseling for sexually active women Included in AWV
Syphilis screening for all pregnant women or other women at increased risk Annually
Well-woman visits to obtain recommended preventive services Annually
Covered Preventive Services for Children (*WCC=Well Child Care)
Alcohol and Drug Use assessments for adolescents Included in WCC
Autism screening for children at 18 and 24 months Included in WCC
Behavioral assessments for children of all ages
Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years
Included in WCC
Blood Pressure screening for children. Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17
years
Included in WCC
Cervical Dysplasia screening for sexually active females Annually
Congenital Hypothyroidism screening for newborns Once, for newborn
Depression screening for adolescents Included in WCC
Developmental screening for children under age 3, and surveillance throughout childhood Included in WCC
Dyslipidemia screening for children at higher risk of lipid disorders
Ages: 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years
As specied
Fluoride Chemoprevention supplements for children without uoride in their water source (requires a prescrip-
tion; covered under the prescription drug plan) As Needed
Gonorrhea preventive medication for the eyes of all newborns Once, for newborn
Hearing screening for all newborns Included in WCC
Height, Weight and Body Mass Index measurements for children
Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years
Included in WCC
Hematocrit or Hemoglobin screening for children Once per lifetime
Hemoglobinopathies or sickle cell screening for newborns Once, for newborn
HIV screening for adolescents at higher risk Annually
Immunization vaccines for children from birth to age 18 —doses, recommended ages, and recommended
populations vary:
Diphtheria, Tetanus, Pertussis Haemophilus inuenzae type b
Hepatitis A Hepatitis B
Human Papillomavirus Inactivated Poliovirus
Inuenza (Flu Shot) Measles, Mumps, Rubella
Meningococcal Pneumococcal
Rotavirus Varicella
As Recommended by the
American Academy of
Pediatrics
Iron supplements for children ages 6 to 12 months at risk for anemia (requires a prescription; covered under the
prescription drug plan)
As Needed
PEIA 2017-2018 SPD ABD-REV.indd 45 7/13/17 9:15 AM
46
Lead screening for children at risk of exposure As Needed
Medical History for all children throughout development
Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years
Included in WCC
Obesity screening and counseling Included in WCC
Oral Health risk assessment for young children
Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years
Included in WCC
Phenylketonuria (PKU) screening for this genetic disorder in newborns Once , for newborn
Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents at higher risk Included in WCC
Tuberculin testing for children at higher risk of tuberculosis
Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years
As specied
Vision screening for all children Included in WCC
Copayment Only
A copayment is a at dollar amount you pay when you receive service(s) from an in-network provider or an approved
non-network provider. When a service is subject to a copayment only, you do not have to meet the deductible before the
PEIA PPB Plans A, B & D begin to pay for that service. e copayment does not count toward your deductible or your
out-of-pocket maximum.
Type of Service Your In-network Cost
Medical Home preventive care or treat illness or injury $20 copayment per visit with no deductible
Physician Ofce Visits treat illness or injury $20 copayment per visit with no deductible
Specialist Ofce Visit $40 copayment per visit with no deductible
Out-of-State Primary Care Ofce Visits (In network) $20 copayment per visit with no deductible
Second Surgical Opinions* $40 copayment per visit with no deductible
* No copayment if required by HealthSmart Care Management.
Copayment, Coinsurance and Deductible
e services listed in the chart are subject to a copayment, annual deductible, and coinsurance.
Type of Service Your In-network Cost
Emergency Services (including supplies) $100 copayment + deductible and coinsurance An additional
$500 copay will apply to claims for injuries resulting from
high risk behaviors.
Non-emergency services at emergency room* $100 copayment + deductible and coinsurance
Ambulatory surgery/Outpatient surgery(facility-based) $100 copayment + deductible and coinsurance
Bariatric surgery and dental procedures $500 copayment + deductible and coinsurance
Outpatient Therapy Services visits 1-20 $10 copayment + deductible and coinsurance
Outpatient Therapy Services visits 21+ $25 copayment + deductible and coinsurance
Out-of-Network transplant services Deductible + coinsurance + additional $10,000
deductible
* Non-emergency services received at the emergency room are very expensive to the PEIA Plans. Members who visit the emergency room for non-emergency
services an excessive number of times may be placed on case management or otherwise have payment for their ER services restricted or terminated by the PEIA
Plans.
Out-of-State Copayment for Certain Services
e services below require a $25 copay, in addition to the usual deductible and coinsurance when received out of state for
PPB Plans A and B only. ese services are widely available in all areas of the West Virginia. e copay applies only to
PEIA 2017-2018 SPD ABD-REV.indd 46 7/13/17 9:15 AM
47
PEIA-insured members living in West Virginia and the contiguous counties of surrounding states when care is received
anywhere outside West Virginia. e additional copay applies to active employees and non-Medicare retirees only.
• Computerized tomography (CT) scans
• Dialysis (per treatment)
• Durable medical equipment purchases that exceed $100
• Magnetic resonance imaging (MRI)
• Magnetic resonance angiogram (MR A)
• All outpatient surgery
Coinsurance and Deductible and Higher/Lower Level of Benefits
Services not listed in the three preceding charts are covered after the deductible is met. e coinsurance amounts are
shown in the chart below:
In WV In-Network Outside WV
WITH Approval from
HealthSmart* Higher
Level of Benefit
In-Network Outside WV
WITHOUT Approval from
HealthSmart
(OOSINNA) Lower Level of
Benefit
Out-of-network Outside
WV WITHOUT Approval
from HealthSmart
Plan A 80/20 70/30 60/40 Not covered
Plan B 70/30 65/35 50/50 Not covered
Plan D 80/20 70/30 n/a Not covered
You pay your deductible, coinsurance, and any charges for services not covered by the plan directly to your health care
provider.
Medical Out-of-Pocket Maximum
e medical out-of-pocket maximum is the most you pay in coinsurance in a plan year. Amounts you pay toward your
annual deductibles, for copayments, for precertication penalties, for prescription drugs, for amounts billed in excess
of what PEIA pays to non-network providers, and for services that are not covered under the plan do not apply toward
your annual medical out-of-pocket maximum. It includes only your medical charges; prescriptions are handled sepa-
rately. See the “Prescription Drug Benet” section for details.
e family out-of-pocket maximum is divided up among the family members. No one member of the family will pay
more than the individual out-of-pocket maximum (see the single out-of-pocket maximum in the chart below). Once
one person has met the individual out-of-pocket maximum, the plan will pay 100% of that person’s covered charges
(less applicable copayments). When another member of the family meets the balance of the family out-of-pocket maxi-
mum, then the plan will pay 100% of covered charges (less applicable copayments) on the entire family for the balance
of the plan year. Alternatively, all members of the family may contribute to the family out-of-pocket maximum with no
one person meeting the individual out-of-pocket maximum; once the family out-of-pocket maximum is met, the plan
will pay 100% of covered charges (less applicable copayments) on all members of the family.
Your out-of-pocket maximum amount depends on your employment status, your salary, your tier of coverage, where
you receive your services, whether your provider is in the PEIA PPO network, and whether you have prior approval for
out-of-network care.
Amounts paid toward the out-of-network, out-of-pocket maximum will also count toward the in-network, out-of-
pocket maximum, but in-network amounts do not count toward the out-of-network, out-of-pocket maximum. Out-of-
network, out-of-pocket maximums are twice the amount of the in-network, out-of-pocket maximums. e following
chart shows the out-of-pocket maximums.
PEIA 2017-2018 SPD ABD-REV.indd 47 7/13/17 9:15 AM
48
Out-of-Pocket Maximum Amounts
Employee Status Employee’s Annual
Salary
Annual In-network
Out-of-Pocket Maximum
Annual In-Network Out-of-
State w/o Approval* Out-of-
Pocket Maximum
PEIA PPB Plans A and D (Active,
State Agency, Colleges and Universi-
ties, Boards of Education)
$ 0 20,000 $1,800/single; $3,600/family $3,600/single; $7,200/family
$20,001 30,000 $2,100/single; $4,200/family $4,200/single; $8,400/family
$30,001 36,000 $2,250/single; $4,500/family $4,500/single; $9,000/family
$36,001 42,000 $2,500/single; $5,000/family $5,000/single; $10,000/family
$42,001 50,000 $2,750/single; $5,500/family $5,500/single; $11,000/family
$50,001 62,500 $2,800/single; $5,600/family $5,600/single; $11,200/family
$62,501 75,000 $2,850/single; $5,700/family $5,700/single; $11,400/family
$75,001 100,000 $2,900/single; $5,800/family $5,800/single; $11,600/family
$100,001 125,000 $3,000/single; $6,000/family $6,000/single; $12,000/family
$125,001 + $3,250/single; $6,500/family $6,500/single; $13,000/family
PEIA PPB Plan B
(state agencies, colleges, universities
and county boards of education)
Not Applicable $3,000/single; $6,000/family $6,000/single; $12,000/family
Non-state Plans A & D Not applicable $2,500/single; $5,000/family $5,000/single; $10,000/family
Non-State Plan B Not applicable $3,000/single; $6,000/family $6,000/single; $12,000/family
Non-Medicare Retirees Plan A Not applicable $1,500/single; $3,000/family $3,000/single; $6,000/family
Non-Medicare Retirees Plan B Not applicable $3,000/single; $6,000/family $6,000/single; $12,000/family
Deputy Sheriff’s Early Retirement
Plan A
Not applicable $2,500/single; $5,000/family $5,000/single; $10,000/family
Deputy Sheriff’s Early Retirement
Plan B
Not applicable $3,000/single; $6,000/family $6,000/single; $12,000/family
State-funded Elected Ofcials Plans
A and D
Not applicable $2,500/single; $5,000/family $5,000/single; $10,000/family
State-funded Elected Ofcials Plan B Not applicable $3,000/single; $6,000/family $6,000/single; $12,000/family
* PEIA PPB Plan D has no out-of-network or out-of-state benet, so this column does not apply to Plan D members.
Benefit Maximums
For certain types of services, the plan will pay up to a set amount per plan year as shown below. Patients experiencing
a severe medical episode and patients with very complicated medical conditions are assigned a nurse case manager. For
catastrophic cases involving serious long-term illness or injury resulting in loss or impaired function requiring medically
necessary therapeutic intervention, the case manager may, based on medical documentation, recommend additional
treatment for services marked with an asterisk (*). For details of these benets, see “What Is Covered” later in this sec-
tion. All services listed below must be medically necessary; otherwise, they are not covered.
Annual Benefit Maximums
Type of Service Benefit Maximum (per member per plan year)
Outpatient Mental Health/Chemical Dependency 20 visits
Christian Science Treatment $1,000
Outpatient Therapy Services
(includes all benets listed in this category under “What is Covered”)
20 visits (total amount allowed for all therapies combined)
Inpatient Rehabilitation 150 days
Skilled Nursing Facility 100 days
PEIA 2017-2018 SPD ABD-REV.indd 48 7/13/17 9:15 AM
49
Lifetime Maximum
e PEIA PPB Plans have no lifetime maximum.
PEIA PPB Plan Fee Schedules and Rates
e PEIA PPB Plans A, B & D pay health care providers according to a maximum fee schedule and rates established by
PEIA. If a provider’s charge is higher than the PEIA maximum fee for a particular service, then the plan will allow only
the maximum fee. e “allowed amount” for a particular service will be the lower of the provider’s charge or the PEIA
maximum fee.
Physicians and other health care professionals are paid according to a Resource Based Relative Value Scale (RBRVS)
fee schedule. is type of payment system sets fees for professional medical services based on the relative amount of
work, practice expense and malpractice insurance expense involved. ese rates are adjusted annually. West Virginia
physicians who treat PEIA patients must accept PEI A’s allowed amount as payment in full; they may not bill additional
amounts to PEIA patients.
Most inpatient hospital services are paid on a “prospective” basis. PEI A’s reimbursement to hospitals is based on Diag-
nosis-Related Groups (DRGs), which is the system used by Medicare. It is a Prospective Payment System (PPS) that
classies medical cases and surgical procedures on the basis of diagnoses. Under this system, West Virginia hospitals
know in advance what PEIA will pay per day or per admission. West Virginia hospitals have been provided specic
information about their reimbursement rates from PEIA. ese rates are also adjusted annually.
Many outpatient hospital services are also paid on a prospective basis. PEIA has adopted a modied version of Medi-
care’s Outpatient Prospective Payment System (OPPS). OPPS reimbursement is based on Ambulatory Payment Clas-
sication (APC) groups. APCs include groups of services that are similar, clinically, and require similar resources. ese
rates are adjusted annually.
Facility Fee Limits
PEIA has established regional Facility Fee Limits for certain outpatient procedures when performed outside West Vir-
ginia. Procedures included in this program appear below. If you are having one of these procedures, consult Healthcare
Blue Book for information about which providers fall within the limits. If you use an out-of-state facility that charges
more than the Facility Fee Limit, you will be responsible for any amount billed that is above the limit. is is in addi-
tion to any deductible, copay or coinsurance you are responsible for. Additionally, the amount in excess of the facility
fee limit is not applied to your out-of-pocket maximum. e facility fee limit applies to the amount billed by the facility
only. Physician and anesthesiologist’s charges will be paid as usual.
PEIA 2017-2018 SPD ABD-REV.indd 49 7/13/17 9:15 AM
50
Procedure Facility
Fee Limit
Abdomen and Pelvis CT (no contrast) $270
Abdomen and Pelvis CT (with and without contrast)
$450
Abdomen and Pelvis CT (with contrast)
$450
Abdominal CT (no contrast)
$145
Abdominal CT (with and without contrast)
$320
Abdominal CT (with contrast)
$280
Abdominal MRI (no contrast)
$330
Abdominal MRI (with and without contrast)
$550
Abdominal MRI (with contrast)
$475
Abdominal Ultrasound
$170
Ankle MRI (no contrast)
$330
Ankle MRI (with and without contrast)
$550
Ankle MRI (with contrast)
$475
Anterior Cruciate Ligament Knee Surgery (ACL)
$8,520
Arm CT (no contrast)
$145
Arm CT (with and without contrast)
$320
Arm CT (with contrast)
$280
Arm MRI (no contrast)
$330
Arm MRI (with and without contrast)
$550
Arm MRI (with contrast)
$475
Bone Density Scan
$112
Brain CT (no contrast)
$145
Brain CT (with and without contrast)
$320
Brain CT (with contrast)
$280
Brain MRI (no contrast)
$330
Brain MRI (with and without contrast)
$550
Brain MRI (with contrast)
$475
Breast Biopsy (with stereotactic or ultrasound
guidance)
$1,300
Breast MRI Bilateral (with and without contrast)
$536
Breast MRI Unilateral (with and without contrast)
$536
Carpal Tunnel Surgery
$1,540
Cataract Surgery
$1,960
Chest CT (no contrast)
$145
Chest CT (with and without contrast)
$320
Chest CT (with contrast)
$280
Chest MRI (no contrast)
$330
Chest MRI (with and without contrast)
$550
Chest MRI (with contrast)
$475
Chest Ultrasound
$170
Procedure Facility
Fee Limit
Cholecystectomy (laparoscopic)
$4,200
Colonoscopy (no biopsy)
$880
Colonoscopy (screening)
$880
Colonoscopy (with biopsy)
$880
Complex Ear Drum Repair (Tympanoplasty)
$4,200
CT Angiography of Abdomen
$325
CT Angiography of Abdomen and Pelvis
$435
CT Angiography of Arm
$325
CT Angiography of Chest
$325
CT Angiography of Head or Neck
$325
CT Angiography of Leg
$325
CT Angiography of Pelvis
$325
Cystoscopy
$600
Digital Diagnostic Mammography (bilateral)
$207
Digital Diagnostic Mammography (unilateral)
$180
Digital Screening Mammography (bilateral)
$182
Ear Tube Placement (Tympanostomy)
$2,110
Elbow MRI (no contrast)
$330
Elbow MRI (with and without contrast)
$550
Elbow MRI (with contrast)
$475
Excise Lecions (laparoscopic)
$4,200
Face and Jaw CT (no contrast)
$145
Face and Jaw CT (with and without contrast)
$320
Face and Jaw CT (with contrast)
$280
Face MRI (no contrast)
$330
Face MRI (with and without contrast)
$550
Face MRI (with contrast)
$475
Fetal Ultrasound
$170
Heart Perfusion Imaging
$1,400
Hernia Repair - Laparoscopic (inguinal, umbilical, or
ventral)
$6,080
Hernia Repair (inguinal, umbilical, or ventral)
$3,000
Hip MRI (no contrast)
$330
Hip MRI (with and without contrast)
$550
Hip MRI (with contrast)
$475
Hysteroscopy (lesion removal or tubal ligation)
$4,420
Hysteroscopy (with biopsy)
$2,100
Jaw MRI (no contrast)
$330
Knee Arthroscopy
$2,450
Knee MRI (no contrast)
$330
Facility Fee Limits
PEIA 2017-2018 SPD ABD-REV.indd 50 7/13/17 9:15 AM
51
Procedure Facility
Fee Limit
Knee MRI (with and without contrast)
$550
Knee MRI (with contrast)
$475
Laparoscopic Hysterectomy
$4,200
Leg CT (no contrast)
$145
Leg CT (with and without contrast)
$320
Leg CT (with contrast)
$280
Leg MRI (no contrast)
$330
Leg MRI (with and without contrast)
$550
Leg MRI (with contrast)
$475
Lithotripsy
$3,850
Nasal Septum Repair
$4,130
Neck CT (no contrast)
$145
Neck CT (with and without contrast)
$320
Neck CT (with contrast)
$280
Neck Ultrasound
$170
Pelvic CT (no contrast)
$145
Pelvic CT (with and without contrast)
$320
Pelvic CT (with contrast)
$280
Pelvic Ultrasound
$170
Pelvis MRI (no contrast)
$330
Pelvis MRI (with and without contrast)
$550
Pelvis MRI (with contrast)
$475
Removal of Adenoids
$4,400
Retroperitoneal Ultrasound
$170
Rotator Cuff Repair (arthroscopic)
$5,520
Rotator Cuff Repair (non-arthroscopic)
$7,460
Shoulder Arthroscopy
$5,520
Shoulder MRI (no contrast)
$330
Shoulder MRI (with and without contrast)
$550
Shoulder MRI (with contrast)
$475
Sleep Study
$960
Spine CT (no contrast)
$145
Spine CT (with and without contrast)
$320
Spine CT (with contrast)
$280
Spine MRI (no contrast)
$330
Spine MRI (with and without contrast)
$550
Spine MRI (with contrast)
$475
Testicular Ultrasound
$170
Tonsillectomy
$2,160
Transthoracic Echocardiogram (TTE)
$500
Procedure Facility
Fee Limit
Transthoracic Echocardiogram (TTE) (with doppler)
$776
Transvaginal Ultrasound
$170
Upper Gastrointestinal Endoscopy (no biopsy)
$830
Upper Gastrointestinal Endoscopy (with biopsy)
$830
Wrist MRI (no contrast)
$330
Wrist MRI (with and without contrast)
$550
Wrist MRI (with contrast)
$475
X-Ray: Abdominal
$112
X-Ray: Ankle
$112
X-Ray: Arm
$112
X-Ray: Bone Age Study
$112
X-Ray: Chest
$112
X-Ray: Collar Bone
$112
X-Ray: Face
$112
X-Ray: Foot
$112
X-Ray: Hand or Wrist
$112
X-Ray: Hip
$112
X-Ray: Jaw
$112
X-Ray: Knee
$112
X-Ray: Leg
$112
X-Ray: Neck
$112
X-Ray: Pelvis
$112
X-Ray: Ribs
$112
X-Ray: Shoulder
$112
X-Ray: Sinus
$70
X-Ray: Skull
$112
X-Ray: Spine
$112
Facility Fee Limits
PEIA 2017-2018 SPD ABD-REV.indd 51 7/13/17 9:15 AM
52
Pre-Service Decisions
e PEIA PPB Plans A, B & D require that certain services and/or items be reviewed in advance to determine whether
they are medically necessary and being provided in the most appropriate setting by a network provider, if possible.
PEIA has three dierent types of pre-service determinations: prior approval, precertication/notication and preautho-
rization which are described on the next few pages.
Important things to remember about pre-service decisions:
• Requests for pre-service decisions should be submitted to HealthSmart Care Management, as early as possible,
in advance of the service/item.
• Services or items may be approved or denied in whole or in part.
• One or more of the pre-service determinations may be required depending on the type of service or item.
• Check with HealthSmart to see if your provider is in-network.
For example, a hospital admission, the procedure to be performed and/or each physician’s services may require pre-
service determinations, particularly if any of these is an out-of-state network provider, a non-network provider or the
service is covered only under limited circumstances.
Each type of pre-service requirement is described below. If you have questions, please call HealthSmart Care Management.
Prior Approval for Out-of-State Services in PEIA PPB Plans A & B (Mandatory)
If you are in PEIA PPB Plan A or B and live in West Virginia or a bordering county of a surrounding state, all services
outside of the State beyond the bordering counties must have prior approval. For services at preferred providers with
prior approval, the plan will pay the higher benet (usually 70% of the contracted payment rate); you will be responsible
for any deductible, copayments and coinsurance (see chart on page 47).
For services for all members provided by out-of-state, in-network providers without prior approval, the plan will pay the
lower OOSINNA benet (usually 60% of PEI A’s maximum allowance). You will be responsible for any deductible, copay-
ments, and 40% coinsurance. Any amount which exceeds PEIA’s maximum allowance will be your responsibility. ose
amounts are considered non-covered services. ey do not count toward the deductible or out-of-pocket maximum.
Out-of-state non-network services are covered only in the case of an emergency or if approved in advance by HealthSmart.
All other out-of-state, non-network services are not covered. You will be responsible for 100% of billed charges. ose
amounts are considered non-covered services. ey do n
ot count toward the deductible or out-of-pocket maximum.
Special arrangements have been made for PEIA PPB Plans A & B participants who live more than one county beyond
the borders of West Virginia. See “Non-resident PPB Plan Participants” on page 43 for more details.
PEIA Plan D members have no benet for out-of-state or out-of-network services, except in the case of a medical emer-
gency which occurs out-of-state, or for the limited number of services not available within West Virginia. For services
not available in West Virginia, HealthSmart Care Management will direct the member to an out-of-state network facil-
ity capable of providing the needed services.
Precertification/Notification Requirements
Precertication of certain services (Mandatory)
e PEIA PPB Plans A, B & D require that certain services and/or types of services be reviewed to determine whether
they are medically necessary and to evaluate the necessity for case management. Some services require “precertica-
tion,” and other services require “notication.” Precertication is performed to determine if the admission/service is
medically necessary and appropriate based on the patient’s documented medical condition.
Precertication is required for the following:
1. All admissions to out-of-state hospitals/facilities
PEIA 2017-2018 SPD ABD-REV.indd 52 7/13/17 9:15 AM
53
2. All admissions to rehabilitation or skilled nursing facilities
3. Any potentially experimental/investigational procedure, medical device, or treatment
4. Autism Spectrum Disorder services
5. Continuous glucose monitors
6. Durable medical equipment purchases and/or rentals of $1,000 or more
7. Elective (non-emergent) facility to facility air ambulance transportation
8. Electroconvulsive shock therapy (ECT)
9. Endoscopic treatment of GERD
10. Heart Perfusion Imaging
11. Home health care
a) exceeding 12 skilled nursing visits
b) I.V. therapy in the home
12. Hyperbaric Oxygen erapy (HBOT)
13. Limited Molecular Diagnostic/Genetic Testing used to diagnose or treat disease. Examples include: Hereditary
Non-polyposis Colorectal Cancer (HNPCC) testing, BRCA gene testing, Oncotype DX breast cancer as-
say, Familial Adenomatous Polyposis (FAP) testing, Catecholaminergic Polymorphic Ventricular Tachycardia
(FPVT) testing
14. Inpatient Mental Health and substance abuse treatment
15. Outpatient CT scan of sinuses or brain
16. Outpatient CTA (CT angiography)
17. Outpatient Dialysis Services
18. Outpatient IMRT (intensity modulated radiation therapy)
19. Outpatient MRI scan of the breast, knee or spine (includes cervical, thoracic, and lumbar)
20. Oupatient PET Scans
21. Oxygen rental and supplies
22. Partial/day mental health or substance abuse treatment programs
23. Sleep studies, services and equipment. See section on “sleep management services” on page 68
24. Specialty drugs
25. SPECT (single photon emission computed tomography) of brain or lung
26. Stereotactic Radiation Surgery and Stereotactic Radiation erapy
27. Surgeries
a) articial disc surgery
b) bariatric surgery
c) cataract surgery
d) cochlear implants
e) colonoscopy (out of state only)*
f) discectomy with spinal fusion surgery
g) elective and cosmetic surgeries including but not limited to abdominoplasty, blepharoplasty, breast
reduction, breast reconstruction, panniculectomy, penile implants/vascular procedures, otoplasty, rhino-
plasty, scar revision, testicular prosthesis, and surgery for varicose veins
h) hysterectomy
PEIA 2017-2018 SPD ABD-REV.indd 53 7/13/17 9:15 AM
54
i) implantable devices including, but not limited to: implantable pumps, spinal cord stimulators, neuro-
muscular stimulators, and bone growth stimulators
j) knee arthroscopy
k) laminectomy, including laminectomy with spinal fusion surgery
l) spinal fusion surgery
m) total joint replacement
n) transplants
o) uvulopalatopharyngoplasty
p) Vertebroplasty, Kyphoplasty, and Sacroplasty
28. Transplants and transplant evaluations (including but not limited to: kidney, liver, heart, lung and pancreas,
small bowel, and bone marrow replacement or stem cell transfer after high dose chemotherapy)
29. TTE Transthoracic Echocardiogram
* Routine colonoscopy at a network provider will not be subject to the precertication penalty.
Notification
Notication to HealthSmart Care Management is required to evaluate the admission/service in order to determine if
the patient’s medical condition will require case management, such as discharge planning for home health care services.
Notication to HealthSmart Care Management is required for the following inpatient admissions to WV facilities:
1. medical (non-surgical),
2. surgical admissions (except those specically listed as requiring precertication),
3. emergency (including chest pain and congestive heart failure, and other cardiac events), and
4. maternity and newborn.
Failure to precertify or notify HealthSmart Care Management of an admission within the timeframes specied in the
following chart will result in a reduction of benets under the PPB Plan of 30%. is 30% penalty will be the responsi-
bility of network providers. For all non-network providers, this 30% penalty will be the responsibility of the insured in
addition to any applicable copayment, coinsurance, deductible, and amounts that exceed PEIA’s maximum allowance.
If the insured or provider feels that HealthSmart Care Management inappropriately denied an admission or the ex-
tension of an admission, or that extenuating circumstances existed that prevented notication to HealthSmart Care
Management within the timeframes set forth, the insured or provider may le an appeal.
Exception: It is the patient’s responsibility to precertify inpatient stays and outpatient procedures when these services are
received out-of-network. If you do not precertify these out-of-network services, you must pay the 30% precertication
penalty in addition to the out-of-network copayment, coinsurance, deductible and amounts that exceed PEIA’s maxi-
mum allowance. Prior approval to use out-of-network providers does not precertify services.
Timely Precertification Requirements
Type of Admission Advance Notice Required
Scheduled:
Planned inpatient admission 3 business days in advance
Inpatient or outpatient elective surgery or procedure 3 business days in advance
Maternity (notify HealthSmart Care Management during your first trimester)
Term pregnancy Within 48 hours of admission
Caesarean section (planned) 3 business days in advance
Caesarean section (emergency) Within 48 hours of admission
Urgent/Emergency service or procedure Within 48 hours of admission
Extended stay Additional days may be recommended based on medical necessity
PEIA 2017-2018 SPD ABD-REV.indd 54 7/13/17 9:15 AM
55
Preauthorization (Voluntary)
Preauthorization is a voluntary process which allows you to contact HealthSmart Care Management in advance of a
procedure to verify that the service is a covered benet and medically necessary so that you can make an informed deci-
sion about the procedure. To obtain preauthorization, ask your provider to send your request to:
HealthSmart Care Management
P.O. Box 1921
Charleston, WV 25327-1921
Your provider should include your name, address, telephone number, your ID number, and all information about the
procedure that’s recommended. HealthSmart Care Management may contact your physician for more information.
Remember, if your request for preauthorization is denied, you will be responsible for paying for the service or procedure
if you choose to have it.
Medical Case Management
If you are experiencing a serious or long-term illness or injury, HealthSmart Care Management program can help you
learn about available resources, provide early support for your family, and nd ways to contain medical costs, including
your out-of-pocket expenses. rough case management HealthSmart Care Management can:
• arrange home care to prevent hospitalization;
• arrange services in the home to facilitate early hospital discharge;
• coordinate care and benets for transplant services.
• obtain discounts for special medical equipment;
• locate appropriate services to meet the patient’s health care needs;
• for catastrophic cases, when medically proven as a part of a comprehensive plan of care, allow additional visits
for outpatient mental health or outpatient therapy services
For catastrophic cases involving serious long-term illness or injury resulting in loss or impaired function requiring
medically necessary therapeutic intervention, the HealthSmart Care Management case manager may, based on medical
documentation, recommend additional treatment for certain therapy services. For details of these benets, see “What Is
Covered” later in this section beginning on page 56.
Transition of Care Program (New Participants Only)
If you are new to the PEIA PPB Plan, and have been receiving medical treatment from an out of state provider, you
may be concerned that your care will be interrupted in your move to this Plan. To assist participants receiving treat-
ment for serious medical conditions from out of state or out of networkproviders, PEIA has a Transition of Care (TOC)
program. If you qualify for TOC, you can continue to receive medical treatment from a non-network provider during a
transition period specied by HealthSmart Care Management and be covered at the in-network benet level.
Following this transition period or after your treatment is complete your medical care must be provided by a network
provider to be eligible for the higher in-network level of benets. Not all conditions will qualify for the TOC program.
Medical conditions likely to qualify for TOC benets include:
• pregnancy,
• recent acute heart attack,
• newly diagnosed cancer requiring surgery, chemotherapy or radiation therapy,
• total joint replacement requiring physical therapy,
• acute trauma such as a bone fracture,
• certain psychiatric treatment or substance abuse programs, and
• recent surgical procedures with complications.
PEIA 2017-2018 SPD ABD-REV.indd 55 7/13/17 9:15 AM
56
Medical conditions which are not likely to qualify for TOC benets include:
• arthritis,
• hypertension,
• diabetes,
• asthma, and/or
• allergies.
In most cases, a network provider can successfully treat these chronic conditions. If there is not a network provider
available to treat your specic illness or condition, HealthSmart Care Management will work with you to provide that
care. Conditions limited or excluded from coverage are not eligible for TOC benets.
To apply for the TOC program, request a copy of the TOC form by calling 1-888-440-7342 or 1-304-353-7820
and submit the completed form to HealthSmart Care Management as indicated on the form. A separate form must be
completed for each out-of-network provider. You will receive a written determination on your request for TOC benets
from the medical management department at HealthSmart Care Management. You must apply for TOC within three
months of your eective date of coverage in Plan A or B.
What Is Covered: Medically-Necessary Services
Covered services must be medically necessary or be one of the specically listed preventive care benets.
Medically necessary health care services and supplies are those provided by a hospital, physician or other licensed health
care provider to treat an injury, illness or medical condition. A service is considered medically necessary if it is:
• consistent with the diagnosis and treatment of the illness or injury;
• in keeping with generally accepted medical practice standards;
• not solely for the convenience of the patient, family or health care provider;
• not for custodial, comfort or maintenance purposes;
• rendered in the most cost-ecient setting and level appropriate for the condition; and
• not otherwise excluded from coverage under the PEIA PPB Plans.
e fact that a physician has recommended a service as medically necessary does not make the charge a covered ex-
pense. PEIA reserves the right to make the nal determination of medical necessity based on diagnosis and supporting
medical data.
Who May Provide Services
e PEIA PPB Plans A, B & D will pay for covered services rendered by a health care professional or facility if the
provider is:
• licensed or certied under the law of the jurisdiction in which the care is rendered;
• providing treatment within the scope or limitation of the license or certication;
• not under sanction by Medicare, Medicaid or both. Services of providers under sanction will be denied for the
duration of the sanction; and
• not excluded by PEIA due to adverse audit ndings.
Types of Services Covered
PEIA PPB Plans A, B & D cover a wide range of health care services. Some major categories are listed below. e
description of each service includes the level of coinsurance and any applicable copayments you must pay when the
service is received from a provider who participates in the PEIA PPO within the State of West Virginia (or in bordering
PEIA 2017-2018 SPD ABD-REV.indd 56 7/13/17 9:15 AM
57
counties of the surrounding states for PEIA PPB Plan A & B members only). If you have questions about coverage of
services, call HealthSmart at 1-888-440-7342 or 1-304-353-7820. Special arrangements that have been made for par-
ticipants in PEIA PPB Plans A & B who live more than one county beyond the borders of West Virginia are explained
on page 43 under “Non-resident PPB Plan A & B Participants”.
In this section, services marked with X require precertication in some or all circumstances.
z Allergy Services. Including testing and related treatment; in-network care covered with applicable coinsurance after
the deductible is met.
✖ Ambulance Services. Emergency ground or air ambulance transportation, when medically necessary to the nearest
facility able to provide needed treatment; in-network care covered with applicable coinsurance after the deductible.
e PEIA allowance for air ambulance transportation is the current Medicare urban rate. Non-medically necessary,
non-emergency ground transportation is not covered. Non-emergency air ambulance transportation requires precer-
tication and is generally not covered.
✖ Ambulatory Surgery. is benet is subject to a $100 copayment and applicable coinsurance after the deductible
has been met. See “Outpatient Surgery” on page 62
z Annual Routine Physical and Screening Examination. e PEIA PPB Plans cover a routine physical and screening
examination once every year for insureds age 16 and over. Exams may be provided more often if the patient’s medi-
cal history indicates a need, but these additional visits are subject to copayments. e routine physical and screening
examination includes history and physical (screening and counseling for alcohol and/or substance abuse, blood pres-
sure, depression, diabetes, domestic violence, nutrition, obesity, physical activity, STD prevention and other health risk
factors as appropriate and provided for by the Patient Protection and Aordable Care Act; review of medications; blood
work including general health panel and lipid panel, and immunizations as recommended by the American Academy
of Family Physicians). Any additional services, including lab work, diagnostic testing and procedures, that are provided
to you during this visit will be subject to your deductible, coinsurance and copayments, if there is a diagnosis to support
them. For more information, see page 44 for a complete list of services covered under the Annual Routine Physical and
Screening. See page 109 for information you can pull out a
nd take to your physician.
✖ Autism Spectrum Disorder. Applied behavior analysis (ABA) services, to the extent mandated by W. Va. Code §5-
16-7(a) (8), when provided in-network are covered with applicable coinsurance after the deductible has been met.
✖ Bariatric surgery. is benet is subject to a $500 copayment and applicable coinsurance after the deductible has
been met. Must meet plan guidelines.
z Cardiac or Pulmonary Rehabilitation. Benets are limited to 3 sessions per week for 12 weeks or 36 sessions per
year covered with applicable coinsurance after the deductible is met.
✖ Chelation erapy. Benets for these services are limited. Contact HealthSmart Care Management for precertica-
tion. If covered, in-network therapy is covered with applicable coinsurance after the deductible has been met.
z Childhood Immunizations. Immunizations, as recommended by the American Academy of Pediatrics, for chil-
dren through age 16 are covered at 100% of allowed charges, including the oce visit. is benet is not subject to
deductible, coinsurance, or copayment. See also Immunizations.
✖ Chiropractic Services. Services of a chiropractor for acute treatment of neuromuscular-skeletal conditions are in-
cluded in the Outpatient erapy Benet (see page 62). Combined coverage for these therapies is limited to a maxi-
mum of 20 visits per person per plan year. Initial 20 visits require a $10 copayment and applicable coinsurance per
visit. Visits 21+, if approved by HealthSmart Care Management, require a $25 copayment and applicable coinsur-
ance per visit. Oce visits are covered with a specialist oce visit copayment and x-rays are covered with applicable
Services marked with X require precertification in some or all circumstances.
PEIA 2017-2018 SPD ABD-REV.indd 57 7/13/17 9:15 AM
58
coinsurance after the deductible is met. Maintenance services are not covered. See Outpatient erapy Services for
more information.
✖ Christian Science Treatment. Treatment for a demonstrable illness or injury if provided in a facility accredited by
the Commission for Accreditation of Christian Science Nursing Facilities/Organizations, Inc. or by a practitioner
accredited by the Mother Church is covered with applicable coinsurance after the deductible is met. No benets will
be paid for the purpose of rest or study, for communication costs, or if the person requiring attention is receiving
parallel medical care. Coverage is limited to a maximum cost to the plan of $1,000 per plan year. If required, this
benet may be extended for inpatient care for up to 60 days per plan year. Inpatient care must be precertied.
✖ Colorectal Cancer Screenings. Routine screening to detect colorectal cancer is covered at 100% in-network with
no deductible or coinsurance required. is benet is covered as follows:
• Fecal-occult blood test—1 in 12 months/age 50 and over
• Flexible sigmoidoscopy—1 in 5 years/age 50 and over
• Colonoscopy for high risk—1 in 24 months/high risk patients*; 1 in 10 years/age 50 and over
• X-ray, barium enema—1 in 5 years/age 50 and over
• X-ray, barium enema—1 in 24 months/high risk patients*
* High risk is dened as a patient who faces high risk for colorectal cancer because of family history; prior experience of cancer or precursor neo-plastic polyps;
history of chronic digestive disease condition (inammatory bowel disease, Crohn’s disease, ulcerative colitis); and presence of any appropriate recognized gene
markers for colorectal cancer or other predisposing factors.
z Cosmetic/Reconstructive Surgery. Services provided when required as the result of accidental injury or disease, or
when performed to correct birth defects are covered with applicable coinsurance after the deductible is met.
z Dental Services (accident-related only). Services provided within six (6) months of an accident and required to
restore tooth structures damaged due to that accident are covered with applicable coinsurance after the $500 copay-
ment and deductible are met. e initial treatment must be provided within 72 hours of the accident. Biting and
chewing accidents are not covered. Services provided more than six (6) months after the accident are not covered.
e Least Expensive Professionally Acceptable Alternative Treatment (LEPA AT) for accident-related dental services
will be covered. For example, the dentist may recommend a crown but the Plan will only provide reimbursement for
a large lling. Contact HealthSmart for more information. For children under the age of 16, the six-month limita-
tion may be extended if an approved treatment plan is provided to HealthSmart within the initial six months.
z Dental Services (impacted teeth). Medically-necessary extraction of impacted teeth is covered with applicable
coinsurance after the $500 copayment and deductible are met. Extractions for orthodontia are not covered.
z DEXA Scans. Bone mass measurement by DEXA is limited to one scan every 24 months for members who meet
one of the following criteria:
1. Member has received results from a peripheral osteoporosis screen indicating moderate or high risk for osteo-
porosis; OR
2. Member has documented clinical risk for osteoporosis.
z Diagnostic testing is covered with applicable coinsurance after the deductible has been met. Routine screen-
ing scans are not covered. Complete details of the DEXA scan payment policy are available on the PEIA website at
www.wvpeia.com.
z Diabetes Education. Services of a diabetes education program that meets the standards of the American Diabetes
Association are covered with applicable coinsurance after the deductible is met. Coverage is limited to six (6) visits
per patient: three visits with the dietician and three visits with a registered nurse. Contact HealthSmart for specic
benet limitations.
Services marked with X require precertification in some or all circumstances.
PEIA 2017-2018 SPD ABD-REV.indd 58 7/13/17 9:15 AM
59
z Dietician Services. Services of a licensed, registered dietician are covered with the appropriate oce visit copay-
ment. Coverage is limited to two visits per year when prescribed by a physician for adult members with chronic
medical conditions. Diabetic patients see Diabetes Education above. Benet may be extended to children who meet
criteria.
✖ Durable Medical Equipment (DME) and Prosthetics. Coverage for the initial purchase and reasonable replace-
ment of standard implant and prosthetic devices, and for the rental or purchase (at the plan’s discretion) of standard
DME, when prescribed by a physician. Prosthetics and DME purchases of $1,000 or more, or rental for more than
3 months must be precertied by HealthSmart Care Management. DME and prosthetics are covered with appli-
cable after the deductible is met. Omnipod and other disposable insulin delivery systems are not covered. Members
living in West Virginia and the contiguous counties of surrounding states pay an additional $25 copay when durable
medical equipment that exceeds $100 is purchased out of state. e copay only applies to active members and non-
Medicare retirees.
z Emergency Services (including supplies; for the rst six visits in a Plan Year). Services received in an emergency
room when the condition has been certied as an emergency are subject to a $100 copayment and applicable coin-
surance after the deductible is met. Members who visit the emergency room for non-emergency services an excessive
number of times may be placed on case management or otherwise have payment for their ER services restricted or
terminated by the PEIA Plans. PEIA will assess an additional emergency room copay of $500 for emergency treat-
ments received as a result of high-risk behaviors, such as:
• Accidents while driving motorcycle or UTV/ATV without a helmet
• DUI/DWI or drug -related accidents
• Failure to wear seatbelt(s)
z Emergency Room Treatment over six visits in a Plan Year (including supplies, testing, consultation, and all as-
sociated costs). Emergency Room treatment should be used only when there is an actual “Emergency Medical Condi-
tion” as dened by applicable State law: “Emergency medical condition” that manifests itself by acute symptoms of suf-
cient severity including severe pain such that the absence of immediate medical attention could reasonably be expected
(by a prudent layperson) to result in serious jeopardy to the individual’s health or with respect to a pregnant woman the
health of the unborn child, serious impairment to bodily functions or serious dysfunction of a bodily part or organ.” If
you have such a condition, PEIA urges you to go immediately to a hospital emergency room.
Because use of the emergency room for non-emergency care is inappropriate and very expensive for the member and the
PEIA Plans, after the sixth emergency room visit by a policyholder and their dependent(s) in a Plan Year, any emergen-
cy room visits will be assumed to be non-emergency care and will not be covered (including associated costs). However,
the member may appeal these claims and if, upon appeal, the claim is shown by the member to be for an actual emer-
gency medical condition, the claim will be adjusted and paid the same as an emergency room claim for the rst six
visits per policyholder per plan year. (See “Appealing a Claim” in this Summary Plan Description).
✖ Home Health Services. Intermittent health services of a home health agency when prescribed by a physician are
covered with applicable coinsurance after the deductible is met. Services must be provided in the home, by or under
the supervision of a registered nurse. e home health services are covered only if they would otherwise have re-
quired connement in a hospital or skilled nursing facility. If more than twelve (12) visits are necessary, precertica-
tion is required.
✖ Hospice Care. When ordered by a physician, hospice care is covered with applicable coinsurance after the deduct-
ible is met.
✖ Hyperbaric Oxygen erapy. Covered with applicable coinsurance after the deductible is met.
Services marked with X require precertification in some or all circumstances.
PEIA 2017-2018 SPD ABD-REV.indd 59 7/13/17 9:15 AM
60
z Immunizations. Following is a list of immunizations and the ages at which PEIA covers them.
• Polio (IPV): At 2 months, 4 months, 6-18 months, and 4-6 years.
• Diphtheria-Tetanus-Pertussis (DTaP): At 2 months, 4 months, 6 months, 15-18 months, 4-6 years, a booster at
age 11-12, and a single dose at age 16-18.
• Tetanus-Diphtheria ( Td): At 11-18 years with booster every 10 years.
• Measles-Mumps-Rubella (MMR): At 12-15 months and 4-18 years.
• Haemophilus Inuenzae type b (Hib): At 2 months, 4 months, 6 months, and 12-15 months OR 2 months, 4
months, and 12-15 months, depending on vaccine type.
• Hepatitis B: At birth-2 months, 1-4 months, and 6-18 months. If missed, get 3 doses starting at age 11 years.
• Hepatitis A: Begin at 6 months, with second dose at least 6 months apart.
• Pneumococcal disease (Prevnar™): At 2 months, 4 months, 6 months, and 12-15 months. If missed, talk to
your health care provider.
• Inuenza: At 6 months and then annually.
• Varicella: At 12-15 months and 4-6 years. Adults, if not previously immunized, 2 doses per lifetime
• Meningococcal: At 2-10 years for certain children as recommended by the American Academy of Pediatrics,
and a booster at age 11-12, and a single dose at age 16-19.
• Human Papillomavirus (HPV): At 11-26 years.
• Rotavirus: At 2 months, 4 months, and 6 months depending on vaccine used.
• Zoster: ages 60 and over
For children through age 16, the plan covers immunizations and the associated oce visit with no deductible, coin-
surance, or copayment required. Also see “Well Child Care” on page 63.
For adults and children over age 16, the plan covers immunizations provided and administered in a physician’s oce
as recommended by the American Academy of Family Physicians at 100% in-network. e associated oce visit is
subject to the applicable copayment unless it is administered at the time of an “Annual Routine Physical and Screen-
ing Examination.” Other immunizations covered with applicable coinsurance after the deductible is met. If pur-
chased at a pharmacy, the member will be reimbursed according to PEI A’s fee schedule.
✖ Inpatient Hospital and Related Services. Connement in a hospital including semi-private room, special care
units, connement for detoxication, and related services and supplies during the connement are covered with
applicable coinsurance after the $100 c
opayment and the deductible is met. Unapproved out-of-network inpatient
admissions are not covered.
✖ Inpatient Medical Rehabilitation Services. When ordered by a physician, coverage is subject to the $100 copay-
ment and applicable coinsurance after the deductible is met and is limited to 150 days per plan year. Unapproved
out-of-network inpatient admissions are not covered.
✖ Intensive Modulated Radiation erapy (IMRT). Covered with applicable coinsurance after the deductible is
met.
z Mammogram. A routine mammogram every 1-2 years for women over 40 to detect breast abnormalities is covered
at 100% in-network with no coinsurance or deductible required. When billed with a medical diagnosis (instead of as
a screening test), it is considered a diagnostic test, and is covered with applicable coinsurance after the deductible is
met.
Services marked with X require precertification in some or all circumstances.
PEIA 2017-2018 SPD ABD-REV.indd 60 7/13/17 9:15 AM
61
✖ Massage erapy. erapeutic services of a licensed massage therapist for treatment of neuromuscular-skeletal con-
ditions are covered under the Outpatient erapy Benet when ordered by a physician. Combined coverage for these
therapies is limited to a maximum of 20 visits per person per plan year. Initial 20 visits require a $10 copayment and
applicable coinsurance per visit. Coverage may be extended beyond the 20-visit limit for members in case manage-
ment due to a catastrophic illness or injury, if approved in advance by HealthSmart Care Management. Visits 21+, if
approved by HealthSmart Care Management, require a $25 copayment and applicable coinsurance per visit. Mainte-
nance services are not covered. Combined coverage for all therapies is limited to a maximum of 20 visits per person,
per plan year. See Outpatient erapy Services for more information.
✖ Mastectomy and Follow-up. If you are receiving benets in connection with a mastectomy due to cancer and elect
breast reconstruction in connection with such benets, you are entitled to the following procedures:
• Reconstruction of the breast on which the mastectomy was performed;
• Reconstructive surgery of the other breast to present a symmetrical appearance; and
• Prostheses and coverage for physical complications at all stages of the mastectomy procedure including
lymphedas.
z Maternity Services. See “Maternity Benets” on page 64 for details.
✖ Mental Health Services.
• Inpatient programs and outpatient partial hospitalization day programs for mental health, chemical depen-
dency and substance abuse services are limited to a maximum of 30 days per patient, per plan year. For out-
patient, partial-day programs, two (2) outpatient days will be counted as one (1) inpatient day when applying
the 30-day maximum. Catastrophic cases will be assigned to a nurse case manager. For these extreme medical
conditions, the case manager may, based on medical documentation, recommend additional treatment. Precer-
tication is required. ese services are covered with applicable coinsurance after the $100 copayment and the
deductible is met. Unapproved out-of-network inpatient admissions are not covered.
• Outpatient mental health, chemical dependency and substance abuse services are limited to a maximum of 20
visits per patient per plan year for short-term individual and/or group outpatient mental health and chemical
dependency services. is benet includes evaluation and referral, diagnostic, therapeutic, and crisis interven-
tion services performed on an outpatient basis (includes a physician’s oce). Catastrophic cases will be as-
signed to a nurse case manager. For these extreme medical conditions, the case manager may, based on medical
documentation, recommend additional treatment beyond the 20 visits. is benet is covered with applicable
coinsurance after the deductible is met.
z MRA. Magnetic Resonance Angiography services when performed on an outpatient basis are covered with appli-
cable coinsurance after the deductible is met. PEIA members living in West Virginia and the contiguous counties
of surrounding states pay an additional $25 copay for MRs received out of state. is copay only applies to active
members and non-Medicare retirees.
✖ MRI. Magnetic Resonance Imaging services when performed on an outpatient basis, are covered with applicable
coinsurance after the deductible is met. MRI of the knee and spine, including cervical, thoracic and lumbar require
precertication. Members living in West Virginia and the contiguous counties of surrounding states pay an addition-
al $25 copay for MRIs received out of state. e copay only applies to active members and non-Medicare retirees.
✖ Neuromuscular stimulators and bone growth stimulators, when criteria are met, are covered with applicable
coinsurance after the deductible is met.
Services marked with X require precertification in some or all circumstances.
PEIA 2017-2018 SPD ABD-REV.indd 61 7/13/17 9:15 AM
62
z Oral Surgery. Only covered for extraction of impacted teeth, orthognathism and medically necessary ridge re-
construction. Requires a $500 copayment, then is covered with applicable coinsurance after the deductible is met.
Dental implants are not covered.
✖ Organ Transplants. See “Organ Transplant Benets” on page 66 for more details.
z Outpatient Diagnostic and erapeutic Services. Laboratory, diagnostic tests, and therapeutic treatments, when
ordered by a physician, are covered with applicable coinsurance after the deductible is met.
✖ Outpatient Surgery. is benet is subject to a $100 copayment with applicable coinsurance after deductible, when
performed in a hospital or alternative facility. Members living in West Virginia and the contiguous counties of sur-
rounding states pay an additional $25 copay for outpatient surgery performed out of state. e copay only applies to
active members and non-Medicare retirees.
✖ Outpatient erapies. Coverage for the following outpatient therapies are combined into one benet and are avail-
able with applicable coinsurance after the deductible is met: physical, massage, occupational, speech, and vision
therapies, osteopathic manipulations and chiropractic treatment. e benet is limited to a maximum of 20 visits
per person per plan year for all of the therapies combined. Coverage may be extended beyond the 20 visit limit for
members in case management due to a catastrophic illness or injury, if approved in advance by HealthSmart Care
Management. Maintenance services are not covered. Initial 20 visits require a $10 copayment per visit. Visits 21+, if
approved by HealthSmart Care Management, require a $25 copayment per visit.
• Chiropractic Treatment. Services of a chiropractor for acute treatment of neuromuscular-skeletal conditions are
included in the Outpatient erapies benet (see above) and are covered with applicable coinsurance after the
deductible and $10 or $25 copayment (details above) are met. Oce visits are subject to a copayment and x-rays
are covered at 80% after the deductible is met. Maintenance services are not covered.
• Massage erapy. When ordered by a physician, therapeutic massage therapy services of a licensed massage
therapist are covered with applicable coinsurance after the deductible and $10 or $25 copayment (details above)
are met.
• Occupational erapy. When ordered by a physician, this benet is included in the Outpatient erapies ben-
et and is covered with applicable coinsurance after the deductible and $10 or $25 copayment (d
etails above)
are met.
• Osteopathic Manipulations. Services of an osteopathic physician to eliminate or alleviate somatic Dysfunction
and related disorders are covered with applicable coinsurance after the deductible and $10 or $25 copayment
(details above) are met.
• Outpatient Physical erapy. When ordered by a physician, this benet is included in the Outpatient era-
pies benet and is covered with applicable coinsurance after the deductible and $10 or $25 copayment (details
above) are met.
• Outpatient Speech erapy. When ordered by a physician, this benet is included in the Outpatient era-
pies benet and is covered with applicable coinsurance after the deductible and $10 or $25 copayment (details
above) are met.
• Vision erapy. is benet is included in the Outpatient erapies benet and is covered with applicable coin-
surance after the deductible and $10 or $25 copayment (details above) are met.
z Pain Management Services. Covered with applicable coinsurance after the deductible is met.
z Pap Smear. An annual Pap smear and the associated oce visit to screen for cervical abnormalities are covered. e
screening is covered in full if conducted as a part of the Routine Physical and Screening Exam. When billed with
Services marked with X require precertification in some or all circumstances.
PEIA 2017-2018 SPD ABD-REV.indd 62 7/13/17 9:15 AM
63
a medical diagnosis (instead of as a screening test), it is considered a diagnostic test, and covered with applicable
coinsurance after the deductible is met.
z Physician’s Oce Visits (treatment for illness, injury, or medical condition). ese visits are subject to a copay-
ment for in-network services. See page 46.
z Professional Services of a physician or other licensed provider for treatment of an illness, injury or medical
condition. Includes outpatient and inpatient services (such as surgery, anesthesia, radiology, and oce visits). Oce
visits to a primary care or specialty care physician are subject to the applicable copayment (see chart on page 46).
Other physician services are covered with applicable coinsurance after the deductible is met.
z Prostate Cancer Screening. For men age 50 and over. e screening is covered in full if conducted as a part of the
Routine Physical and Screening Exam. e PSA blood test associated with this screening, when ordered by a physi-
cian, is covered at 100% with no deductible or coinsurance in-network.
z Second Surgical Opinions. Oce visits for second surgical opinions are subject to a copayment per visit. Second
surgical opinions are paid at 100% if required by HealthSmart Care Management.
✖ Specialty Injectable Medications. Coverage is provided for treatments utilizing specialty drugs through a pro-
gram managed by HealthSmart Benet Solutions. Specialty medications covered under the medical benet plan are
subject to applicable coinsurance after the deductible is met. Specialty medications covered under the prescription
drug program are covered with a $100 copay if on the WV Preferred Drug List and a $150 copay if not on the WV
Preferred Drug List, after the prescription drug deductible is met.
✖ SPECT. Single Photon Emission Computed Tomog raphy is covered with applicable coinsurance after the deductible
is met. SPECT of brain or lung requires precertication.
✖ Skilled Nursing Facility Services. Connement in a skilled nursing facility including semi-private room, related
services and supplies is covered with applicable coinsurance after the $100 copayment and the deductible is met.
Connement must be prescribed by a physician in lieu of hospitalization. Coverage is limited to 100 days per plan
year. Unapproved out-of-network inpatient admissions are not covered.
✖ Sleep Management Services. All sleep testing, equipment and supplies for resident PPB Plan members are covered
through a network of West Virginia providers and require precertication through Sleep Management Solutions, if
determined to be otherwise covered. Non-resident PPB Plan members should call HealthSmart Care Management
for precertication of sleep management services. See further details under Sleep Management Services later in this
section.
z Smoking Cessation. See “ Tobac co Cessation” on page 72 for details.
z Telehealth. Services a of telehealth physician provided through PEI A’s telehealth vendor, iSelectMD, are covered at
100% after a $40 copayment.
z Travel Benets. Members are eligible for some reimbursement for travel benets (mileage and tolls). See Travel
Benets on page 68.
z Urgent Care. Services from an urgent care center are covered with a $50 copayment.
z Well Child Care. For children through age 16, the plan covers routine oce visits for preventive care as recom-
mended by the American Academy of Pediatrics. ese visits are covered at 100% of allowed charges and are not
subject to copayment or coinsurance or deductible. is oce visit, generally, includes, but is not limited to:
• height and weight measurement;
• blood pressure check;
Services marked with X require precertification in some or all circumstances.
PEIA 2017-2018 SPD ABD-REV.indd 63 7/13/17 9:15 AM
64
• vision and hearing screening;
• developmental/behavioral assessment; and
• physical examination.
Well Child Care oce visits are recommended by the American Academy of Pediatrics at the following ages:
• Infancy: 1 month, 2 months, 4 months, 6 months, 9 months and 12 months.
• Early childhood: 15 months, 18 months, 24 months, 30 months, 3 years and 4 years.
• Late childhood: Annually from ages 5 through 12.
• Adolescence: Annually from ages 13 through 16.
Adolescents over the age of 16 receive the Annual Routine Physical and Screening Examination benet described on
page 57.
Maternity Benefits
e PEIA PPB Plans A, B & D provide coverage for maternity-related professional and facility services, including
prenatal care, midwife services and birthing centers. Maternity related services are covered for the employee and
covered dependents.
Contact HealthSmart Care Management during the rst trimester of your pregnancy or as soon as your pregnancy is
conrmed. HealthSmart can assist you in identifying possible factors that may put you at risk for premature labor and
delivery. If risk factors are identied, HealthSmart Care Management nurses will work with you and your doctor to
help safeguard the health of mother and baby.
You will need to contact HealthSmart Care Management anytime you are admitted to the hospital during your preg-
nancy and within 48 hours of your admission for delivery, even if you are discharged in less than 48 hours.
Payment Level
Maternity services for routine prenatal care, delivery and follow-up are paid at 100% of allowed charges under a global
fee after the deductible has been met. An obstetrical prole and one ultrasound are also paid at 100% of allowed charg-
es after the deductible is met. Other maternity services, including hospital charges and anesthesia services, are paid with
applicable coinsurance after the deductible is met, for in-network care.
Maternity Pre-payment Benefit
If your attending provider requests a deposit for maternity care before delivery, PEIA PPB Plans A, B & D will make
an advance payment of up to $500. is will be deducted from the global fee paid after delivery. To receive this benet,
please contact HealthSmart Care Management and request a Maternity Pre-payment form.
High-Risk Birth Score Program
For infants identied at birth as being at risk for health problems, PEIA PPB Plans A, B & D will pay for six oce
visits between the age of two weeks and 24 months in addition to PEIA’s regular Well Child Care benets. ese addi-
tional visits are paid at 100% of allowed charges and are not subject to the deductible. HealthSmart Care Management
will notify those families who qualify for this benet.
Enrolling Your Newborn
Please be sure you remember to add your newborn to your PEIA PPB Plan coverage by completing a Change-in-Status
form. See the Eligibility Section at the front of this booklet for more information or online at www.wvpeia.com under
“Manage My Benets”.
Nursery Charges
If the baby is enrolled for coverage under the PEIA PPB Plan A or B, charges for the newborn nursery care will be paid
in the baby’s name. If the baby is not enrolled for coverage under the Plan, charges for a normal, healthy newborn’s
PEIA 2017-2018 SPD ABD-REV.indd 64 7/13/17 9:15 AM
65
nursery care will be covered as part of the mother’s maternity benet, and all other claims will be denied. If the new-
born is covered under another plan, coordination of benets rules will apply.
Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act
PEIA is required by law to provide you with the following statement of rights. PEIA’s maternity benet meets or ex-
ceeds all of the requirements of the Newborns’ and Mothers’ Health Protection Act.
Under federal law, group health plans and health insurance issuers oering group health insurance coverage gener-
ally may not restrict benets for any hospital length of stay in connection with childbirth for the mother or newborn
child to less than 48 hours following a vaginal delivery, or less than 96 hours following a delivery by Cesarean section.
However, the plan or issuer may pay for a shorter stay if the attending provider (e.g., your physician, nurse midwife, or
physician assistant), after consultation with the mother, discharges the mother or newborn earlier.
Also, under federal law, plans and issuers may not set the level of benets or out-of-pocket costs so that any later portion
of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion
of the stay.
In addition, a plan or issuer may not, under federal law, require that a physician or other health care provider obtain
authorization for prescribing a length of stay of up to 48 hours (or 96 hours). However, to use certain providers or facili-
ties, or to reduce your out-of-pocket costs, you may be required to obtain precertication. For information on precerti-
cation, contact your plan administrator.
Comprehensive Care Partnership (CCP) Program
PEIA oers a healthcare program that allows you to receive primary care services while paying less. is program,
called the Comprehensive Care Partnership (CCP) program, is designed to promote quality of care, preventive services
and appropriate use of health services to identify health problems early and maintain control of chronic conditions. is
benet option is available to PEIA PPB Plan A, B and D insureds.
Members who enroll in the CCP Program will have reduced or no copayments, deductibles or coinsurance for specied
services at their CCP provider. CCP providers are expected to provide primary care services, coordination of care, and
some CCP locations also provide specialty care services and/or laboratory services. If a CCP member uses any provider
outside the CCP, including another primary care provider, the copayment for the oce visit will be $40.
e purpose of the CCP and the “Patient-Centered Medical Home” is to promote the use of health services to keep the
patient well, identify health problems early, maintain control of chronic conditions and to promote ecient utilization
of healthcare resources. As such, the following is required of the CCP health center:
• Remind you when services are due;
• Perform an initial evaluation to include an assessment of your preventive health care services and overall health
status;
• Provide the information you need to care for yourself;
• Maintain an electronic medical record, which includes a summary of key health and preventive care history,
medicines, and a provision for delivering such information to you as needed;
• Provide 24-hour telephone access to a medical provider;
• Coordinate with specialists to ensure that all information and treatment plans are consistent;
• Notify you of any changes to covered services;
• Notify PEIA of non-compliant members who should be removed from the program.
Members who enroll in the CCP do so by choice. e member agrees to receive his/her primary healthcare from the
CCP provider. Enrolled members have reduced or no copayments, coinsurance or deductibles to meet for specied
PEIA 2017-2018 SPD ABD-REV.indd 65 7/13/17 9:15 AM
66
services provided at their CCP location. e success of the program requires a working partnership between the CCP
provider and the patient/member. Participating members agree to:
• Use their chosen CCP provider for all health care available at their designated CCP.
• Contact their CCP provider before receiving medical care from providers with the exception of emergency cases.
• Participate in initial and regular health assessments at least every two years. e purpose of the assessment is to
collect the health history and clinical data needed to identify the preventive services needed, plan the patient’s
care, and address all healthcare questions.
• Members who do not comply with the requirements of the program may be dis-enrolled.
NOTE: If you want to continue using other primary care providers and/or specialists for much of your health care, the
CCP may not be for you.
To enroll in the CCP program, simply:
• Review the CCP provider list on PEI A’s website at www.wvpeia.com and choose the provider location to serve
as your CCP provider;
• Click on the green “Manage My Benets” button in the upper right corner, register on the site or use your
existing credentials to log-in and choose your CCP provider;
• Or complete the CCP program enrollment form from the website, note the CCP location of choice and the
seven digit provider ID number, then sign it and return it to PEIA at the address provided, or you may give it to
a receptionist at one of the health centers;
Your CCP will be eective the rst day of the month following receipt of your completed enrollment form, if it is re-
ceived no later than the 25th. If the form is received after the 25th, then enrollment may be delayed a month.
Medical Home
PEI A’s Medical Home program allows PEIA PPB Plan A, B & D members to choose a West Virginia physician
who has joined PEI A’s Medical Home Program from our provider directory to serve as your medical home. (Go to
www.wvpeia.com and click “Forms & Downloads” and “Medical Home Program Forms” to nd the Provider Di-
rectory.) Medical Home providers are denoted with MHP in the directory. When you choose and use your Medical
Home, you will pay a $20 oce visit copayment for each visit.
e intent of this program is to connect members with a physician who can oversee and coordinate all of their care. You
ARE NOT required to have a referral to see a specialist, and this plan does not limit your ability to see any network
doctor you choose. You may name a Medical Home each year during open enrollment, and you may make one change
during the plan year, if you wish, unless there are extenuating circumstances, such as the death of your Medical Home
physician or a move that makes it inconvenient for you to access care from your Medical Home.
If you are a PPB Plan participant and you choose a Medical Home, you can still see any network physician you choose.
Oce visits to your Medical Home or any other primary care provider will have a $20 copay. Specialist oce visits will
have a $40 copay per visit.
Organ Transplant Benefits
Organ transplants are covered when deemed medically necessary and non-experimental. ey are subject to precerti-
cation and case management by HealthSmart Care Management. You should contact HealthSmart Care Management
as soon as your doctor determines you or a member of your family covered by PEIA PPB Plans A, B or D may need
a transplant. All transplants require precertication for determination of medical necessity. You should advise your
physician that HealthSmart Care Management needs to coordinate the care from the initial phase when considering a
transplant procedure, initial workup for transplant through the performance of the procedure and the care following
the actual transplant.
PEIA 2017-2018 SPD ABD-REV.indd 66 7/13/17 9:15 AM
67
Any services and supplies that are required for donor/procurement as a result of a surgical transplant procedure for a
participant will be covered. Benets for such charges, services and supplies are not provided under the PPB Plan if ben-
ets are provided under another group plan or any other group or individual contract or any arrangement of coverage
for individuals in a group (whether an insured or uninsured basis), including any prepayment coverage.
Testing for persons other than the chosen donor is not covered.
Organ Transplant Network (OTN)
e PEIA PPB Plan uses a network of providers for organ transplant services. is helps to control health care costs for
both you and the plan. PEI A’s primary OTN facilities are:
• University of Kentucky’s UK HealthCare
• Cleveland Clinic
• WVU Hospital for bone marrow
• Charleston Area Medical Center (CAMC) for kidney
For services not available at these facilities, PEIA uses Aetna’s Institutes of Excellence transplant network.
HealthSmart Care Management will work with patients and physicians to determine which facility best serves the
patient’s medical needs.
OTN Benefits
Reduced Costs: Once the annual deductible and out-of-pocket maximum have been met, you will pay no more coin-
surance on the negotiated fees for pre-transplant, transplant, and follow-up services. Copayments for oce visits and
other services described on page 46 will still apply.
Travel Allowance: Because network facilities may be located some distance from the patient’s home, reimbursement
benets include up to $5,000 per transplant for patient travel, lodging and meals related to visits to the transplant facil-
ity or physician. A portion of this benet is available to cover the travel, lodging and meals for a member of the patient’s
family or a friend providing support. Receipts are required for payment of meals and lodging; cost estimates are not ac-
ceptable. No alcoholic beverages will be reimbursed. Mileage will be reimbursed at the federal mileage rate for medical
expenses.
NOTE: To seek reimbursement for transplant-related travel expenses, use the Medical Claim Form on
www.wvpeia.com and submit the form to HealthSmart, the third-party administrator. All claims must be submitted
within the six-month timely ling period, including the submission of all lodging and travel expenses.
Medical Case Management: HealthSmart Care Management oers support and assistance in evaluating treatment
options and referrals to the prescription drug administrator. Management begins early when the po
tential need for
a transplant is identied, and continues through the surgery and follow-up. When the need for a transplant presents
itself, call HealthSmart Care Management at 1-888-440-7342.
You should contact HealthSmart Care Management as soon as you learn that you or a member of your family covered
by PEIA PPB Plans A, B or D may need a transplant. All transplants must be precertied through HealthSmart Care
Management.
Out-of-Network Organ Transplant Benefits
For patients who choose to use a non-network facility for transplant services, there is no coverage for out-of-network
facilities, unless approved in advance by HealthSmart Care Management. No travel benets will be provided for out-of-
network transplants (except medically necessary ambulance transport).
PEIA 2017-2018 SPD ABD-REV.indd 67 7/13/17 9:15 AM
68
Transplant-Related Prescription Drugs
PEIA PPB Plans A, B & D cover transplant-related immunosuppressant prescription drugs at 100%, after you have met
your prescription drug deductible (if they are lled at a network pharmacy). ese are covered through the Prescription
Drug Plan and processed by the prescription drug administrator. Details of the PEIA Prescription Drug Plan are found
in the “Prescription Drug Benets” section starting on page 79.
Medical case management of transplant patients includes referral to the prescription drug administrator for waiver of
copayment on transplant-related immunosuppressant drugs. HealthSmart Care Management will make arrangements
with the prescription drug administrator to waive copayments on drugs used to sustain the transplant.
Sleep Management Services
e PEIA PPB Plans cover services for the diagnosis and treatment of sleep apnea and other sleep-related conditions
that can aect your health. To ensure compliance and to administer prescribed sleep services at the highest quality,
HealthSmart Benet Solutions, the third-party administrator for PEIA, has contracted with Sleep Management Solu-
tions (SMS) to provide sleep diagnostic and therapy management services for PPB Plan members. A precertication
process has been established to qualify services as medically necessary and appropriate. PEIA requires that the ordering
physician request approval from SMS prior to a member receiving sleep services that include sleep testing, sleep therapy
or sleep therapy supplies.
Using evidence-based guidelines, SMS will review your request for a sleep study and make recommendations for those
studies that can be performed in the member’s home. If the member is appropriate for a diagnostic home sleep study,
the member will be directed to an SMS-contracted home sleep testing provider.
In addition to managing sleep testing services, SMS also manages PAP therapy services by providing prior approval for
PAP therapy and supply requests. SMS directs the member to an SMS-contracted DME provider. In addition, SMS
provides comprehensive support for members’ prescribed PAP therapy to provide assistance with adherence to therapy
through the iComply program.
To obtain prior authorization for sleep services, you may call SMS at 1-888-49-SLEEP (75337), or you may fax your re-
quest to1-888-571-8816 using the Prior Authorization Fax Form found at http://www.carecentrix.com/Our-Products/
Sleep-Management-Solutions Non-resident PPB Plan members must call HealthSmart Care Management for precerti-
cation of sleep management services.
Specialty Injectable Program
e PEIA PPB Plans cover specialty injectable drugs through a program managed by HealthSmart. e program
provides comprehensive direction to policyholders and their dependents for treatments utilizing specialty drugs. If your
physician prescribes a specialty drug, that physician, you or the pharmacist must call HealthSmart at 1-888-440-7342
(Providers press 2, then 3, then 1; Members press 1, then 3, then 1). HealthSmart will review the drug for medical ne-
cessity. If approved, HealthSmart will coordinate the purchase through the approved source and contact you and your
physician with additional details including where the physician should call in the prescription, how you will receive the
drug and discuss any educational needs. If denied, HealthSmart will contact your physician for additional information
which may allow approval of the requested medication.
Many specialty medications have manufacturer programs which will nancially assist patients in the purchase of the
medication. PEIA requires that if a nancial assistance program is available, you must participate in the program. Only
your actual out-of-pocket payments will count toward your drug deductible and annual out-of-pocket maximum; not
amounts discounted o the price by the manufacturer or seller of the specialty medication.
PEIA 2017-2018 SPD ABD-REV.indd 68 7/13/17 9:15 AM
69
Travel Benefits
If a covered PEIA participant travels more than 60 miles, one-way, from their home, to receive care in West Virginia,
the PPB Plan will reimburse the policyholder some of the travel expenses related to their medical care.
Limitations and requirements:
• Only mileage and tolls are covered.
• Mileage will be reimbursed at the federal mileage rate for medical expenses in eect for the time period.
• You must provide receipts for tolls.
• Travel must be on the same day as the medical procedure.
• Other travel related expenses are not covered.
• Benet is only for care and services received at providers in West Virginia. Travel to providers outside of West
Virginia is not covered except as specied in the Summary Plan Description.
• Maximum reimbursement shall not exceed $250 per benet year.
NOTE: To seek reimbursement for travel expenses, use the Medical Travel Expense Reimbursement Request Form on
www.wvpeia.com, and submit the form to PEIA, 601 57th St., SE, Suite 2, Charleston, WV 25304-2345. All claims
must be submitted within the six-month timely ling period, including the submission of all lodging and travel expenses.
PEIA 2017-2018 SPD ABD-REV.indd 69 7/13/17 9:15 AM
70
Healthy Tomorrows
e PEIA PPB Plans have a program called Healthy Tomorrows that coordinates all of PEI A’s continuing lifestyle man-
agement programs under one umbrella. e programs included in Healthy Tomorrows are detailed below:
The Healthy Tomorrows Initiative
e PEIA Finance Board adopted the Healthy Tomorrows initiative for active employees and non-Medicare retirees in
the PEIA PPB Plans.
Healthy Tomorrows is an initiative to encourage active employees and non-Medicare retirees in the PEIA PPB Plans to
name and develop a relationship with a primary care physician (PCP). If you have a family plan, only the policyholder
has to complete the Healthy Tomorrows requirements, not dependents.
Phase ree – To avoid the deductible penalty for Plan Year 2018, policyholders were required to have a PCP, be tested,
and have their blood pressure, blood glucose and cholesterol within an acceptable range or have a physician’s certica-
tion that those numbers cannot be met using the form printed in the Plan Year 2017 Shopper’s Guide between April 1,
2016, and May 15, 2017.
In any year that the policyholder does not comply with the initiative, and meet the deadline, he or she will pay an ad-
ditional $500 medical deductible. e additional deductible will be added to a single plan or a family plan deductible.
For Plan Year 2019, the Healthy Tomorrows initiative will continue, with policyholders, once again, meeting the re-
quirements for Phase ree listed above. e penalty, however, will change from an increased medical deductible to a
monthly premium penalty for those who do not comply.
NOTE: PEIA covers an annual physical for members at no cost. Take the Adult Annual Physical and Screening Ex-
amination Form on page 109 and the Healthy Tomorrows reporting form on page 111 to your doctor.
Face-to-Face (F2F) Diabetes Program
PEI A’s F2F Diabetes Program is a statewide, two-year program for PPB Plan members (subject to the availability of
providers) open to active employees and non-Medicare retirees who have diabetes.
Under the program, members and/or their dependents with diabetes or gestational diabetes agree to make regular visits
to a participating provider of their choosing for counseling and health education services. e provider works with each
member over the course of the two-year program to ensure he/she gets the best diabetes care possible by monitoring:
a) recommended testing and treatment of diabetes;
b) the member’s currently prescribed medicines and knowledge about how to take them; and
c) physical activity and nutrition plan to assist the member in achieving optimal health.
New members enrolling in the F2F Diabetes program will have 12 months from the date of enrollment to get their
HbA1c at a value of 8 or below (or provide a physician’s statement of why they cannot). Members benet from partici-
pating in the F2F Diabetes program by improving their health and quality of life, and by saving money, since copay-
ments are waived for generic and brand-preferred diabetes related prescription drugs, and/or supplies. Copayments
are waived only at retail pharmacies, not mail order. Copayments are not waived on brand non-preferred prescription
drugs. PEIA benets from the member’s better management of their disease through fewer health care costs from the
disease or its complications.
Members participating in the F2F Diabetes program must be tobacco free and must be eligible for the tobacco-free
premium discount, which means they must have been tobacco free for a minimum of six months prior to enrollment in
the program. F2F is a twice-in-a-lifetime benet (with the exception of gestational diabetes). Members who either failed
PEIA 2017-2018 SPD ABD-REV.indd 70 7/13/17 9:15 AM
71
to comply or dropped out of the program may re-enroll after a 12-month waiting period, which begins on the date
PEIA disenrolls you from the program. Prior bariatric surgery will make the member ineligible to participate in F2F.
For more information or an application, check the PEIA website, www.wvpeia.com, or the F2F Care Management
Programs website, www.peiaf2f.com, or call PEIA Customer Service at 1-888-680-7342.
Hemophilia Disease Management Program
To provide quality care at a reasonable cost, PEIA has partnered with the Charleston Area Medical Center (CAMC)
and West Virginia University Hospitals (WVUH) to provide a Hemophilia Care Program to PEIA PPB Plan members.
Members who participate in the program will be eligible for the following benets:
• An annual evaluation by specialists in the Hemophilia Disease Management Program which will be paid at
100% with no deductible, copay or coinsurance. (is evaluation is not intended to replace or interrupt care
provided by your existing medical home provider or specialists. is evaluation does not include routine or sick
care visits with your doctor or ER.)
• Hemophilia factor expenses incurred at CAMC or W VUH will be paid at 100% with no deductible, copay or
coinsurance.
• Reimbursement for travel and lodging for an annual evaluation
a) Child and 1 or 2 parents
b) Adult and an accompanying adult
c) Lodging will be at an approved travel lodge for a maximum of two (2) nights for one room only.
d) Gas will be reimbursed at the federal rate for one vehicle only.
e) Receipts for food will be paid at 100% for the child and parents or for the 2 adults.
Lodging and Travel Expenses:
Lodging expenses include:
a) a) Expenses incurred by the patient traveling between his or her home and the participating facility to
receive services in connection with the Hemophilia Disease Management Program.
b) b) Expenses incurred by the patient’s companion to enable the patient to receive services from the He-
mophilia Disease Management Program.
1. For children under the age of 18, lodging will be covered for one (1) or two (2) parents.
2. For patients over the age of 18, lodging will be covered for one (1) companion.
Lodging will be covered at 100% of the charge at an approved travel lodge.
Tr
avel expenses (gas & meals) include:
1. Expenses incurred while traveling with the patient between the patient’s home and the medical facility to re-
ceive services in connection with the Hemophilia Disease Management Program.
2. Gas receipts are required for reimbursement.
3. Reimbursement of meal expenses up to $30 per day per person. Receipts are required for the reimbursement of
meals.
All claims must be submitted within the six-month timely ling period, including the submission of all lodging and
travel expenses.
For more information about this program please contact: HealthSmart at 888-440-7342.
Weight Management Program
PEIA oers a facility-based weight management program for PEIA PPB plan A, B and D members who have a Body
Mass Index (BMI) of 25 or greater or a waist circumference of 35 inches or greater for women or 40 inches or greater
PEIA 2017-2018 SPD ABD-REV.indd 71 7/13/17 9:15 AM
72
for men. e program includes comprehensive services from registered and licensed dietitians, degreed exercise physi-
ologists and personal trainers at approved tness centers. e current list of participating facilities is on PEI A’s website
at www.wvpeia.com. is is a twice per lifetime benet with a copayment of $20 per month. Members who previ-
ously participated in the PEIA Weight Management Program but did not complete a full two years may be eligible for a
second program attempt of one year’s length. e benet is dierent for members of Plan C, which is an IRS-qualied
High-Deductible Health Plan (HDHP). For more information about Plan C, download Summary Plan Description
(Plan C) at www.wvpeia.com or call 1-888-680-7342.
To enroll, you must complete the application, which includes some medical information, and provide written ap-
proval from your physician. For more information or to enroll in the program, call 1-866-688-7493 or go to
www.wvpeia.com.
Tobacco Cessation
PEIA PPB Plans A, B & D provide benets for participants who wish to quit smoking or using smokeless tobacco
products. Only those members who have been paying the Standard (tobacco-user) premium are eligible for the Tobacco
Cessation benet. If you signed an adavit claiming to be tobacco-free, you will be declined the Tobac co Cessation
benet.
To access the benets, simply visit your medical home/primary care provider. PEIA will cover an initial and follow-
up visit to your physician or nurse practitioner. PEIA covers both prescription and non-prescription tobacco cessation
medications if they are dispensed with a prescription. PEIA will cover two 12-week cycles of drug therapy, even if more
than one type of therapy is used. If extended therapy is required, the provider must submit a written appeal to the Di-
rector of PEIA with proof of medical necessity.
You can use the benet (oce visits and prescriptions) twice per year (rolling 12 month period). For pregnant partici-
pants, PEIA will provide 100% coverage for the tobacco cessation benet during any pregnancy.
Payment Level
PEIA will cover an initial and follow-up visit to your physician or nurse practitioner at no cost to the member.. Tobac -
co-cessation products are available at no cost to the member; both the deductible and the copayment are waived when
prescribed by a physician and purchased at a network pharmacy.
PEIA Pathways to Wellness
e PEIA Pathways to Wellness program has been discontinued. PEIA is seeking another program to replace it, and
will distribute information about the new program as soon as it is available.
PEIA 2017-2018 SPD ABD-REV.indd 72 7/13/17 9:15 AM
73
What Is Not Covered
Some services are not covered by the PEIA PPB Plans regardless of medical necessity. Some specic exclusions are listed
below. If you have questions, please contact HealthSmart at 1-888-440-7342 or 1-304-353-7 820. e following ser-
vices are not covered:
1. Acupuncture
2. Aqua therapy
3. Autopsy and other services performed after death, including transportation of the body or repatriation of
remains
4. Biofeedback
5. Chemical dependency treatments when a patient leaves the hospital or facility against medical advice
6. Coma stimulation
7. Cosmetic or reconstructive surgery when not required as the result of accidental injury or disease, or not per-
formed to correct birth defects. Services resulting from or related to these excluded services also are not covered
8. Custodial care, intermediate care (such as residential treatment centers), domiciliary care, respite care, rest cures,
or other services primarily to assist in the activities of daily living, or for behavioral modication, including
applied behavior analysis (ABA), except to the extent ABA is mandated to be covered for treatment of autism
spectrum disorder by W. Va. Code §5-16-7(a)(8)
9. Dental implants, whether medically indicated or not
10. Dental services including dental implants, routine dental care, x-rays, treatment of cysts or abscesses associated
with the teeth, dentures, bridges, or any other dentistry and dental procedures
11. Daily living skills training
12. Duplicate testing, interpretation or handling fees
13. Education, training and/or cognitive services, unless specically listed as covered services
14. Elective abortions
15. Electronically controlled thermal therapy
16. Emergency evacuation from a foreign country, even if medically necessary
17. Expenses for which the patient is not responsible, such as patient discounts and contractual discounts
18. Expenses incurred as a result of the commission of a felony, while incarcerated or while under the control of the
court system
19. Experimental, investigational or unproven services, unless pre-approved by HealthSmart Care Management
20. Fertility drugs and services
21. Foot care. Routine foot care including:
• Removal in whole or in part of: corns, calluses (thickening of the skin due to friction, pressure, or other ir-
ritation), hyperplasia (overgrowth of the skin), or hypertrophy (growth of tissue under the skin);
• Cutting, trimming, or partial removal of toenails;
• Treatment of at feet, fallen a
rches, or weak feet; and
• Strapping or taping of the feet
22. Genetic testing for screening purposes is generally not covered, unless specically mandated by the Patient Pro-
tection and Aordable Care Act. See Precertication on page 53 for exceptions
23. Glucose monitoring devices, except Lifescan One Touch models covered under the prescription drug
benet
24. Homeopathic medicine
25. Hospital days associated with non-emergency weekend admissions or other unauthorized hospital days prior to
scheduled surgery
26. Hypnosis
27. Incidental surgery performed during medically necessary surgery
28. Infertility and sterility services of in vitro fertilization and gamete intrafallopian transfer (GIFT), embryo trans-
port, surrogate parenting, and donor semen, any other method of articial insemination, and any other related
services, including the workup for infertility treatment.
PEIA 2017-2018 SPD ABD-REV.indd 73 7/13/17 9:15 AM
74
29. Maintenance outpatient therapy services, including, but not limited to:
• Chiropractic
• Massage erapy
• Occupational erapy
• Osteopathic Manipulations
• Outpatient Physical erapy
• Outpatient Speech erapy
• Vision erapy
30. Marriage counseling
31. Medical equipment, appliances or supplies of the following types:
• augmentative communication devices
• bariatric beds and chairs
• bathroom scales
• educational equipment
• environmental control equipment such as air conditioners, humidiers or dehumidiers, air cleaners or
lters, portable heaters
• dust extractors
• equipment or supplies which are primarily for patient comfort or convenience, such as bathtub lifts or seats;
massage devices; elevators; stair lifts; escalators; hydraulic van or car lifts; orthopedic mattresses; walking
canes with seats; trapeze bars; child strollers; lift chairs (including Hoyer lifts); recliners; contour chairs;
adjustable beds; or tilt stands
• equipment which is widely available over the counter such as wrist stabilizers and knee supports
• exercise equipment such as exercycles; parallel bars; walking, climbing or skiing machines.
• hearing aids of any type
• hygienic equipment such as bed baths, commodes, and toilet seats
• motorized scooters
• nutritional supplements, over-the-counter (OTC) formula, food liquidizers or food processors
• Omnipod, V-go, Finesse and other disposable insulin delivery systems
• orthopedic shoes, unless attached to a brace
• professional medical equipment such as blood pressure kits or stethoscopes
• replacement of lost or stolen items
• supplies such as tape, alcohol, Q-tips/swabs, gauze, bandages, thermometers, aspirin, diapers (adult or in-
fant), heating pads or ice bags
• standing/tilt wheel chairs
• traction devices
• vibrators
• whirlpool pumps or equipment
• wigs or wig styling
32. Medical rehabilitation and any other services that are primarily educational or cognitive in nature
33. Mental health or chemical dependency services to treat mental illnesses which will not substantially improve
beyond the patient’s current level of functioning
34. Optical services:
• Routine eye examinations, refractions, eye glasses, contact lenses and ttings
• Glasses and/or contact lenses following cataract surgery
• Low-vision devices, including magniers, telescopic lenses and closed circuit television systems
35. Oral appliances, including, but not limited to, those treating sleep apnea
36. Orientation therapy
37. Orthodontia services
38. Orthotripsy
39. Physical examinations and routine oce visits except those covered under the Periodic Physicals benet
PEIA 2017-2018 SPD ABD-REV.indd 74 7/13/17 9:15 AM
75
40. Personal comfort and convenience items or services (whether on an inpatient or outpatient basis) such as televi-
sion, telephone, barber or beauty service, guest services, and similar incidental services and supplies, even when
prescribed by a physician
41. Physical conditioning and work hardening. Expenses related to physical conditioning programs and work hard-
ening such as athletic training, body building, exercise, tness, exibility, diversion, or general motivation
42. Physical, psychiatric, or psychological examinations, testing, or treatments not otherwise covered under the
plan, when such services are:
• conducted for purposes of medical research;
• for participation in athletics;
• needed for marriage or adoption proceedings;
• related to employment;
• related to judicial or administrative proceedings or orders;
• to obtain or maintain a license or ocial document of any type; or
• to obtain or maintain insurance
43. Provider charges for phone calls, prescription rells, or physician-to-patient phone consultations
44. Radial keratotomy, Lasik procedure and other surgery to correct vision. Surgery to prevent legal blindness or
restore vision from legal blindness is covered, if not correctable by lenses or other more conservative means
45. Reversal of sterilization and associated services and expenses
46. Safety devices. Devices used specically for safety or to aect performance primarily in sports-related activities
47. Screenings, except those specically listed as covered benets
48. Service/therapy animals and the associated services and expenses, including training.
49. Services rendered by a provider with the same legal residence as a participant, or who is a member of the policy-
holder’s family. is includes spouse, brother, sister, parent, or child
50. Services rendered outside the scope of a provider’s license
51. Sex transformation operations and associated services and expenses
52. Skilled nursing services provided in the home, except intermittent visits covered under the Home Health Care
benet
53. Sensory stimulation therapy
54. Take-home drugs provided at discharge from a hospital or any facility
55. TMJ. Treatment of temporomandibular joint (TMJ) disorders. Including intraoral prosthetic devices or any
other method of treatment to alter vertical dimension or for temporomandibular joint dysfunction not caused
by documented organic disease or acute physical trauma
56. e dierence between private and semi-private room charges
57. erapy and related services for a patient showing no progress
58. erapies rendered outside t
he United States that are not medically recognized within the United States
59. Transportation other than medically-necessary emergency ambulance services, or as approved under the Organ
Transplant Network benet or the Travel Benet
60. War-related injuries or illnesses. Treatment in a State or Federal hospital for military or service-related injuries
or disabilities
61. Weight loss. Health services and associated expenses intended primarily for the treatment of obesity and morbid
obesity, including wiring of the jaw, weight-control programs, weight-control drugs, screening for weight-con-
trol programs, and services of a similar nature, except those services provided through the Weight Management
Program oered by PEIA
62. Work-related injury or illness
PEIA 2017-2018 SPD ABD-REV.indd 75 7/13/17 9:15 AM
76
How to File a Claim
Filing a Medical Claim
Medical claims are processed by HealthSmart Benet Solutions and should be submitted to:
HealthSmart Benefit Solutions, P.O. Box 2451, Charleston, WV 25329-2451
is post oce box should be used only for PEIA claims. Please do not submit PEIA claims to other HealthSmart post
oce boxes. is will only delay their processing.
To process a medical claim, HealthSmart requires a complete itemization of charges including:
• the patient’s name;
• the nature of the illness or injury;
• date(s) of service;
• type of service(s);
• charge for each service;
• diagnosis and procedure codes;
• identication number of the provider; and
• Medical ID number of the policyholder.
If the necessary information is printed on your itemized bill, you do not need to use a PEIA claim form to submit your
charges. Cash register receipts and canceled checks are not acceptable proof of your claim.
If you have other insurance which is primary, you need to submit an Explanation of Benets (EOB) from the other in-
surance which shows the amount the primary insurance paid with each claim, or ask your provider to do so if the claim
is being submitted for you.
You have six (6) months from the date of service to le a medical claim. If PEIA is your secondary insurer, you have
six (6) months from the date of your primary insurer’s Explanation of Benets processing date to le your claim with
PEIA. If you do not submit claims within this period, they will not be paid, and you will be responsible for payment to
the provider.
If your claim is for an illness or injury wrongfully or negligently caused by someone else, and you expect to be reim-
bursed by another party or insurance plan, you must le a claim with PEIA within six (6) months of the date of service
to ensure that the covered services will be paid. Later, if you receive payment for the expenses, you will have to repay the
amount you received from PEIA. See “Subrogation” on page 103 for details.
Filing Claims for Court-ordered Dependents (COD)
If you are the custodial parent of a child who is covered under the other parent’s PEIA plan as a result of a court order,
you may submit claims directly to HealthSmart using the special claim forms provided by PEIA. You can also receive
all benet information published by PEIA, and reimbursements for medical claims can be sent directly to you. For pre-
scription drugs, you must use your I.D. card at a participating pharmacy. To make arrangements for this, please contact
PEIA at 1-304- 558-7850, or toll-free at 1-888 -680-7342.
Claims Incurred Outside of the U.S.A.
If you or a covered dependent incur medical expenses while outside the United States, you may be required to pay the
provider yourself. Request an itemized bill containing all the information listed above from your provider and submit
the bill along with a claim form to HealthSmart or the prescription drug administrator.
HealthSmart or the prescription drug administrator will determine, through a local banking institution, the currency
exchange rate and you will be reimbursed according to the terms of the plan you’re enrolled in.
PEIA 2017-2018 SPD ABD-REV.indd 76 7/13/17 9:15 AM
77
Appealing a Claim
PEIA PPB Plans
If you are a PEIA PPB Plan participant or provider and think that an error has been made in processing your claim or
reviewing a service, the rst step is to call the ird Party Administrator to verify that a mistake has been made. (For
information about prescription drug appeals, see page 94) All appeals must be initiated within 60 days of claim pay-
ment or denial.
Type of Error Who to Call Where to Write
Medical claim or case management denial HealthSmart Benet Solutions
1-888-440-7342
HealthSmart Benet Solutions
P.O. Box 366
Charleston, WV 25322
Out-of-state care denial or denial of precertication HealthSmart Care Management
1-888-440-7342
HealthSmart Care Management
P.O. Box 1921
Charleston, WV 25327-1921
Prescription drug claim CVS Caremark
1-844-260-5894
CVS Caremark
P. O. Box 52084
Phoenix, AZ 85072-2084
If your medical claim or service has been denied, or if you disagree with the determination made by one of the ird
Party Administrators, the second step is to appeal in writing within 60 days of the denial to the ird Party Admin-
istrator at the address listed above. Explain what you think the problem is, and why you disagree with the decision.
Please have your physician provide any additional relevant clinical information to support your request. e ird Party
Administrator will respond to you by reprocessing the claim or sending you a letter.
If this does not resolve the issue, the third step is to appeal in writing to the director of the PEIA. e participant,
provider or covered dependent must request a review in writing within sixty (60) days of getting the decision from the
ird Party Administrator. Facts, issues, comments, letters, Explanations of Benets (EOBs), and all pertinent informa-
tion about the case should be included and mailed to:
Director, Public Employees Insurance Agency, 601 57th Street, SE, Suite 2, Charleston, WV 25304-2345
When your request for review arrives, the PEIA will reconsider the entire case, taking into account any additional ma-
terials which have been provided. A decision, in writing, explaining the reason for modifying or upholding the original
disposition of the claim will be sent to the insured or his or her authorized representative. If additional information is
required to render a decision, this information will be requested in writing. e additional information must be re-
ceived within 60 days of the date of the letter. If the additional information is not received, the case will be closed.
External Review: If we have denied your request for the provision of or payment for a health care service or course of
treatment, you may have a right to have our decision reviewed by independent health care professionals who have no
association with us if our decision involved making a judgment as to the medical necessity, appropriateness, health care
setting, level of care or eectiveness of the health care service or treatment you requested. Exercise this right by submit-
ting a request for external review within 4 months after receipt of the notice of denial to the PEIA Clinical Unit, 601
57th Street, SE, Suite 2, Charleston, WV 25304-2345. For standard external review, a decision will be made within
45 days of receiving your request. If you have a medical condition that would seriously jeopardize your life or health or
would jeopardize your ability to regain maximum function if treatment is delayed, you may be entitled to request an
expedited external review of our denial. If our denial to provide or pay for health care service or course of treatment is
based on a determination that the service or treatment is experimental or investigational, you also may be entitled to le
a request for external review of our denial. External review is the nal level of appeal. External review is not available for
items or treatments that are simply not covered by the Plan.
PEIA 2017-2018 SPD ABD-REV.indd 77 7/13/17 9:15 AM
78
Managed Care Plan Members
If you are a managed care plan member, and you think that an error has been made in processing your claim, the rst
step is to call your managed care plan to discuss the matter.
If your claim has been denied, or if you disagree with the determination made by your managed care plan, the second
step is to appeal in writing within 60 days of the denial to your managed care plan. Instructions for ling that appeal
are in your “Evidence of Coverage” provided by your managed care plan.
If you are not satised with the response from your managed care plan, you may appeal in writing to the director of the
PEIA. You or your covered dependents must request a review in writing within sixty (60) days of getting the decision
from your managed care plan. Facts, issues, comments, letters, Explanations of Benets (EOBs), and all pertinent infor-
mation about the claim and review should be included. e appeal should be mailed to:
Director, Public Employees Insurance Agency, 601 57th Street, SE, Suite 2, Charleston, WV 25304-2345
When your request for review arrives, the PEIA will reconsider the entire case, taking into account any additional
materials that have been provided. A decision, in writing, explaining the reason for modifying or upholding the original
disposition of the claim will be sent to the insured or his or her authorized representative.
If additional information is required to render a decision, this information will be requested in writing. e additional
information must be received within 60 days of the date of the letter. If the additional information is not received, the
case will be closed.
If you disagree with the decision of the PEIA director, you have one nal level of appeal to the West Virginia Insur-
ance Commissioner. Instructions for this appeal are also provided in your “Evidence of Coverage” from your man-
aged care plan.
PEIA 2017-2018 SPD ABD-REV.indd 78 7/13/17 9:15 AM
79
Prescription Drug Benets
Along with your PEIA PPB Plan medical coverage, you also have prescription drug coverage. e prescription drug
program is administered by CVS Caremark. ere are three parts to the program:
1. the Retail Pharmacy Program gives you access to local participating pharmacies to get your prescriptions lled;
2. the CVS Caremark Mail Service Pharmacy Program lets you order your prescriptions through the mail, saving
you time and money by having your maintenance medications delivered to your door;
3. the HealthSmart Specialty Medication Program provides access to your common specialty medications through
the mail, saving you time by having your medications delivered to your door or to your physician’s oce.
Your prescription drug benets pay for a wide range of medications, with diering copayments depending on where
you purchase those drugs, and whether you purchase generic or brand name drugs.
What You Pay
Deductible
During any plan year, if you or your eligible dependents incur expenses for covered prescription drugs, you must meet a
deductible before the plan begins to pay. e deductibles are:
Prescription Drug Deductibles
PPB Plan A or D PPB Plan B
Policyholder Only $75 $150
Policyholder & Child(ren) $150 $300
Family $150 $300
Family with Employee Spouse $150 $300
e family deductible is divided up among the family members. No one member of the family will pay more than the
individual deductible. Once that person has met the individual deductible, the plan will begin paying on that person.
When another member of the family meets the individual deductible, then the plan will begin paying on the entire
family. Alternatively, all members of the family may contribute to the family deductible with no one person meeting
the individual deductible; once the family deductible is met, the plan pays on all members of the family. After you meet
your deductible, you will pay copayments or coinsurance based on the amount and type of drug you’re taking. e fol-
lowing chart shows the copayments and coinsurance.
PEIA 2017-2018 SPD ABD-REV.indd 79 7/13/17 9:15 AM
80
Copayments and Coinsurance
Once you meet your deductible, you pay a copayment or coinsurance to obtain drugs. Copayments and coinsurance are
the portion of the cost that you are required to pay per new or rell prescription. e rest of the cost is paid by PEIA.
Several factors determine your copayment or coinsurance.
Prescription Drug Copayments and Coinsurance
PEIA PPB Plan A or D
Up to a 30-day supply 90-day supply*
Generic Drug $10 $20
Brand-name drug listed on the WV Preferred Drug List $25 $50
Brand-name drug not listed on the WV Preferred Drug List
#
75% Coinsurance 75% Coinsurance
Common Specialty Medications on WV Preferred rug List $100 not available
Common Specialty Medications NOT on WV Preferred Drug List
†
$150 not available
PEIA PPB Plan B
Generic Drug $10 $20
Brand-name drug listed on the WV Preferred Drug List $30 $60
Brand-name drug not listed on the WV Preferred Drug List
#
75% Coinsurance 75% Coinsurance
Common Specialty Medications on WV Preferred Drug List $100 not available
Common Specialty Medications NOT on WV Preferred Drug List
†
$150 not available
*For maintenance medications only. See the Maintenance Medications section for the list of qualifying medications. You must purchase all medications on the Main-
tenance Drug List in 90-day supplies through a Retail Maintenance Network pharmacy or through Mail Service. Read on for details.
† Should your doctor prescribe or you request the brand-name Specialty Medication when a generic drug is available, you must pay 75% coinsurance.
# Should your doctor prescribe or you request the brand-name drug when a generic drug is available, you must pay 75% coinsurance.
Generic Drugs
e brand name of a drug is the product name under which the drug is advertised and sold. Generic medications have
the same active ingredients and are subject to the same rigid U.S. Food and Drug Administration (FDA) standards for
quality, strength and purity as their brand-name counterparts. Generic drugs usually cost less than brand-name drugs.
Please ask your doctor to prescribe generic drugs whenever possible.
West Virginia Preferred Drug List (WVPDL)
e West Virginia Preferred Drug List (WVPDL) is a list of carefully selected medications that can assist in maintain-
ing quality care while providing opportunities for cost savings to the member and the plan. Under this program, your
plan requires you to pay a lower copayment for medications on the WVPDL and a higher copayment for medications
not on the WVPDL. By asking your doctor to prescribe WVPDL medications, you can maintain high quality care
while you help to control rising health-care costs.
Here’s how the copayment structure works:
• Highest Cost: You will pay a 75% coinsurance for brand-name drugs that are not listed on the WVPDL.
• Middle Cost: You will pay a mid-level copayment for brand-name drugs that are listed on the WVPDL.
• Lowest Cost: You will pay the lowest copayment for generic drugs. Generic drugs are subject to the same rigid
U.S. Food and Drug Administration standards for quality, strength and purity as their brand-name counter-
parts. Generic drugs usually cost less than brand-name drugs. Please ask your doctor to prescribe generic drugs
for you whenever possible.
Sometimes your doctor may prescribe a medication to be “dispensed as written” when a WVPDL brand name or generic
alternative drug is available. As part of your plan, an CVS Caremark pharmacist or your retail pharmacist may discuss with
your doctor whether an alternative formulary or generic drug might be appropriate for you. Your doctor always makes the
nal decision on your medication, and you can always choose to keep the original prescription at the higher copayment.
PEIA 2017-2018 SPD ABD-REV.indd 80 7/13/17 9:15 AM
81
Drugs on the WVPDL are determined by the CVS Caremark Pharmacy and erapeutics Committee. e commit-
tee, made up of physicians, meets quarterly to review the medications currently on the Formulary, and to evaluate new
drugs for addition to the Formulary. e Formulary may change periodically, based on the recommendations adopted
by the committee.
If you have any questions, please call CVS Caremark Customer Care at 1-84 4-260-5894.
Prescription Out-of-Pocket Maximum
PEIA has an out-of-pocket maximum on drugs of $1,750 for an individual and $3,500 for a family. Once you have met
the out-of-pocket maximum, PEIA will cover the entire cost of your prescriptions for the balance of the plan year. e
out-of-pocket maximum only includes actual copays, not deductibles or other charges, and is separate from your medi-
cal out-of-pocket maximum.
Getting Your Prescriptions Filled
Using a Retail Network Pharmacy
CVS Caremark has a nationwide network of pharmacies. To get a prescription lled, simply present your medical/
prescription drug ID card at a participating CVS Caremark network pharmacy. You can purchase acute medications
at any CVS Caremark network pharmacy. Maintenance medications must be purchased from a Retail Maintenance
Network pharmacy or using the CVS Caremark Mail Service Pharmacy Program (see below for details). You may rell
your prescription when 75% of the medication is used up or 80% of a controlled substance is used up.
Your ID card contains personalized information that identies you as a PEIA PPB Plan member, and ensures that you
receive the correct coverage for your prescription drugs.
If you use an CVS Caremark pharmacy, you do not have to le a claim form. e pharmacist will le the claim for you
online, and will let you know your portion of the cost.
If you use a network pharmacy and choose not to have the pharmacist le the claim for you online, you will pay 100%
of the prescription price at the time of purchase. All applicable management, such as prior authorization, step therapy,
and quantity limits still apply. You may submit the receipt with a completed claim form to CVS Caremark for reim-
bursement. e prescription receipt must be attached to the form. You will usually be reimbursed within 30 days from
receipt of your claim form. You will be reimbursed the amount PEIA would have paid, less your required copayment,
and your deductible (if applicable). is reimbursement is usually less than you paid for the prescription.
If you need claim forms, call CVS Caremark Customer Care at 1-844-260-5894 or visit their website at
www.caremark.com.
To nd the participating pharmacies nearest you, call CVS Caremark Customer Care at 1-844-260-5894 and
use the voice-activated Pharmacy Locator System. If you have Internet access, you can nd a pharmacy online at
www.caremark.com.
PEIA 2017-2018 SPD ABD-REV.indd 81 7/13/17 9:15 AM
82
Using the Retail Maintenance Network
If you take a drug on a long-term basis, you MUST purchase a 90-day supply of that drug if it is on the maintenance
list (see the Maintenance Drug List later in this section) from a Retail Maintenance Network pharmacy Check with
your local pharmacist to verify participation.
Maintenance Drug Copayments
PEIA PPB Plan A or D PEIA PPB Plan B
Up to 30-day supply 90-day supply* Up to 30-day supply 90-day supply*
Generic medication Not Covered $20 Not Covered $20
Brand-name medication listed on the WV
Preferred Drug List
Not Covered $50 Not Covered $60
Brand-name medication not listed on the WV
Preferred Drug List
#
Not Covered 75% coinsurance Not Covered 75% coinsurance
* For maintenance medications only. See the Maintenance Medications section for the list of qualifying medications. You must purchase all medications on the
Maintenance Drug List in 90-day supplies through a Retail Maintenance Network pharmacy or through Mail Service. Read on for details.
# Should your doctor prescribe or you request the brand-name drug when a generic drug is available, you must pay 75% coinsurance.
Using Non-Network Pharmacies
If you use a non-participating pharmacy, you will pay 100% of the prescription price at the time of purchase, and sub-
mit a completed claim form to CVS Caremark. e prescription receipt must be attached to the form. You will usually
be reimbursed within 21 days from receipt of your claim form. You will be reimbursed the amount PEIA would have
paid at a participating pharmacy, less your required copayment and your deductible (if applicable). is reimbursement
is usually less than you paid for the prescription. All applicable management, such as prior authorization, step therapy,
and quantity limits still apply.
If you purchase a Maintenance Medication at a non-network pharmacy, you will not be reimbursed for your purchase.
Maintenance Medications must be purchased from Retail Maintenance Network pharmacies or using the CVS Care-
mark Mail Service Pharmacy Program.
If you need claims forms, call CVS Caremark Customer Care at 1-84 4-260-5894 or visit their website at
www.caremark.com.
Using the CVS Caremark Mail Service Pharmacy Program
CVS Caremark provides a convenient mail service pharmacy program for PEIA PPB Plan insureds. You may use the
mail service pharmacy if you’re taking medication to treat an ongoing health condition, such as high blood pressure,
asthma, or diabetes. When you use the mail service pharmacy, you must order a 90-day supply of a medication on the
maintenance list, as prescribed by your doctor, and pay the member cost share indicated above. You may rell your pre-
scription when 75% of the medication is used up. CVS Caremark’s licensed professionals ll every prescription follow-
ing strict quality and safety controls. If you have questions about your prescription, registered pharmacists are available
around the clock to consult with you.
New Prescriptions and the Mail Service Pharmacy
If you want to use the mail service pharmacy, the rst time you are prescribed a medication that you will need on an
ongoing basis, ask your doctor for two prescriptions: the rst for a 14-day supply to be lled at a participating retail
pharmacy; the second, for a 90-day supply, to be lled through the mail service pharmacy. ere are several ways to
submit your mail service prescriptions. Just follow the steps below. Some restrictions apply.
1. Ordering new prescriptions. Ask your doctor to prescribe your medication in a 90-day supply for maintenance
medications, plus rells if appropriate. Mail your prescription and required copayment along with an order
form in the envelope provided. Or ask your doctor to fax your order to 1-800-378-0323. You will need to give
your doctor your member ID number located on your ID card.
PEIA 2017-2018 SPD ABD-REV.indd 82 7/13/17 9:15 AM
83
2. Relling your medication. A few simple precautions will help ensure you don’t run out of your prescription.
Remember to reorder on or after the rell date indicated on the rell slip. Or reorder when you have less than
14 days of medication left.
a) Rells online: Log on or register at CVS Caremark’s website at www.caremark.com. Have your mem-
ber ID number, the prescription number (it’s the 9-digit number on your rell slip), and your credit
card ready when you log on.
b) Rells by phone: Call 1-84 4-260-5894 and use the automated rell system. Have your member ID
number, rell slip with the prescription number, and your credit card ready.
c) Rells by mail: Use the rell and order forms provided with your medication. Mail them with your
copayment.
3. Delivery of your medication. Prescription orders receive prompt attention and, after processing, are usually sent
to you by U.S. mail or UPS within two weeks. Your enclosed medication will include instructions for rells, if
applicable. Your package may also include information about the purpose of the medication, correct dosages,
and other important details.
4. Paying for your medication. You may pay by check, money order, VISA, MasterCard, Discover, American
Express, electronic check, or PayPal. Please note: e pharmacist’s judgment and dispensing restrictions, such as
quantities allowable, govern certain controlled substances and other prescribed drugs. Federal law prohibits the
return of any dispensed prescription medicines.
Prior Authorization
Your prescription drug program provides coverage for some drugs only if they are prescribed for certain uses and
amounts, so those drugs require prior authorization for coverage. Prior Authorization is handled by the Rational Drug
erapy Program (RDT). If your medication must be authorized, your pharmacist or physician can initiate the review
process for you. e prior authorization process is typically resolved over the phone; if done by letter it can take up to
two business days. If your medication is not approved for plan coverage, you will have to pay the full cost of the drug.
PEIA will cover, and your pharmacist can dispense, up to a ve-day supply of a medication requiring prior authorization
for the applicable copayment. is policy applies when your doctor is either unavailable or temporarily unable to complete
the prior authorization process promptly. Prior authorizations may be approved retroactively for up to 30 days to allow time
for the physician to work with and provide documentation to R DT. If the prior authorization is ultimately approved, your
pharmacist will be able to dispense the remainder of the approved amount with no further copayment for that month’s
supply if you have already paid the full copayment. All prior authorization requests must be reviewed annually.
e medications listed below require prior authorization:
1. amphetamines (Adderall XR®, Vyvanse®)
2. Anabolic Steroids (Anadrol, Oxandrin)
3. armodanil (Nuvigil®)
4. atomoxetine (Strattera®)
5. becaplermin (Regranex®)
6. buprenorphine (Subutex®)
7. buprenorphine/naloxone (Suboxone®, Bunavail™, Zubsolv®)
8. Butrans Patch
9. chenodiol (Chenodal™)*
10. cinacalcet (Sensipar®)
11. Compounded Medications
12. cyclosporine ophthalmic emulsion (Restasis®)
13. diclofenac sodium gel (Solaraze®)
14. edoxaban tosylate (Savaysa™)
15. enfuvirtide (Fuzeon®)*
PEIA 2017-2018 SPD ABD-REV.indd 83 7/13/17 9:15 AM
84
16. Sacubitril/Valsarten (Entresto)
17. fentanyl oral and topical (Abstral®, Actiq®, Duragesic®, Fentora®, Lazanda®, and Subsys™)
18. Hydrocodone Extended Release (Zohydro ER)
19. linezolid (Zyvox®)
20. metformin ext-rel (Fortamet/Glumetza)
21. modanil (Provigil®)
22. omeprazole sodium bicarbonate (Zegerid)
23. Oral Acne medications (Absorica, Clavaris)
24. Specialty medications *
25. stimulants (Concerta®, Focalin XR®, methylphenidate)
26. tazarotene (Tazorac®)
27. testosterone products (oral, topical, injectable products)
28. tolvaptan (Samsca®)
29. Topic al Antifungals (Jublia, Kerydin)
30. tretinoin cream (e.g. Retin-A) for individuals 35 years of age or older
31. vacation supplies of medication for foreign travel (allow 7 days for processing)
32. vorapaxar (Zontivity®)
*These drugs must be purchased through the Common Specialty Medications Program. See information later in this section.
is list is subject to change during the plan year if circumstances arise which require adjustment. Changes will be
communicated to members in writing. e changes will be included in PEI A’s Plan Document, which is led with the
Secretary of State’s oce, and will be incorporated into the next edition of the Summary Plan Description.
Drugs with Special Limitations
Step Therapy
Step erapy promotes appropriate utilization of rst-line drugs and/or therapeutic categories. Step erapy requires
that participants receive one or more rst-line drug(s), as dened by program criteria before prescriptions are covered for
second-line drugs in dened cases where a step approach to drug therapy is clinically justied. To promote use of cost-
eective, rst-line therapy, PEIA uses step therapy in the following therapeutic classes:
1. Angiotensin II Receptor Antagonists (Benicar, Benicar HCT, Tekturna, Tektu rna HC T, Edarbi, Edarbyclor)
2. Anti-depressants (Pristiq®, Aplenzin®, Khedezla®, Fetzima™, Irenka)
3. Benign Prostatic Hypertrophy (Cardura/ X L®, Rapao®)
4. Bisphosphonates (Fosamax Plus D™,. Binosto®)
5. Cholesterol-lowering medications ( Altoprev®,, Crestor®, Vytorin®, Livalo™, Liptruzet™)
6. Insulins (Apidra, Humalog, Humalog Mix, Humulin 70/30, Humulin N, Humulin R, Novolin R Relion,
Novolin N Relion, Novolin 70/30 Relion)
7. Febuxostat (Uloric®)
8. Fenobrates (Triglide®, Fenoglide®)
9. Lyrica®, Gralise®, Horizant®
10. Migraines (Sumavel Dosepro™, Alsuma,, Treximet®, Onzetra Xsail, Zembrace)
11. Nasal Steroids ( Beconase AQ®, Veramyst®,Omnaris®, Dymista®, Qnasl®, Zetonna®)
12. Non-Steroidal Anti-inammatory Drugs (brand-name NSAID e.g., Cambia®, Duexis, fenoprofen 200mg,
Fenortho 200mg, Flector®, Pennsaid®, Nalfon, Tivorbex, Vivlodex, Zipsor, Zorvolex)
13. Ophthalmic prostaglandins (Lumigan®, Travatan/Z®, Zioptan®)
14. Overactive Bladder: (Oxytrol, Tovia z®, Vesicare®, Enablex®, Gelnique®, Myrbetriq®)
15. Proton Pump Inhibitors (e.g., Dexilant®, Prilosec/Protonix/Zegerid Powder packets, compounding kits for PPI
suspension formulations)
PEIA 2017-2018 SPD ABD-REV.indd 84 7/13/17 9:15 AM
85
16. Sedative Hypnotics (Belsomra,, Rozerem™, Edluar™, Zolpimist™, Silenor®)
17. Selective Serotonin Reuptake Inhibitors (e.g., Pexeva, Viibyrd®, Trintellix)
18. Tetrac yclines (e.g., Adoxa®, Doryx®, Oracea®, Solodyn®, Oraxyl®, Vibramycin®)
19. Topic a l Acne products, kits and cleansers (e.g., Acanya, Aczone, Akne-Mycin, Azelex, Clindagel, Fabior, Pan-
oxyl, Riax, Tretin-X)
20. Topic a l immunomodulators (Elidel®, Protopic®)
is list is subject to change during the plan year, if circumstances arise which require adjustment. Changes will be
communicated to members in writing. e changes will be included in PEI A’s Plan Document, which is led with the
Secretary of State’s oce, and will be incorporated into the next edition of the Summary Plan Description.
Quantity Limits (QL)
Under the PEIA PPB Plan Prescription Drug Program, certain drugs have preset coverage limitations (quantity limits).
Quantity limits ensure that the quantity of units supplied in each prescription remains consistent with clinical dosing
guidelines and PEI A’s benet design. Quantity limits encourage safe, eective and economic use of drugs and ensure
that members receive quality care. If you are taking one of the medications listed below and you need to get more of the
medication than the plan allows, ask your pharmacist or doctor to call RDT to discuss your rell options.
1. Antipsychotic Drugs (Abilify® 30 units, Abilify Discmelt® 60 units, FanaptTM 60 units, Geodon® 60 units, In-
vega® varies, Risperdal® 60 units, Saphris® 60 units, Seroquel/XR® varies, Zyprexa® 30 units, and Zyprexa Zydis®
30 units, Latuda® 30 units)
2. Antiemetics:
• Aloxi® is limited to 2vials per 21 days.
• Anzemet® is limited to 6 tablets per 21 days
• Anzemet 100/5 & 12.5/0.625 injection is limited to 15ml per 180 days.
• Akynzeo is limited to 2 capsules per 21 days
• Cesamet® is limited to 18 capsules per 30 days.
• Emend® 40 mg is limited to 3 capsule per 6 months.
• Emend® 80 mg is limited to 4 capsules per 21 days.
• Emend® 150 mg vial are limited to 2 vials per 21 days.
• Emend® 125 mg is limited to 2 capsules per 21 days.
• Emend® Tri-fold Pack is limited to 2 packages per 21 days.
• Kytril® is limited to 12 tablets per 21 days.
• Kytril 0.1mg/ml is limited to 2ml per 21 days.
• Kytril 1mg/ml is limited to 2ml per 21 days.
• Kytril 4mg/4ml (1mg/ml) injection is limited to 2ml per 21 days.
• Marinol is limited to 60 capsules per 25 days.
• Netupitant-Palonosetron is limited to 2 capsules per 21 days.
• Sancuso® is limited to 2 patches per 21 days.
• Varubi is limited to 4 tablets per 21 days.
• Zofran® 24 mg is limited to 2 tablets per 21 days.
• Zofran® 4mg and 8 mg are limited to 18 tablets per 21 days.
• Zofran® ODT 4mg and 8 mg are limited to 18 tablets per 21 days.
• Zofran® Solution is limited to 200 ml per 21 days.
• Zofran 2mg/ml injection is limited to 20ml per 21 days.
• Zofran 40mg/20mg (2mg/ml) is limited to 20ml per 21 days.
• Zuplenz® is limited to 18 lms per 21 days.
3. Abstral®, Actiq®, Fentora®, Onsolis, Subsys® Coverage is limited to 120 units per 30 days; Lazanda®. Coverage is
limited to 30 bottles per 30 days.
4. Buprenorphine/naltrexone containing products (Bunavail™, Suboxone®, Subutex® and Zubsolv®) is limited to
24mg in initial 60-day period then 16mg.
PEIA 2017-2018 SPD ABD-REV.indd 85 7/13/17 9:15 AM
86
5. Cholesterol Lowering Medications. (Advicor® varies, Caduet® 30 units, Vytorin® 30 units, Altoprev® 30 units,
Crestor® 30 units, Lescol® varies, Lipitor® 30 units, Liptruzet® 30 units, lovastatin varies, Mevacor® 30 units,
Pravachol® 30 units, pravastatin sodium 30 units, Simcor® 30 units, simvastatin 30 units, Zocor® 30 units and
Livalo® 30 units)
6. Enbrel®. Coverage is limited to 4 syringes or 8 vials per 28 days.
7. Estrogen patches: Alora®, Estraderm®, Minivelle®, Vivelle/Dot® limit is 8 patches/28 days. Climara/Pro and Me-
nostar® limit is 4 patches per 28 days.
8. Humira®. Coverage is limited to 2 syringes/pens per 28 days.
9. Lidocaine/Lidocaine topical products is limited to one tube/pack every 25 days
10. Migraine medications. Coverage is limited to quantities listed below:
Generic name Brand name Quantity Level Limit for 30-Day Period
Almotriptan tablets 6.25 mg Axert® 12 tablets
Almotriptan tablets 12.5 mg Axert® 12 tablets
Diclofenac potassium, 50 mg powder packet Cambia™ 9 packets
Dihydroergotamine nasal spray vials, 4 mg/mL vial Migranal® 1 kits = 8 unit dose sprayers
Eletriptan 20 mg, 40 mg Relpax® 12 tablets
Frovatriptan tablets 2.5 mg Frova® 18 tablets
Naratriptan tablets 1 mg, 2.5 mg Amerge® 12 tablets
Rizatriptan tablets 5 mg, 10 mg Maxalt® 18 tablets
Rizatriptan tablets 5 mg, 10 mg, orally disintegrating tablets Maxalt-MLT® 18 tablets
Sumatriptan injection pre-lled auto-injectors, 6 mg/0.5 ml Alsuma® 6 kits (12 syringes)
Sumatriptan autoinjector 3mg/0.5ml Zembrace Symtouch 24 injectors (12ml)
Sumatriptan injection syringes, 6 mg/0.5 ml Imitrex® Statdose
System®
6 kits = 12 injections
Sumatriptan injection vials, 4 mg/0.5 ml Generics 18 vials
Sumatriptan injection vials, 6 mg/0.5 ml Imitrex®, generics 12 vials
Sumatriptan nasal spray 20 mg Imitrex®, generics 2 boxes = 12 unit dose spray devices
Sumatriptan nasal spray 5 mg Imitrex®, generics 4 boxes = 24 unit dose spray devices
Sumatriptan nasal spray 11mg Onzetra Xsail 1 kit=8 pouches
Sumatriptan needle-free injection vial 4 mg/0.5m Sumavel™ DosePro™ 3 boxes=18 needle-free devices
Sumatriptan tablets 25 mg, 50 mg, 100 mg Imitrex®, generics 12 tablets
Sumatriptan (85 mg) naproxen sodium (500 mg) tablets TreximetTM 9 tablets
Sumatriptan (10 mg) and naproxen sodium (60 mg) tablets TreximetTM 9 tablets
Zolmitriptan nasal spray 5 mg Zomig® 2 boxes = 12 unit dose spray devices
Zolmitriptan tablets 2.5 mg and 5 mg, orally disintegrating Zomig-ZMT® 12 tablets
Zolmitriptan tablets 2.5 mg, 5 mg Zomig® 12 tablets
11. Multiple Sclerosis: Avonex® 4 units per 30 days, Betaseron®/Extavia 14 or 15 units per 30 days, Copaxone® 1 kit
per 30 days, Rebif ® 1 pkg/12 syringes per 30 days.
12. Nuvigil ®. Coverage limit varies.
13. Opioid pain medications have a quantity limit (QL) for all medications in the opioid class. Additional quanti-
ties require Prior Authorization. Long-acting Opioids and Immediate-acting Opioids – quantities vary based on
strength of medications. Medications in this class include, hydrocodone products, Avinza, Nucynta, Nucynta
ER, Xartemis XR. Kadian, Embeda, morphine products, Oxycontin, Hysingla ER, Zohydro ER, Opana, Opa-
na ER, methadone, codeine products, hydromorphone products, oxycodone products, Meperidine products,
PEIA 2017-2018 SPD ABD-REV.indd 86 7/13/17 9:15 AM
87
Exalgo, Vicoprofen, Talwin NX, Tramadol and Tramadol-containing products, Soma and Soma-containing
products.
14. Other Antidepressants (Budeprion SR® 60 units, Budeprion X L® 30 units, Bupropion HCL SR® 60 units, For-
vo® XL 30 units, Wellbutrin SR® 60 units, and Wellbutrin X L® 30 units, Aplenzin® 30 units)
15. Provigil®. Coverage limit varies.
16. Sedative Hypnotics (Ambien®, Ambien CR™, Doral®, estazolam, urazepam, Intermezzo®, Lunesta™, Restoril®,
Rozerem™, Sonata®, Edluar™, Silenor®, temazepam, triazolam). Coverage is limited to 15 units per 30 days. Zol-
pimist™ coverage is limited to 1 bottle.
17. Selective Serotonin Reuptake Inhibitors (Celexa® 30 units, citalopram HBR 30 units, uoxetine HCL varies,
uvoxamine maleate varies, Lexapro® 30 units, Luvox CR® varies, paroxetine HCL® varies, Paxil® varies, Paxil
CR® 60 units, Pexeva® varies, Prozac Weekly® 5 units, Sarafem® 30 units, Selfemra™ varies, sertraline HCL® var-
ies, Viibyrd® 30 units, and Zoloft® varies)
18. Serotonin and Norepinephrine Reuptake Inhibitors (Cymbalta® varies, Eexor® varies, Eexor XR® varies, Pris-
tiq® 30 units, Savella® varies, venlafaxine ER® Varies, Viibryd® 1 pack)
19. Sprix. Coverage is limited to 5 days of therapy per prescription.
20. Tamiu® and Relenza®. Coverage is limited to one course of treatment every 90 days. Additional quantities
require prior authorization from R DT.
21. Toradol. Coverage is limited to 20 tablets per prescription.
22. Respiratory/Asthma inhalers, nasal steroid inhalers, and COPD inhalers are limited to quantity in accordance
with FDA-approved dosing.
23. Acetaminophen and Aspirin containing pain reliever medications are limited to quantities not to exceed 4
grams of acetaminophen or aspirin per day.
24. Amphetamines, methylphenidate and stimulant products to treat ADHD or narcolepsy are subject to limits on
quantity within FDA approved doses.
25. Gabapentin (Neurontin). Coverage is limited to 3,600mg per day.
Maintenance Medications
PEIA changed its Maintenance Medication benet starting July 1, 2017. All Maintenance Medications must now be
purchased in 90-day supplies from a Retail Maintenance Network Pharmacy or through CVS mail service.
You must receive a 90-day supply of the medications and classes listed below. Maintenance medications dispensed in
quantities less than 90 days are not covered by the plan. If you are starting on a new maintenance medication, you may
receive up to two 30-day lls to be sure you tolerate the medication and that your dosage is correct. After the second
30-day ll, the maintenance medication will be covered only in a 90-day supply, and only when lled at a Retail Main-
tenance Network pharmacy or using the CVS Caremark Mail Service Pharmacy Program.
1. Allergies
2. Alzheimer’s Disease
3. Antipsychotics
4. Blood Modiers/inners
5. Cancer (non-specialty)
6. Contraceptives/Hormone Replacement
7. Depression
8. Diabetes
9. Lifescan One Touc h test strips/lancets
10. Digestive Enzymes
11. Diuretics
12. Enlarged Prostate
13. Glaucoma
14. Gout
15. High Blood Pressure & Heart Disease
16. High Cholesterol
17. Immune Disorders (non-specialty)
18. Inammatory Bowel Disease (non-specialty)
19. Irritable Bowel Disease
20. Kidney Disease
21. Osteoporosis
22. Overactive Bladder
23. Parkinson’s Disease
24. Respiratory Agents
25. Rheumatoid Arthritis
26. Seizure Disorders
27. yroid
28. Ulcer/GERD
PEIA 2017-2018 SPD ABD-REV.indd 87 7/13/17 9:15 AM
88
Common Specialty Medications
All specialty medications require Precertication. e process begins with a call to HealthSmart Specialty Drug Pro-
gram at 1-888-440-7342. HealthSmart will review the drug for medical necessity, and if approved, will coordinate the
purchase through an approved source. Many specialty medications have manufacturer programs which will nancially
assist patients in the purchase of the medication. PEIA requires that if a nancial assistance program is available, you
must participate in the program. Specialty drugs have the following key characteristics:
• Need frequent dosage adjustments
• Cause more severe side eects than traditional drugs
• Need special storage, handling and/or administration
• Have a narrow therapeutic range
• Require periodic laboratory or diagnostic testing
After you have met your prescription drug deductible, the copayment on these medications will generally be $100 for
any Common Specialty Medications on the WV Preferred Drug List and $150 for any Common Specialty Medications
not on the WV Preferred Drug List; however, certain specialty medications are subject to variable copayments, depend-
ing on the availability of programs. Only your actual out-of-pocket payments will count toward your drug deductible
and annual out-of-pocket maximum, not amounts discounted o the price by the manufacturer or seller of the special-
ty medication. Contact HealthSmart to verify copayments. ese drugs are not available in 90-day supplies. If you are
prescribed one of these common specialty medications, call HealthSmart at 1-888-440-7342.
Common Specialty Medications
Drug Name Category Drug Name Category
Acthar® HP Multiple Sclerosis Inlyta® Cancer
Actimmune Anti-Neoplastic Intron A® Interferons
Adcirca® [QLL] Pulmonary Hypertension Jaka® Cancer
Anitor Anti-Neoplastic Kalydeco® Respiratory conditions
Ampyra Multiple Sclerosis Kineret® Inammatory Conditions
Aranesp® Anemia Kuvan Enzyme deciencies
Avonex® [QLL] Multiple Sclerosis Letairis® Pulmonary Arterial Hypertension
Betaseron® [QLL] Multiple Sclerosis Leukine® Hematopoietic
Boniva® Osteoporosis Lupron Depot® Endometriosis, Anti-Neoplastic, Precocious Puberty
Cerezyme® Gaucher Disease Lupron Depot® - Ped Precocious Puberty
Copaxone® [QLL] Multiple Sclerosis Lupron® Anti-Neoplastic
Eligard Anti-Neoplastic Methotrexate Anti-Neoplastic; Anti Arthritis
Enbrel® [QLL] Inammatory Conditions Neulasta® [QLL] Neutropenia
Epclusa* Hepatitis C Neupogen® Neutropenia
Epogen® Anemia Nexavar® Anti-Neoplastic, Immunosuppressant
Forteo® [QLL] Osteoporosis Norditropin® Growth Hormone
Genotropin® Growth Hormone Nutropin® Growth Hormone
Gilenya® Multiple Sclerosis Octreotide Acetate Endocrine disorders
Gleevec® Anti-Neoplastic Pegasys® [QLL] Hepatitis C
Harvoni* Hepatitis C Peg-Intron® [QLL] Hepatitis C
Humatrope® Growth Hormone Procrit® Anemia
Humira® [QLL] Inammatory Conditions Pulmozyme® Cystic Fibrosis
Incivek Hepatitis Rebif® [QLL] Multiple Sclerosis
PEIA 2017-2018 SPD ABD-REV.indd 88 7/13/17 9:15 AM
89
Drug Name Category Drug Name Category
Revatio® [QLL] Pulmonary Arterial Hypertension Tobi® [QLL] Cystic Fibrosis
Revlimid® Anti-Neoplastic,
Immunosuppressant
Tracleer® Pulmonary Arterial Hypertension
Riba pak Hepatitis Tykerb Anti-Neoplastic
Ribavirin® Hepatitis C Tyvaso® Pulmonary Arterial Hypertension
Sandostatin LAR Endocrine disorders Victrelis® Hepatitis
Simponi® Rheumatoid Arthritis Votrient Anti-Neoplastic
Sprycel Anti-Neoplastic Xalkori® Cancer
Sutent® Anti-Neoplastic Xeloda® Anti-Neoplastic
Tarceva® Anti-Neoplastic Xenazine® CNS Disorders
Tasigna Anti-Neoplastic Zarxio Neutropenia
Temodar® Anti-Neoplastic Zoladex® Anti-Neoplastic
Tev-Tropin® Growth Hormone Zolinza Anti-Neoplastic
Thalomid® Anti-Neoplastic Zytiga® Anti-Neoplastic
Thyrogen® Kit Diagnostic
All Common Specialty Medications require Precertication from HealthSmart. [QLL] is drug is subject to Quantity
Level Limits (QLL). is list is not all-inclusive and is subject to change throughout the Plan Year.
* Coverage of this drug is limited to a once-in-a-lifetime course of treatment.
Diabetes Management
PEIA covers diabetes management items under its Maintenance Medication benet, which means that needles, sy-
ringes, lancets and test strips must be purchased in 90-day supplies from a Retail Maintenance Network Pharmacy or
through CVS mail service. For patients just starting use of needles, syringes, lancets or test strips, PEIA will permit two
30-day lls of the new item at a network pharmacy, but after that, all items must be purchased in 90-day supplies from
a Retail Maintenance Network Pharmacy or through CVS mail service.
Blood Glucose Monitors: Covered diabetic insureds can receive a free Lifescan One Touch Verio, One Touch Verio
Flex, One Touch Verio IQ, One Touch Ultra 2, and One Touch Ultra Mini blood glucose monitor with a current
prescription. All major chain pharmacies and some doctor’s oces have vouchers for the One Touch meters. Ta ke your
prescription to them or call the CVS Caremark Diabetic Meter Program at 1-877-418-4746 to request a meter.
Glucose Test Strips: e plan covers only Lifescan One Touch Ultra test strips, One Touc h Verio test strips, One
Touch test strips, and One Touch Blue test strips at the preferred copayment of $50 per 90-day supply for PPB Plans A
and D, and $60 per 90-day supply for PPB Plan B. Other brands require a 100% copayment.
Needles/Syringes and Lancets: e plan covers only BD needles and syringes. You can obtain a supply of disposable
needles/syringes and lancets for the copayments listed below:
Diabetes Management Copayments
PEIA PPB Plan A or D PEIA PPB Plan B
Up to 30-day supply 90-day supply* Up to 30-day supply 90-day supply*
Lifescan One Touch Glucose test
strips, as noted above
Not covered $50 Not Covered $60
BD needles/syringes Not Covered $20 Not Covered $20
Lancets Not Covered $20 Not Covered $20
* You must purchase all Diabetes Management items in 90-day supplies through a Retail Maintenance Network pharmacy or through Mail Service.
PEIA 2017-2018 SPD ABD-REV.indd 89 7/13/17 9:15 AM
90
Tobacco Cessation Program
PEIA has a tobacco cessation program that includes coverage for both prescription and over-the-counter (OTC) tobacco
cessation products. For a full description of the benets, please see “Tobacco Cessation” on page 72. e drugs are cov-
ered under your prescription drug program.
What is Covered?
PEIA will cover prescription and over-the-counter (OTC) tobacco cessation products if they are dispensed with a prescrip-
tion. Tol l-f ree numbers are provided by the manufacturers of most of these products for phone coaching and support.
Coverage is limited to two twelve-week cycles per rolling twelve-month period. Tobacco-cessation products are avail-
able at no cost to the member; both the deductible and the copayment are waived when prescribed by a physician and
purchased at a network pharmacy.
Who is Eligible for Tobacco Cessation?
Only those members who have been paying the Standard (tobacco-user) premium are eligible for this benet. If you
have signed an adavit claiming to be tobacco-free, and then you attempt to use the tobacco cessation benet, you will
be declined services. Pregnant women will be oered 100% coverage during any pregnancy.
Drugs or Services That Are Not Covered
Your plan does not cover the following medications or services:
1. Anorexients (any drug used for the purpose of weight loss)
2. Anti-wrinkle agents (e.g., Renova®)
3. Bleaching agents (e.g., Eldopaque®, Eldoquin Forte®, Melanex®, Nuquin®, Solaquin®)
4. Charges for the administration or injection of any drug
5. Compounds containing one or more ingredients which are commercially available in alternate medications, are
an over-the-counter (OTC) product or lack clinical evidence in compounded dosage forms. is list is subject
to change throughout the Plan Year.
6. Contraceptive devices and implants
7. Diagnostic agents
8. Drugs dispensed by a hospital, clinic or physician’s oce
9. Drugs labeled “Caution-limited by federal law to investigational use,” or experimental drugs not approved by
the FDA, even though a charge is made to the individual.
10. Drugs requiring prior authorization when prescribed for uses and quantities not approved by the FDA
11. Drugs requiring a prescription by State law, but not by federal law (State controlled) are not covered
12. Erectile dysfunction medications
13. Fertility drugs
14. Fioricet® with Codeine (butalbital/acetaminophen caeine with codeine)
15. Fiorinal® with Codeine (butalbital/aspirin/caeine with codeine)
16. Hair growth stimulants
17. Homeopathic medications
18. Immunizations, biological sera, blood or blood products, Hyalgan®, Synvisc®, Remicade®, Synagis®, Xolair®,
Amevive®, Raptiva®, Vivitrol® (these are covered under the medical plan)
19. Latisse™
20. Medical or therapeutic foods
21. Medication which is to be taken by or administered to an individual, in whole or in part, while he or she is a
patient in a hospital, sanitarium, or extended care facility.
PEIA 2017-2018 SPD ABD-REV.indd 90 7/13/17 9:15 AM
91
22. Medication for which the cost is recoverable under any Workers’ Compensation or occupational disease law, or
any State or governmental agency, or medication furnished by any other Drug or Medical Service for which no
charge is made to the member.
23. Newly released prescription medications that have been on the market less than 12 months
24. Non-legend drugs
25. Omnipod V-go®, Finesse® or other disposable insulin delivery systems.
26. Pentazocine/Acetaminophen (Talacen®)
27. Prescription drug charges not led within 6 months of the purchase date, if PEIA is the primary insurer, or within
6 months of the processing date on the Explanation of Benets (EOB) from the other plan, if PEIA is secondary.
28. Replacement medications for lost, damaged or stolen drugs
29. Requests for less than a 90-day supply of maintenance medications, or requests for more than a 30-day supply
of short-term medications.
30. Stadol® Nasal Spray (butorphanol)
31. erapeutic devices or appliances, including support garments and other non-medicinal substances, regardless
of intended use, except those listed above.
32. Unit dose medications
33. Vacation supplies, unless leaving the country. If you are leaving the country, and want PEIA to cover a vacation
supply, you must submit documentation (copy of an airline ticket, travel agency itinerary, etc.) to substantiate
your international travel arrangements. Please allow seven (7) days for processing.
Other Important Features of Your Prescription Drug Program
Your prescription drug program is designed to provide the care and service you expect, whether it’s keeping a record of
your medication history, providing toll-free access to a registered pharmacist, or keeping you in touch with any changes
to your program.
CVS Caremark uses the health and prescription information about you and your dependents to administer your
benets. ey also use information and prescription data from claims submitted nationwide for reporting and analysis
without identifying individual patients.
When your prescriptions are lled at one of CVS Caremark’s mail service pharmacies or at a participating retail phar-
macy, pharmacists use the health and prescription information on le for you to consider many important clinical fac-
tors including drug selection, dosing, interactions, duration of therapy and allergies. CVS Caremark’s pharmacists may
also use information received from your network retail pharmacy.
Drug Utilization Review
Under the drug utilization review program, prescriptions lled through the mail service pharmacy and participating
retail pharmacies are examined by CVS Caremark for potential drug interactions based on your personal medication
prole. e drug utilization review is especially important if you or your covered dependents take many dierent medi-
cations or see more than one doctor. If there is a question about your prescription, your pharmacist may notify your
doctor before dispensing the medication.
Education and Safety
You will receive information about critical topics like drug interactions and possible side eects with every new
prescription CVS Caremark mails. Your retail pharmacy may also provide you with drug information. By visiting
www.caremark.com, you also can access other health-related information. Click on Health Resources to browse infor-
mation relative to specic health interests, get safety tips and answers to the most commonly asked medication ques-
tions, or just keep up with timely health issues. To view health information personalized to t your interests, register
PEIA 2017-2018 SPD ABD-REV.indd 91 7/13/17 9:15 AM
92
with www.c aremark.com. Any written health information cannot replace the expertise and advice of health care prac-
titioners who have direct contact with a patient. All CVS Caremark health information is designed to help you commu-
nicate more eectively with your doctor and, as a result, understand more completely your situation and choices.
Health Management
Based on your prescription and health information, CVS Caremark may provide information to you on one or more
of CVS Caremark’s Care Management programs, provided as a service to you by PEIA. Program participants gener-
ally receive educational mailings and may receive a follow-up call from an CVS Caremark pharmacist or nurse. CVS
Caremark develops these programs to support your doctor’s care, and they may contact your doctor regarding your
participation in these programs.
Coordination of Benefits
If another insurance carrier is the primary insurer for a policyholder or a dependent, or if you are Medicare-eligible,
PEIA will pursue coordination of benets.
1. Commercial Insurance: As a secondary payor, PEIA will pay only if the other insurance plan’s benet is less
than what PEIA would have provided as the primary insurer. If PEIA is the secondary insurer, you must submit
the following documentation to CVS Caremark to have the secondary claim processed:
• a completed CVS Caremark claim form;
• the receipt from the pharmacy; and
• an Explanation of Benets from the primary plan or a pharmacy printout that shows the amount paid by
the primary plan.
You will usually be reimbursed within 30 days from receipt of your claim form.
If you need claims forms, call CVS Caremark’s Member Services at 1-844-260-5894 or visit their website at
www.caremark.com.
2. Medicare Part B: If Medicare is the primary insurer, Medicare must be billed rst for any drugs covered by
Medicare Part B. Your pharmacist should bill Medicare Part B as the primary insurer. HealthSmart will receive
the crossover claims from Medicare Part B and pay the pharmacy directly. is will save you money since PEIA
will pay the member responsibility for prescription drugs covered by Medicare Part B. You should not pay any
deductible or co-insurance for Medicare Part B-covered drugs. You can nd a listing of pharmacies willing to
bill Medicare and accept assignment on our web page at www.wvpeia.com or by calling our customer service
unit at 1-888-680-7342. ese classes of drugs are usually covered by Medicare Part B:
a) Immunosuppressants
b) Oral Chemotherapeutic medications
c) Drugs for nausea associated with chemo meds
d) Diabetic testing supplies
e) Limited Inhalation therapies
PEIA 2017-2018 SPD ABD-REV.indd 92 7/13/17 9:15 AM
93
How to File a Claim
Filing a Prescription Drug Claim
Prescription drug claims are processed by CVS Caremark and should be submitted to:
CVS Caremark P.O. Box 52136 Phoenix, AZ 85072-2136
To process a prescription drug claim, ESI requires a prescription receipt/label which includes:
• Pharmacy Name/Address
• Date Filled
• Drug Name, Strength and NDC
• Rx Number
• Quantity
• Days Supply
• Price
• Patient’s Name
Claims received missing any of the above information may be returned or payment may be denied or delayed.
Cash register receipts and canceled checks are not acceptable proof of your claim.
If you have other insurance which is primary, you need to submit an Explanation of Benets (EOB) from the other in-
surance which shows the amount the primary insurance paid with each claim, or ask your provider to do so if the claim
is being submitted for you. You have six (6) months from the date of service to le a prescription claim. If PEIA is your
secondary insurer, you have six (6) months from the date of your primary insurer’s Explanation of Benets processing
date to le your claim with PEIA. If you do not submit claims within this period, they will not be paid.
If your claim is for an illness or injury wrongfully or negligently caused by someone else, and you expect to be reim-
bursed by another party or insurance plan, you must le a claim with PEIA within six (6) months of the date of service
to ensure that the covered services will be paid. Later, if you receive payment for the expenses, you will have to repay the
amount you received from PEIA. See “Subrogation” on page 103 for details.
Filing Claims for Court-ordered Dependents (COD)
If you are the custodial parent of a child who is covered under the other parent’s PEIA plan as a result of a court order,
you must use your I.D. card at a participating pharmacy to receive prescription benets.
Claims Incurred Outside of the U.S.A.
If you or a covered dependent incur prescription drug expenses while outside the United States, you will be required to
pay the provider yourself. Request an itemized bill containing all the information listed above from your provider and
submit the bill along with a claim form to ESI.
ESI will determine, through a local banking institution, the currency exchange rate and you will be reimbursed accord-
ing to the terms of PEIA PPB Plans A, B & D.
PEIA 2017-2018 SPD ABD-REV.indd 93 7/13/17 9:15 AM
94
Appealing a Drug Claim
If you think that an error has been made in processing your prescription drug claim or in a prescription benet deter-
mination or denial, rst call CVS Caremark or RDT (depending on the nature of your complaint) to ask for details.
If you are not satised with the outcome of your telephone inquiry, the second step is to appeal to CVS Caremark or
RDT in writing. Please have your physician provide any additional relevant clinical information to support your re-
quest. Mail your request with the above information to:
Type of Error Who to Call Where to Write
Prior Authorization error or denial
(for Physician’s ofces or pharmacists ONLY)
RDT 1-800-847-3859 Rational Drug Therapy Program
WVU School of Pharmacy
P.O. Box 9511 HSCN
Morgantown, WV 26506
Prescription drug claim payment error or denial CVS Caremark
1-844-260-5894
CVS Caremark
P.O. Box 52084
Phoenix, AZ 85072-2084
CVS Caremark or RDT will respond in writing to you and/or your physician with a letter explaining the outcome of
the appeal. If this does not resolve the issue, the third step is to appeal in writing to the director of PEIA. Your physi-
cian must request a review in writing within sixty (60) days of receiving the decision from CVS Caremark or R DT.
Mail third step appeals to:
Director, Public Employees Insurance Agency, 601 57th St. SE, Charleston, WV 25304-2345.
Facts, issues, comments, letters, Explanations of Benets (EOBs), and all pertinent information about the claim and
review should be included. When your request for review arrives, PEIA will reconsider the entire case, taking into ac-
count any additional materials that have been provided. A decision, in writing, explaining the reason for modifying or
upholding the original disposition of the claim will be sent to the covered person or his or her authorized representative.
For more information about your drug coverage, please contact CVS Caremark at 1-844-260-5894.
External Review: If we have denied your request for the provision of or payment for a health care service or course of
treatment, you may have a right to have our decision reviewed by independent health care professionals who have no
association with us if our decision involved making a judgment as to the medical necessity, appropriateness, health care
setting, level of care or eectiveness of the health care service or treatment you requested. Exercise this right by submit-
ting a request for external review within 4 months after receipt of the notice of denial to the PEIA Clinical Unit, 601
57th Street, SE, Suite 2, Charleston, WV 25304-2345. For standard external review, a decision will be made within
45 days of receiving your request. If you have a medical condition that would seriously jeopardize your life or health or
would jeopardize your ability to regain maximum function if treatment is delayed, you may be entitled to request an
expedited external review of our denial. If our denial to provide or pay for health care service or course of treatment is
based on a determination that the service or treatment is experimental or investigational, you also may be entitled to le
a request for external review of our denial. External review is the nal level of appeal. External review is not available for
drugs, services or items which are simply not covered by the Plan, or for a change in drug cost-sharing tier.
PEIA 2017-2018 SPD ABD-REV.indd 94 7/13/17 9:15 AM
95
How to Reach CVS Caremark
On the Internet: Reach CVS Caremark at www.caremark.com. Visit CVS Caremark’s website anytime to learn about
patient care, rell your mail service prescriptions, check the status of your mail service pharmacy order, request claim
forms and mail service order forms or nd a participating retail pharmacy near you.
By Telephone: For those insureds who do not have access to CVS Caremark via the Internet, you can learn more about
your program by calling CVS Caremark Customer Care at 1-844-260-5894, 24 hours a day, 7 days a week.
Special Services: CVS Caremark continually strives to meet the special needs of PEI A’s insureds: You may call a regis-
tered pharmacist at any time for consultations at 1-844-260-5894.
PEI A’s hearing-impaired insureds may use CVS Caremark’s TDD number at 1-800-863-5488.
Visually impaired insureds may request that their mail service prescriptions include labels in Braille by calling
1-844-260-5894.
Controlling Costs
Prohibition of Balance Billing
All PEIA health plans are governed in part by the Omnibus Health Care Act which was enacted by the West Virginia
Legislature in April 1989. is Law requires that any West Virginia health care provider who treats a PEIA insured
must accept assignment of benets and cannot balance bill the insured for any portion of charges over and above the
PEIA fee allowance or for any discount amount applied to a provider’s charge or payment. is is known as the “prohi-
bition of balance billing.”
e prohibition of balance billing applies when services are provided in West Virginia and when the PEIA PPB plan is
the primary payor. When the PEIA PPB plan is the secondary payor, the provider may bill you for disallowed amounts
and for the provider discounts. Remember, you are always responsible for deductibles, copayments, coinsurance
amounts and non-covered services.
A PEIA insured who has Medicare as the primary payor has protection against balance billing when the provider ac-
cepts Medicare assignment. If the provider accepts Medicare assignment, you are not responsible for amounts which
exceed the Medicare allowances.
New Technologies
Upon FDA approval of new technology, PEIA determines whether or not to cover the item, service or procedure. ese
new technologies may or may not be covered. PEIA often waits until the new technology proves eective before approv-
ing coverage. If y
ou have concerns about coverage of a new technology, contact HealthSmart for details.
Preferred Provider Organizations
For services provided outside the State of West Virginia, HealthSmart utilizes several networks. ese networks review
their providers for quality standards like licensing, background and treatment patterns. As part of their agreement with
the network, the amount paid for services is a discounted amount. For details of which networks HealthSmart uses, see
“PEIA’s Networks” on page 39.
After you receive medical attention, your claim will be routed to HealthSmart Benet Solutions. All PPO providers are
paid directly, relieving you of any hassle and worry. You will need to pay for out-of-pocket expenses (deductibles, copay-
ments, coinsurance amounts and non-covered services). HealthSmart Benet Solutions will send you an Explanation of
Benets (EOB).
PEIA 2017-2018 SPD ABD-REV.indd 95 7/13/17 9:15 AM
96
Out-of-State Provider Waiver (PEIA PPB Plans A & B ON LY )
To assist participants in PEIA PPB Plans A & B who receive medical treatment outside of West Virginia from providers
who do not participate in Aetna Signature Administrators PPO, guidelines have been established to review and approve
waiver requests when you are billed for the balance not paid by PEIA and not applied to your OOSINNA deductible
and out-of-pocket maximum. e rst $500 of expenses which exceed the allowed amount will be your responsibility.
Amounts in excess of $500 may be eligible for an out-of-state provider waiver when:
1. the PEIA PPB Plan is the primary payor for the services provided; and
2. you are billed for amounts which exceed the fee allowance; and
3. you must receive out-of-state services because:
a) an emergency arises; or
b) the insured lives or is traveling out-of-state;
c) the medically necessary service is not available in West Virginia (or within a reasonable travel time); or
d) due to geographic location, PEIA has determined that services are only available out-of-state; and
4. you do not have other insurance which will pay toward the balance.
Expenses eligible for waivers are those which exceed the maximum fee allowances. Amounts applied toward your
OOSINNA deductible, your out-of-network coinsurance amount, penalties, and non-covered services will not be
considered for a waiver. To request a waiver, send your balance bill from the provider, a copy of your Explanation of
Benets (EOB) indicating the amount already paid by PEIA, and a written request including the reason you chose an
out-of-state provider to:
Director, Public Employees Insurance Agency, 601 57th St. SE, Charleston, WV 25304-2345.
You may obtain a PEIA Out-of-State Waiver Form from our website at www.wvpeia.com or by calling PEIA at
1-304-558-7850 or toll-free at 1-888-680-7342. A waiver form is not required if you send the above-requested infor-
mation. e request for an Out-of-State Waiver must be submitted within six months of the processing date on the
Explanation of Benets (EOB) to be eligible for additional payments.
e Out-of-State Waiver program is NOT available for members of PEIA PPB Plans C or D. e program is
also not available for air ambulance fees in excess of the PEIA allowance.
PPB Plan C is an IRS-qualied, High-Deductible Health Plan (HDHP). For more information about Plan C, down-
load the Summary Plan Description (Plan C) at www.wvpeia.com or call 1-888-680-7342.
Patient Audit Program
e Patient Audit Program oers rewards when you help detect and correct mistakes on your health care bills. Examine
your medical bills for these two types of mistakes:
1. charges for services not received; and
2. overcharges or overpayments resulting from clerical error or miscalculation.
3. any claim for a condition not present on admission, such as a hospital acquired infection or fall.
Reported errors must be at least $50.00 to qualify for the Patient Audit Program and must be submitted within 60 days
of the processing date on the Explanation of Benets (EOB). Complete the Patient Audit Report Form from PEIA and
submit it, along with an itemized bill from the provider, the corrected bill (or explanation of disagreement), and a copy
of the EOB, to PEIA.
PEIA and HealthSmart or CVS Caremark will investigate and recover the overpayment, if justied, from the provider of
services. When the overpayment is processed you will be paid 50% of the recovered amount, up to $1,000 per plan year.
HMO members are not eligible to participate in the Patient Audit Program.
PEIA 2017-2018 SPD ABD-REV.indd 96 7/13/17 9:15 AM
97
Healthcare Fraud and Abuse
By law, PEIA must report suspected fraud to the WV Insurance Commission. In addition, PEIA works with the US
Attorney’s oce in the investigation of potential fraud and /or abuse.
Examples of Provider Fraud:
• waiving member copays;
• balance billing members for services;
• billing for services not provided;
• billing for a non-covered service as a covered service (e.g. billing a “tummy tuck” (non-covered) as a hernia
repair (covered);
• billing that appears to be a deliberate claim for duplicate payments for the same services;
• misrepresenting dates, services or identities of members or providers;
• intentional incorrect reporting of diagnoses or procedures to maximize payment (up-coding);
• billing for separate parts of a procedure rather than the whole (unbundling);
• accepting or giving kickbacks for member referrals;
• prescribing additional and unnecessary treatments (over-utilization).
Examples of Member Fraud:
• providing false information when applying for PEIA coverage;
• forging or selling prescription drugs;
• “loaning” or using another’s insurance card.
How to Report Healthcare Fraud and Abuse
If you suspect healthcare fraud, please call the PEIA toll-free number (1- 888-680-7342) and ask to speak with a mem-
ber of the Special Investigations Tea m or complete the Health Care Fraud and Abuse Form on PEI A’s website. You will
be asked to provide as much information as possible. PEIA will investigate your concern(s) and if appropriate, refer the
information to the appropriate legal authorities.
Coordination of Benefits
In its eort to control health care costs, the PEIA PPB Plan has a coordination of benets (COB) provision. Under this
provision, when a person covered by PEIA also has coverage under another policy (or policies), there are certain rules
determining which policy is required to pay benets rst. e policy paying rst is called the primary plan, and any
other applicable policy is called the secondary plan.
HealthSmart, on PEIA’s behalf, will request information about other coverage using a questionnaire mailed to the poli-
cyholder periodically. If the policyholder fails to respond to the questionnaire, claims will be denied until the informa-
tion is received. If you have health insurance coverage in addition to the PEIA PPB Plan, it is important to understand
how the coordination of benets provision works. In many instances, if the PEIA PPB Plan is secondary, PEIA will pay
little or nothing of the balance of your medical bill. An example of this situation is provided on the next page. In some
cases it may be nancially advisable to elect only one insurance coverage. If, after reviewing this section, you have ques-
tions concerning how PEI A’s coordination of benets provision may aect you, contact a PEIA claims representative at
1-304-558-7850 or toll-free at 1-888-680-7342.
Coordinating PEIA Benefits with Other Plans
COB will occur when an employee, retired employee or dependent has health coverage under the PEIA PPB Plan and
also under:
1. any government program or other coverage required or provided by law;
PEIA 2017-2018 SPD ABD-REV.indd 97 7/13/17 9:15 AM
98
2. any plan covering individuals as a group, including insured, uninsured and pre-payment arrangements;
3. automobile insurance medical pay provisions whether individual or group. PEIA will pay as primary plan and
subrogate against the medical payment coverage;
4. group-type hospital indemnity benets exceeding $100 per day;
5. for spouses and dependents only, individual hospital and surgical or major medical insurance in which that
spouse or dependent is the policyholder. Individual and surgical or major medical insurance does not include
any individual supplemental accident and sickness policy which meets the denition of a limited benets
policy or certicate under W. Va. Code §3-16E-2(a). ese individual policies must meet all of the following
conditions:
a) the policy covers a specied disease, accident only, disability, or other limited benets;
b) the policy is specically designed, represented and sold as a supplement to other basic sickness and ac-
cident coverage; and
c) the entire premium for the policy is paid by the insured or insured’s family.
Which Plan Pays First
For active employees, the PEIA PPB Plan is your primary plan in almost every circumstance. If your spouse is covered
through his or her employer, that plan is usually the primary plan for your spouse. e primary plan is determined by
the rst of the following rules which applies:
A. any plan with no coordination of benets provision is always primary;
B. the plan which covers the person as an active or retired employee, member or subscriber (other than as a
dependent) is always primary to a plan which covers the person as a dependent. When two public employees,
both eligible to enroll for PEIA coverage in their own names, are married and covered under one PEIA fam-
ily plan, then the spouse, covered as a dependent, will be treated as an employee under these rules;
C. for an active employee’s dependent who has coverage as a retired employee from his or her former employer
and is also covered by Medicare, benets are determined in this order:
1) the plan which covers the individual as a dependent of an active employee will pay rst;
2) Medicare will pay next;
3) the plan which covers the person as a retired employee will pay last.
D. for a dependent child of parents not separated or divorced, if two or more plans cover the child as a
dependent:
1) the plan of the parent whose birthday falls earlier in the year will be primary; or
2) if both parents have the same birthday, the plan which has covered one parent longer will be pri-
mary; or
3) if the other plan uses the parent’s gender to determine benets, and the plans do not agree on the
order of benets, then the rule of the other plan will determine the order of benets.
E. for a dependent child of parents who are separated or divorced, if two or more plans cover the child as a
dependent, benets are determined in this order:
1) the plan of the parent who has custody will pay rst;
2) the plan of the spouse of the parent who has custody will pay next;
3) the plan of the parent who does not have custody will pay last.
Exception: If a court decree states that one of the parents is responsible for the health care expenses of the child, and the
plan of that parent has knowledge of those terms, then that plan is primary. e plan of the other parent will then be
secondar y, and the plan of the spouse of the parent with custody of the child will pay third. For PEIA to pay according
to this paragraph, you need to provide a copy of the court decree.
F. for a dependent child of divorced parents with joint custody, if the court decree does not specify which par-
ent is responsible for health care coverage, then Rule “4.” above will apply;
PEIA 2017-2018 SPD ABD-REV.indd 98 7/13/17 9:15 AM
99
G. for a dependent child of separated parents with joint custody, if the court decree does not specify which par-
ent is responsible for health care coverage, then Rule “4.” above will apply;
H. for a dependent child who has coverage under either or both parents’ plans and also has coverage as a depen-
dent under a spouse’s plan, the Plan which has covered the dependent the longest will be primary;
I. in the event the dependent child’s coverage under the spouse’s plan began on the same date as the dependent
child’s coverage under the parents’ plans, the order of benets shall be determined by applying the birthday
rule to the dependent child’s parent and the dependent’s spouse;
J. a plan which covers an employee (and, consequently, his or her dependents) as an active employee, rather
than as a laid-o employee or retired employee, will pay before a plan which covers a laid-o or retired
employee. If the other plan does not have this rule, and the plans disagree about the order of benets, this
paragraph is disregarded;
K. if a person is covered under a right of continuation policy as required by the Consolidated Omnibus Reconcilia-
tion Act (COBR A) of 1987, as amended, and is also covered under another plan, the following rules will apply:
1) the benets of a plan covering the person as an employee, member or subscriber (or as that person’s
dependent) will be primary;
2) the benets under the continuation coverage will be secondary;
L. if none of the above rules applies, the plan which has covered the employee, member or subscriber the lon-
gest will be primary.
How Coordination of Benefits Works
When a claim is made, the primary plan pays its benets without regard to any other plans. en the secondary plan
pays its benets, adjusting for the benet paid by the primary plan. e amount that the PEIA PPB Plan will pay as a
secondary plan depends on what the primary plan pays. To calculate the amount PEIA will pay as a secondary plan,
you subtract the amount your primary plan pays from the amount PEIA would have paid if there were no other in-
surance. If the other plan paid as much or more than PEIA would have paid as the primary plan, t
hen PEIA will pay
nothing as the secondary plan. If the other plan paid less than PEIA, then PEIA will pay the dierence up to what it
would have paid if there had been no other insurance.
As you can see in the following chart, the PEIA PPB Plan will pay very little or nothing as a secondary plan. For this
reason, you should consider whether it makes sense to keep both plans.
“Carve-out” Coordination of Benefits Example
If PEIA is primary: If PEIA is secondary:
Total Charge $120 Total Charge $120
PEIA Allowed Amount $100 Other Plan’s Allowed Amount $96
PEIA Pays $80 PEIA Pays $0
* You Owe $20 * You Owe $24
*Assumes any deductible has been met.
ere are several issues to consider if you are thinking about dropping one of your plans:
• Prescription Drug Coverage: PEI A’s coverage is generous. Compare the benets of both plans, including
deductibles.
• Mental Health Benets: Many plans pay only 50% or limit the number of admissions per lifetime. e PEIA
PPB Plan pays mental health benets with the same cost-sharing as other medical benets with no limit when
services are precertied.
• Maternity Services: PEIA pays 100% of the physician’s allowed charges, after the deductible is met.
• Balance Billing Prohibition: PEIA protects you from network providers billing you for amounts which exceed
PEI A’s allowed amounts, but only if the PEIA PPB plan is the primary payor. In the above example, with the
PEIA plan as your primary plan, you would not be responsible for the dierence between the total charge and
the amount allowed by PEIA. e balance billing provision does not apply when the PEIA PPB plan is the
PEIA 2017-2018 SPD ABD-REV.indd 99 7/13/17 9:15 AM
100
secondary plan or when the provider is not in the PEIA PPB plan network. If the primary plan denies pay-
ment and the PEIA PPB plan is the secondary insurer, then PEIA becomes the primary plan, if the services are
covered by PEIA.
If you have questions about your coverage, or need help comparing plans, you may call the PEIA Customer Service
Unit at 1-304-558-7850 or toll-free 1-888-680-7342.
Medicare
For most retirees and their Medicare-eligible dependents covered by PEIA and Medicare, regardless of age (see excep-
tion below), PEIA’s Medicare Advantage plan is the primary insurer.
When you become an eligible beneciary of Medicare, you must enroll in Medicare Parts A and B and send a copy of
your Medicare card to PEIA. Part A is an entitlement program and is available without payment of a premium to most
individuals. Part B is the supplementary medical insurance program that covers physician services, outpatient labora-
tory and x-ray tests, durable medical equipment and outpatient hospital care. Part B requires payment of a monthly
premium. You MUST NOT enroll in a separate Medicare Part D plan, since PEIA will provides prescription drug
coverage for retirees with Medicare.
If you do not enroll in Medicare Parts A & B, your coverage may be terminated.
If you or your dependents have other coverage in addition to PEIA and Medicare, contact HealthSmart or PEIA to deter-
mine what coverage will be primary, secondary or tertiary (third) and whether you need to enroll in Medicare Part B.
Exception: If you are entitled to Medicare as an End Stage Renal Disease (ESRD) beneciary, call HealthSmart or
PEIA to determine who the primary insurer will be.
Whenever you or your covered dependents become eligible for Medicare, you should send a copy of your Medicare card
to PEIA.
Members enrolled in an HMO when they become Medicare-eligible will be transferred to the Special Medicare Plan.
Special Medicare Plan
PEIA created the Special Medicare plan to accommodate the needs of two specic groups of Medicare-eligible
members:
1. Members who are unable to access medical care through the PEI A’s Medicare Advantage Plan due to provider
limitations are permitted, on a case-by-case basis, to move into PEI A’s Special Medicare Plan.
2. Employees who retire after the beginning of a plan year, and retired employees who become eligible for Medi-
care during the Plan year. Retired members who are enrolled in an HMO when they become Medicare-eligible
will be transferred to PEI A’s Special Medicare Plan. ese members in the Special Medicare Plan will be moved
to PEIA’s Medicare Advantage Plan at the beginning of the next plan year (the following January).
Most members are enrolled in the Special Medicare Plan for less than a year. ose who become eligible for Medicare
in the middle of a plan year, move into the Special Medicare Plan, and are transferred to the PEIA Medicare Advantage
Plan at the beginning of the next Medicare plan year.
Under the Special Medicare plan, the member purchases traditional Medicare Parts A and B, and their secondary
medical and prescription claims are paid by HealthSmart and CVS Caremark, respectively. Medical and Prescription
Drug benets under the Special Medicare Plan are generally the same as those provided under the PEI A’s Medicare
Advantage plan.
PEIA 2017-2018 SPD ABD-REV.indd 100 7/13/17 9:15 AM
101
e Medicare retiree’s plan year is from January 1 to December 31 of each year. Below are the benets for Plan Year
2017:
Service Description Medicare Retiree Benefit
Plan Year 2017
January – December 2017
Annual Deductible $100
Primary Care Ofce Visit $20
Specialty Ofce Visit $40
Emergency Room $50
Hospital Inpatient care $100 per admission
Outpatient and Ofce Surgery $100
Other services (testing, etc.) $0
Medical Out-Of-Pocket Maximum $750
Prescription Drug Deductible $75
Generic Drugs Copayment $10
Preferred Drug Copayment $25
Non-preferred Drug Copayment 75% coinsurance
Specialty Drug Copayment $100 preferred/$150 non-preferred
Prescription Drug Out-of-Pocket Maximum $1,750
e benets described in the “What is Covered” section beginning on page 56 will be provided to members of the
Special Medicare plan with no deductible and no coinsurance, but with the copayments and out-of-pocket maximum
detailed in the chart above.
ere are two main dierences between the Special Medicare Plan and the Humana Medicare Advantage and Prescrip-
tion Drug (MAPD) plan.
1. e non-preferred drug costs – in the Special Medicare Plan, the non-preferred drug cost-sharing is 75% coin-
surance; in the MAPD plan, the non-preferred drug copayment is $50 per 30-day supply.
2. e MAPD plan oers a free gym membership through a program called Silver Sneakers. Silver Sneakers is not
available in the Special Medicare Plan.
ose who become eligible for the Special Medicare plan during a plan year have the right to request immediate enroll-
ment in the Humana plan. Call PEIA for details.
If you have questions about the benets of the Special Medicare plan, please contact PEI A’s customer service unit at
1-888-680-7342.
Medicare for Active Employees
For PEIA PPB Plan active employees and their dependents that are age 65 or older and eligible for Medicare, as long as
you are an active employee, PEIA will be your primary insurer, except in a few rare cases. As long as you are an active
employee, you and your Medicare-eligible dependents do not need to sign up for Medicare Part B and pay the premi-
um. When you prepare to retire, you and any Medicare-eligible dependents must enroll for Medicare Part B. If you do
not enroll in Medicare Parts A & B, your coverage may be terminated.
You DO NOT need to enroll in Medicare Part D as an active employee or upon retirement.
For PEIA PPB Plan active employees who are also eligible for Medicare, and Medicare is the primary payor, PEIA will
use the traditional method of coordinating benets.
PEIA 2017-2018 SPD ABD-REV.indd 101 7/13/17 9:15 AM
102
If you become eligible for Medicare prior to age 65, you must send a copy of your Medicare card to PEIA. is notica-
tion may allow PEIA to reduce your premiums, and will make the claims payment process go much more smoothly.
Benefit Assistance Program
Medicare-eligible retired employees with 15 or more years of service whose annual household income falls below 250%
of the federal poverty level, and who are members of the PEIA PPB Plan can qualify for benet assistance. Retired
employees who are using sick or annual leave or years of service to extend their employer-paid insurance qualify for
this program if their annual income meets the guidelines. e details of the Benet Assistance Program are described
in the Evidence of Coverage produced by Coventry. Since Benet Assistance is not available to non-Medicare retirees,
there is no further discussion of it here. If you are interested in the details of the program, you can nd more informa-
tion online at www.wvpeia.com. If you believe you qualif y, contact PEIA for an application, or you can print a copy at
www.wvpeia.com.
Medicare Part D
Medicare oers prescription drug coverage through Medicare Part D. Please be aware that you DO NOT have to
purchase Medicare Part D coverage.
PEIA’s Medicare Advantage Plan: Humana provides prescription drug coverage for retirees in the Medicare Advan-
tage Plan through a Medicare Part D plan.
Special Medicare Plan: PEIA continues to provide creditable prescription drug coverage to our members in the Special
Medicare Plan, and Medicare Part D will be of little or no use to you. If you enroll in a Medicare Part D plan, PEIA will
reject your prescription at the pharmacy, and require the pharmacy to bill the Medicare Prescription Drug Plan rst.
For those “dual eligibles” that have both Medicare and Medicaid, you will be automatically enrolled in a Medicare
Part D plan. Using the Medicare Part D plan will be to your benet, since it is a better benet to the “dual eligible”
member.
Medicare Part D Creditable Coverage Notice
e coverage you have now through West Virginia PEIA is considered by Medicare to be creditable coverage, or cover-
age as good as or better than that oered under Medicare’s standard Part D benet. If you are eligible for Medicare and
decide to opt out of this plan’s coverage, you should consider joining another plan as soon as possible to avoid having to
pay a late enrollment penalty. If you choose to leave this plan and do not join another plan within 63 days of the termi-
nation date of this coverage, you will be charged a late enrollment penalty of at least 1% per month you went without
coverage as good as or better than that oered under Medicare Part D.
When can you change to a different plan?
Generally, Medicare-eligible members can change plans during the yearly enrollment period (called the “annual coordi-
nated election period”). Generally, this is the only time of year to choose a dierent Medicare plan. Certain individuals,
such as those with Medicaid, those who get “Extra Help” paying for their drugs, or those who move out of the geo-
graphic service area, can make changes at other times.
PEIA 2017-2018 SPD ABD-REV.indd 102 7/13/17 9:15 AM
103
Recovery of Incorrect Payments
If PEIA discovers that a claim has been paid incorrectly, or that the charges were excessive or for non-covered services,
PEIA has the right to recover its payments from any person or any entity.
You must cooperate fully with the PEIA to help it recover any such payment. e PEIA may request refunds or deduct
overpayments from a provider’s check in order to recover incorrect payments. is provision shall not limit any other
remedy provided by law.
Subrogation and Reimbursement
PEIA may pay medical expenses on an insured’s behalf in those situations where an injury, sickness, disease or disabil-
ity, is caused in whole or in part by, or results from, the acts or omissions of a third party, or from the acts or omissions
of a PEIA insured where other insurance (such as auto or homeowners) is available. As a condition of receiving such
expenses, the PEIA and its agents have the right to recover the cost of such medical expenses from the responsible party
directly (whether an unrelated third party or another covered insured) or from their insured, if they have already been
reimbursed by another. is right is known as subrogation.
e PEIA is legally subrogated to its insured as against the legally responsible party, but only to the extent of the medi-
cal expenses paid on the insured’s behalf by the PEIA attributable to such sickness, injury, disease, or disability. PEIA
has the right to seek repayment of expenses from, among others, the party that caused the illness or injury, his or her
liability carrier or the PEIA insured’s own auto insurance carrier in cases of uninsured, underinsured motorist coverage,
or medical pay provisions. Subrogation applies, but it is not limited to, the following circumstances:
1. payments made directly by the person who is liable for a PEIA insured’s sickness, injury, disease or disability, or
any insurance company which pays on behalf of that person, or any other payments on his or her behalf;
2. any payments, settlements, judgments, or arbitration awards paid by any insurance company under an unin-
sured, underinsured motorist policy or medical pay provisions on the insured’s behalf; and
3. any payments from any source designed or intended to compensate a PEIA insured for sickness, injury, disease,
or disability sustained as the result of the negligence or wrongful action or alleged negligence or wrongful ac-
tion of another person.
Your Responsibilities:
It is the obligation of the PEIA insured to:
1. notify the PEIA in writing of any injury, sickness, disease or disability for which the PEIA has paid medical ex-
penses on behalf of a PEIA insured that may be attributable to the wrongful or negligent acts of another person;
2. notify the PEIA in writing if the insured retains services of an attorney, and of any demand made or lawsuit
led on behalf of a PEIA insured, and of any oer, proposed settlement, accepted settlement, judgment, or
arbitration award;
3. provide the PEIA or its agents with information it requests concerning circumstances that may involve subroga-
tion, provide any reasonable assistance requested in assimilating such information and cooperate with the PEIA
or its agents in dening, verifying or protecting its rights of subrogation and reimbursement; and
4. promptly reimburse the PEIA for benets paid on behalf of a PEIA insured attributable to the sickness, injury,
disease, or disability, once they have obtained money through settlement, judgment, award, or other payment.
Non-Compliance
Failure to comply with any of these requirements may result in:
1. the PEIA’s withholding payment of further benets; and
PEIA 2017-2018 SPD ABD-REV.indd 103 7/13/17 9:15 AM
104
2. an obligation by the PEIA insured to pay costs, attorneys’ fees and other expenses incurred by the PEIA in
obtaining the required information or reimbursement.
By acceptance of benets paid under the plan, the PEIA insured agrees that PEI A’s rights of subrogation and reim-
bursement shall have a priority lien and the right of rst recovery against any settlement or judgment obtained by or on
behalf of an insured. is right shall exist without regard to allocation or designation of the recovery.
ese provisions shall not limit any other remedy provided by law. is right of subrogation shall apply without regard
to the location of the event that led to or caused the applicable sickness, injury, disease or disability.
Please note: As with any claim, the claims resulting from an accident or other incident which may involve subrogation
should be submitted within the PEIA’s timely ling requirement of six (6) months. It is not necessary that any settle-
ment, judgment, award, or other payment from a third party have been reached or received before ling a claim with
the PEIA or with one of the managed care plans associated with the PEIA.
Amending the Benet Plan
e West Virginia Public Employees Insurance Agency reserves the right to amend all or any portion of this Sum-
mary Plan Description in order to reect changes required by court decisions, legislation, actions by the Finance Board,
actions by the Director or for any other matters as are appropriate. e Summary Plan Description will be amended
within a reasonable time of any such actions. All amendments to the Summary Plan Description must be in writing,
dated and approved by the Director. e Director shall have sole authority to approve amendments. e Summary Plan
Description and all approved amendments will be led with the oce of the West Virginia Secretary of State.
PEIA 2017-2018 SPD ABD-REV.indd 104 7/13/17 9:15 AM
105
HIPAA Notice of Privacy Practices
Effective date of this notice: September 23, 2013
If you have questions about this notice, please contact the person listed under “Who to Contact” THIS NOTICE DESCRIBES HOW MEDICAL IN-
FORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.
Summary
In order to provide you with benefits, PEIA will receive personal information about your health, from you, your physicians, hospitals, pharmacies, and
others who provide you with health care services. We are required to keep this information confidential. This notice of our privacy practices is intended
to inform you of the ways we may use your information and the occasions on which we may disclose this information to others.
Occasionally, we may use members’ information when providing treatment. We use members’ health information to provide benefits, including making
claims payments and providing customer service. We disclose members’ information to health care providers to assist them to provide you with treat-
ment or to help them receive payment, we may disclose information to other insurance companies as necessary to receive payment, we may use the
information within our organization to evaluate quality and improve health care operations, and we may make other uses and disclosures of members’
information as required by law or as permitted by PEIA policies.
Kinds Of Information That This Notice Applies To
This notice applies to any information that is created, received, used, or maintained by PEIA or its Business Associates that relates to the past, present,
or future physical or mental health, healthcare, or payment for the healthcare of an individual.
Who Must Abide by This Notice
• PEIA
• All employees, staff, students, volunteers, contractors, and other personnel who work for and/or under the direct control of PEIA.
The people and organizations to which this notice applies (referred to as “we,” “our,” and “us”) have agreed to abide by its terms. We may share your
information with each other for the purpose(s) of treatment, and as necessary for payment and healthcare operations activities as described below.
Our Legal Duties
• We are required by law to maintain the privacy and security of your health information.
• We are required to provide this notice of our privacy practices and legal duties regarding health information to anyone who asks fo
r it.
• We are required to respond to your requests or concerns within a timely manner.
• We are required to abide by the terms of this notice until we officially adopt a new notice.
How We May Use or Disclose Your Health Information.
This notice describes how we may use your personal, protected health information, or disclose it to others, for a number of different reasons. For each
reason, we have written a brief explanation. We also provide some examples. These examples do not include all of the specific ways we may use or
disclose your information. But any time we use your information, or disclose it to someone else, it will fit one of the reasons listed here.
1. Treatment. We may use your health information to provide you with medical care and services. This means that our employees, staff, students, vol-
unteers and others whose work is under our direct control, may read your health information to learn about your medical condition and use it to help
you make decisions about your care. For instance, a health plan nurse may take your blood pressure at a health fair and use the results to discuss
with your health issues. We will also disclose your information to others to provide you with options for medical treatment or services. For instance,
we may use health information to identify members with certain chronic illnesses, and send information to them or to their doctors regarding treat-
ment alternatives.
2. Payment. We will use your health information, and disclose it to others, as necessary to make payment for the health care services you receive.
For instance, an employee in our customer service department or at our claims processing administrators may use your health information to help
pay your claims. And we may send information about you and your claim payments to the doctor or hospital that provided you with the health care
services. We will also send you information about claims we pay and claims we do not pay (called an “explanation of benefits”). The explanation of
benefits will include information about claims we receive for the subscriber and each dependent that are enrolled together under a single contract or
identification number. Under certain circumstances, you may receive this information confidentially: see the “Confidential Communication” section in
this notice. We may also disclose some of your health information to companies with whom we contract for payment-related services. For instance,
if you owe us money, we may give information about you to a collection company that we contract with to collect bills for us. We will not use or dis-
close more information for payment purposes than is necessary.
3. Health Care Operations. We may use your health information for activities that are necessary to operate this organization. This includes reading
your health information to review the performance of our staff. We may also use your information and the information of other members to plan what
services we need to provide, expand, or reduce. We may also provide health information to students who are authorized to receive training here. We
may disclose your health information as necessary to others who we contract with to provide administrative services or health care coverage. This
includes our third-party administrators, available managed care plans, lawyers, auditors, accreditation services, and consultants, for instance. These
third-parties are called “Business Associates” and are held to the same standards as PEIA with regard to ensuring the privacy, security, integrity, and
confidentiality of your personal information. If, in the course of healthcare operations, your confidential information is transmitted electronically, PEIA
requires that information to be sent in a secure and encrypted format that renders it unreadable and unusable to unauthorized users.
4. Legal Requirement to Disclose Information. We will disclose your information when we are required by law to do so. This includes reporting informa-
tion to government agencies that have the legal responsibility to monitor the state health care system. For instance, we may be required to disclose
your health information, and the information of others, if we are audited by state auditors. We will also disclose your health information when we
PEIA 2017-2018 SPD ABD-REV.indd 105 7/13/17 9:15 AM
106
are required to do so by a court order or other judicial or administrative process. We will only disclose the minimum amount of health information
necessary to fulfill the legal requirement.
5. Public Health Activities. We will disclose your health information when required to do so for public health purposes. This includes reporting certain
diseases, births, deaths, and reactions to certain medications. It may also include notifying people who have been exposed to a disease.
6. To Report Abuse. We may disclose your health information when the information relates to a victim of abuse, neglect or domestic violence. We will
make this report only in accordance with laws that require or allow such reporting, or with your permission.
7. Law Enforcement. We may disclose your health information for law enforcement purposes. This includes providing information to help locate a sus-
pect, fugitive, material witness or missing person, or in connection with suspected criminal activity. We must also disclose your health information
to a federal agency investigating our compliance with federal privacy regulations. We will only disclose the minimum amount of health information
necessary to fulfill the investigation request.
8. Specialized Purposes. We may disclose the health information of members of the armed forces as authorized by military command authorities. We
may disclose your health information for a number of other specialized purposes. We will only disclose as much information as is necessary for the
purpose. For instance, we may disclose your information to coroners, medical examiners and funeral directors; to organ procurement organizations
(for organ, eye, or tissue donation); or for national security, intelligence, and protection of the president. We also may disclose health information
about an inmate to a correctional institution or to law enforcement officials, to provide the inmate with health care, to protect the health and safety of
the inmate and others, and for the safety, administration, and maintenance of the correctional institution.
9. To Avert a Serious Threat. We may disclose your health information if we decide that the disclosure is necessary to prevent serious harm to the
public or to an individual.
The disclosure will only be made to someone who is able to prevent or reduce the threat.
10. Family and Friends. We may disclose your health information to a member of your family or to someone e
lse who is involved in your medical care or
payment for care.
11. This may include telling a family member about the status of a claim, or what benefits you are eligible to receive. In the event of a disaster, we may
provide information about you to a disaster relief organization so they can notify your family of your condition and location. We will not disclose your
information to family or friends if you object.
12. Research. We may disclose your health information in an appropriately de-identified format in connection with approved medical research projects.
Federal rules govern any disclosure of your health information for research purposes without your authorization.
13. Information to Members. We may use your health information to provide you with additional information. This may include sending newsletters or
other information to your address. This may also include giving you information about treatment options, alternative settings for care, or other health-
related options that we cover.
14. Health Benefits Information. If your enrollment in PEIA’s health plan is offered through your employer, your employer may receive limited informa-
tion, as necessary, for the administration of their health benefit program. The employers will not receive any additional information unless it has been
de-identified or you have authorized its release.
15. PEIA will not release, disclose, exchange, and/or sell your health information for use in marketing or for-profit ventures by third parties.
Your Rights
1. Authorization. We may not use or disclose your health information for any purpose that is listed in this notice without your written authorization. We
will not use or disclose your health information for any other reason without your authorization. We will only disclose the minimum amount of health
information necessary to fulfill the authorization request. If you authorize us to use or disclose your health information in additional circumstances,
you have the right to revoke the authorization at any time. For information about how to authorize us to use or disclose your health information, or
about how to revoke an authorization, contact the person listed under “Who to Contact” at the end of this notice. You may not revoke an authoriza-
tion for us to use and disclose your information to the extent that we have taken action in reliance on the authorization. If the authorization is to permit
disclosure of your information to an insurance company as a condition of obtaining coverage, other law may allow the insurer to continue to use your
information to contest claims or your coverage, even after you have revoked the authorization.
2. Request Restrictions. You have the right to ask us to restrict how we use or disclose your health information. We will consider your request. But we
are not required to agree. If we do agree, we will comply with the request unless the information is needed to provide you with emergency treatment.
We cannot agree to restrict disclosures that are required by law.
3. Confidential Communication. If you believe that the disclosure of certain information could endanger you, you have the right to ask us to communi-
cate with you at a special address or by a special means. For example, you may ask us to send explanations of benefits that contain your health in-
formation to a different address rather than to home. Or you may ask us to speak to you personally on the telephone rather than sending your health
information by mail. We will agree to any reasonable request.
4. Inspect And Receive a Copy of Health Information. You have a right to inspect the health information about you that we have in our records, and
to receive a copy of it. This right is limited to information about you that is kept in records that are used to make decisions about you and certain
specific exclusions do apply. For instance, this includes claim and enrollment records. If you want to review or receive a copy of these records, you
must make the request in writing. We will accept electronic request for releases of information in the form of e-mails or other electronic means. If you
choose, you may receive your records in an electronic format but PEIA has the right to make sure that electronic information is delivered in s safe,
secure, and confidential format. We may charge a fee for the cost of copying, mailing and/or e-mailing the records. To ask to inspect your records, or
to receive a copy, contact the person listed under “Who to Contact” at the end of this notice. We will respond to your request within 30 days. We may
deny you access to certain information. If we do, we will give you the reason, in writing. We will also explain how you may appeal the decision.
5. Amend Health Information. You have the right to ask us to amend health information about you which you believe is not correct, or not complete. You
must make this request in writing, and give us the reason you believe the information is not correct or complete. We will respond to your request in
writing within 30 days. We may deny your request if we did not create the information, if it is not part of the records we use to make decisions about
you, if the information is something you would not be permitted to inspect or copy, or if it is complete and accurate.
6. Accounting of Disclosures. You have a right to receive an accounting of certain disclosures of your information to others. This accounting will list
the times we have given your health information to others. The list will include dates of the disclosures, the names of the people or organizations to
PEIA 2017-2018 SPD ABD-REV.indd 106 7/13/17 9:15 AM
107
whom the information was disclosed, a description of the information, and the reason. We will provide the first list of disclosures you request at no
charge. We may charge you for any additional lists you request during the following 12 months. You must tell us the time period you want the list
to cover. You may not request a time period longer than six years. We cannot include disclosures made before April 14, 2003. Disclosures for the
following reasons will not be included on the list: disclosures for treatment, payment, or health care operations; disclosures for national security
purposes; disclosures to correctional or law enforcement personnel; disclosures that you have authorized; and disclosures made directly to you.
7. Paper Copy of this Privacy Notice. You have a right to receive a paper copy of this notice. If you have received this notice electronically, you may
receive a paper copy by contacting the person listed under “Who to Contact” at the end of this notice.
8. Complaints. You have a right to complain about our privacy practices, if you think your privacy has been violated. You may file your complaint with
the person listed under “Who to Contact” at the end of this notice. You may also file a complaint directly with the: Region III, Office for Civil Rights,
U.S. Department of Health and Human Services, 150 South Independence Mall West, Suite 372, Public Ledger Building, Philadelphia, PA 19106-
9111. All complaints must be in writing. We will not take any retaliation against you if you file a complaint.
Our Right to Change This Notice
We reserve the right to change our privacy practices, as described in this notice, at any time. We reserve the right to apply these changes to any
health information which we already have, as well as to health information we receive in the future. Before we make any change in the privacy practices
described in this notice, we will write a new notice including the change. The new notice will include an effective date. We will make the new notice
available to all subscribers within 60 days of the effective date.
Who to Contact
Contact the person listed below:
• For more information about this notice, or
• For more information about our privacy policies, or
• If you have any q
uestions about the privacy and security of your records, or
• If you want to exercise any of your rights, as listed on this notice, or
• If you want to request a copy of our current notice of privacy practices.
Privacy Of ficer, West Virginia Public Employees Insurance Agency, 601 57th St. SE, Charleston, WV 25304-2345, 304-558-7850 or 1-888-680-7342
Copies of this notice are also available at the reception desk of the PEIA office at the address above. This notice is also available by e-mail. Send an
e-mail to: PEIA.Help @wv.gov.
June 1, 2004
Revised: August 2, 2013
Effective date: September 23, 2013
PEIA 2017-2018 SPD ABD-REV.indd 107 7/13/17 9:15 AM
108
PEIA 2017-2018 SPD ABD-REV.indd 108 7/13/17 9:15 AM
109
PEIA Adult Annual Routine Physical and Screening Examination
Primary Care Visit
You are entitled under the Patient Protection and Affordable Care Act (PPACA) to an annual primary care
visit that is covered at 100% with no deductible, copayment or coinsurance once per plan year.* We
recommend your Annual Routine Physical and Screening Examination be provided by your C CP, MHP or
primary care physician. This visit includes the following:
History & Physical to include:
⊕ Screening and counseling for
•Alcoholand/orsubstanceabuse•Bloodpressure
•Depression •Diabetes
•Domesticviolence •Nutrition
•Obesity •Physicalactivity
•STDprevention •OtherhealthriskfactorsasappropriateandprovidedforbyPACA
⊕ Review of medications
Blood Work to include:
⊕ General Health Panel
⊕ Lipid Panel
Immunizations as recommended by the American Academy of Family Physicians
Any additional services, including lab work, diagnostic testing and procedures with the appropriate diag-
nosis, that are provided to you during this visit will be subject to your deductible, coinsurance and copay-
ments. This may result in additional out-of-pocket costs!
To the Provider:
Bill one of the following codes for this visit:
⊕ 99381-99397 for the annual adult preventative care visit
The most commonly used diagnosis code for this visit is:
⊕ Z00.00
If you are CLIA certified, you may process labs in your office. You can bill the following for the lab work:
Panel
Code
Component
Code
Code Description
80061 Lipid Panel
80050 - General Health Panel -- includes the following component:
- 80053 Comprehensive Metabolic Panel -- includes the following component code:
- 84443 Thyroid Stimulating Hormone (TSH) plus ONE of the following CBC or combination
of CBC component codes for the same patient on the same date of service:
- 85025 Blood Count; complete (CBC) automated (Hgb, Hct, RBC, WBC and platelet
count) and automated differential WBC count
- 85027 +
85004
Blood Count; complete (CBC) automated (Hgb, Hct, RBC, WBC and platelet count)
AND
Blood count; automated differential WBC count
- 85027 +
85007
Blood count; complete (CBC) automated (Hgb, Hct, RBC, WBC and platelet count)
AND
Blood count; blood smear, microscopic examination with manual differential
WBC count
- 85027 +
85009
Blood count; complete (CBC) automated (Hgb, Hct, RBC, WBC and platelet count)
AND
Blood count; manual differential WBC count, buffy coat
If you are not CLIA certified, labs must be performed and billed by a CLIA certified provider.
Bill appropriate immunization codes.
*More details are available in the PEIA Summary Plan Description What Is Covered section.
Tear this page out and take it to your doctor!
PEIA 2017-2018 SPD ABD-REV.indd 109 7/13/17 9:15 AM
110
PEIA 2017-2018 SPD ABD-REV.indd 110 7/13/17 9:15 AM
111
PEIA 2017-2018 SPD ABD-REV.indd 111 7/13/17 9:15 AM
Plan Year 2018
July 1, 2017-June 30, 2018
Public Employees
Insurance Agency
601 57th Street, SE / Suite 2
Charleston, WV 25304-2345
PRSRT STD
U.S. POSTAGE
PAID
CHARLESTON, WV
PERMIT NO. 55
Summary Plan Description
PPB Plans A, B and D
WHO WHY PHONE WEBSITE
PEIA Answers to
questions about the
PEIA PPB Plans
888-680-7342
(toll-free)
www.wvpeia.com
HealthSmart Answers to
questions about
eligibility, benets
and network.
888-440-7342
(toll-free)
www.healthsmart.com
The Health Plan
HMOs & PPO
Answers to
questions about
The Health Plan’s
Benets
800-624-6961
(toll-free) or
740-695-3585
www.healthplan.org
Minnesota Life Answers to
questions about life
insurance or to le a
life insurance claim
800-203-9515
(toll-free)
Mountaineer Flexible
Benets
Dental, vision,
disability insurance,
exible spending
accounts, etc.
844-559-8248
(toll-free)
www.myfbmc.com
PEIA 2017-2018 SPD ABD-REV.indd 112 7/13/17 9:15 AM
