The information below contains basic facts about health insurance coverage but is not intended to provide specific details about individual benefit programs.

For answers that are specific to your own individual health coverage, please contact your Human Resource Department, your Plan Administrator, the member service line of your Insurance Plan, or the broker responsible for your Insurance Plan.

In addition, you may want to click on to the Health Insurance Glossary for definitions of common health insurance terms.

• Are immunizations covered under health insurance?

• Is there a pre-existing limitation on my policy? What is a pre-existing condition?

• Why doesn't my plan cover certain prescriptions?

• What is my drug coverage?

• What is a drug formulary?

• What is the co-pay for prescriptions? Can we get lower co-pay for prescriptions? Why is my co-payment so high for drugs?

• Is wellness covered? What are some examples of wellness programs?

• Why are physicals not required to be a covered expense for persons over a certain age when the medical community recommends screening and certain tests?

• Can I go to the chiropractor or do I need a referral from my doctor?

• What is coverage like for an out–of-state school for child?

• What happens if I am traveling and I have an emergency?

Are immunizations covered under health insurance?

Childhood immunizations are typically covered by Insurance Plans and should be given for your child based on his/her age. Your physician can assist you with the schedule of how these shots should be administered.

Always confirm with your employer or your Insurance Plan that the immunizations are covered before you go to get your child immunized. With so many variations in insurance plan coverage, it is unlikely that your doctor will know what your insurance will cover.

Adult immunizations like flu and pneumonia vaccine may or may not be covered by your Plan. Check your Member Handbook or contact your employer or the Member Services Department of your Plan for assistance.

Always confirm with your employer or your Plan that the immunizations are covered under your insurance or if you are responsible to pay for them. With so many variations in insurance plan design, it is unlikely that your doctor will know what your personal insurance will cover.

Is there a pre-existing limitation on my policy? What is a pre-existing condition?

It is important that you determine if your employer's plan has a pre-existing clause. It is very important to understand the kind of health insurance coverage that you have because one insurance company can offer many different kinds of coverage under many different kinds of plans.

So, even if you and someone else you know deal with the same insurance company, the kinds of health care benefits that each of you can receive might be very different.

Check your Member Handbook, contact your employer , or call the Member Services Department of your Plan for assistance.

A Pre-existing Condition is an illness or condition that was treated or diagnosed before a policy was issued. Many insurance policies will not pay for any charges to treat pre-existing conditions, or will only cover treatments after the policy has been in force for a specified period of time. The length of that specified period of time will vary according to the group or individual coverage. You will have to check with your employer to see how your individual plan is designed.

Recent Pennsylvania laws allow employees to keep continued coverage when they change jobs and then obtain health insurance through a group health plan. You can ask your employer for this information.

If a person had group health coverage for one year (18 months for late enrollees), then switched jobs and went to another plan, the new health plan cannot impose another pre-existing condition exclusion period, provided there is no break in the coverage for more than 63 days.

Pregnancy is not a pre-existing condition. Newborns and adopted children who are covered within 30 days of birth, adoption, or placement for adoption are not subject to a 12-month waiting period.

An individual who meets certain criteria is considered an eligible individual and is guaranteed the right to buy individual health coverage from Blue Cross and Blue Shield plans in Pennsylvania without a pre-existing condition exclusion period.

To be an eligible under the Blue Cross, Blue Shield criteria, an individual:

1. must have had 18 months of continuous credible coverage, at least the last day of which was under a group health plan.
2. must have used up any COBRA continuation coverage for which they were eligible.
3. must not be eligible for Medicare, Medicaid or a group health plan.
4. must not have other health insurance.
5. must apply for health insurance for which they are eligible within 63 days of losing prior coverage.

Why doesn't my plan cover certain prescriptions?

Coverage for prescription drugs is determined by your employer's benefit plan. Check your Member Handbook for information on the medicines that are covered under your plan and for your financial responsibility when you purchase these drugs if your doctor prescribes them for you.

You can also contact your Insurance Plan or a pharmacy to find out if a specific drug is covered or not.

An insurance company can offer many different kinds of coverage under many different kinds of plans. So, even if you and someone else you know have the same insurance company, the kinds of prescription benefits for each of you can be very different.

What is my drug coverage?

Coverage for prescription drugs is determined by your employer's benefit plan. Check your Member Handbook for information on the medicines that are covered under your specific Plan and for your financial obligations to purchase these drugs if your doctor prescribes them for you. You may have to pay something out-of-pocket for at least part of the cost of your prescriptions. Thias wuill vary according to the plan your employer has purchased from the insurance company.

You can also contact your Plan or the pharmacy to find out if a specific drug is covered or not.

Many Insurance Plans require enrollees to use certain drugs for certain conditions. This drug formulary is a list of the drugs and medications that an insurance company will pay for when a doctor prescribes them. Formularies are used by most managed care plans and vary by insurance company and insurance plan design. A physician is required to use only formulary drugs unless there are valid medial reasons to use a non-formulary drug.

Contact your pharmacy or Plan to find out if a specific drug is covered on your formulary, and if your financial responsibility is lower if your physician prescribes a generic instead of a brand name drug.

An insurance company can offer many different kinds of coverage under many different kinds of plans. So, even if you and someone else you know deal with the same insurance company, the kinds of prescription benefits for each of you can be very different.

What is a drug formulary?

A formulary is a list of the drugs and medications that an insurance company will pay for when a doctor prescribes them. Formularies are used by most managed care plans and vary by insurance company and insurance plan design. A physician is required to use only formulary drugs unless there are valid medial reasons to use a non-formulary drug. .

Contact your pharmacy or Plan to find out if a specific drug is covered on your formulary, and if your co-payments are lower if your physician prescribes a generic instead of a brand name drug.

What is the co-pay for prescriptions? Can we get lower co-pay for prescriptions? Why is my co-payment so high for drugs?

Coverage for prescription drugs is determined by your employer's benefit plan. Different Plans have different requirements. Check your Member Handbook for general information on the medicines that are covered and for your financial obligations to purchase these drugs if your doctor prescribes them for you. You can also contact your Plan or the pharmacy to find out if a specific drug is covered or not.

An insurance company can offer many different kinds of coverage under many different kinds of plans. So, even if you and someone else you know deal with the same insurance company, the kinds of prescription benefits for each of you can be very different.

Is wellness covered? What are some examples of wellness programs?

Wellness programs may or not be a component of your Plan. Some examples of wellness programs are smoking cessation, weight loss, and membership in a health spa. Check your Member Handbook for covered services or confirm your coverage with your employer or your Plan's Member Services department to avoid unnecessary out-of-pocket expenses.

An insurance company can offer many different kinds of coverage under many different kinds of plans. So, even if you and someone else you know deal with the same insurance company, the kinds of wellness benefit for each of you can be very different.

Why are physicals not required to be a covered expense for persons over a certain age when the medical community recommends screening and certain tests?

Physicals may or may not be a component of your plan. Your employer or Plan's Member Services can answer this for you. You should confirm your benefits before accessing service to get the maximum benefit from your coverage.

Are vision exams covered?

Vision services may or may not be a component of your plan. Vision services are often “carved out” to a company such as Lens Crafters, Davis Vision, etc.

Other benefit plans may pay only for the vision exam. You should confirm your benefits before accessing services so that you know what your financial obligations will be.

Your Member Handbook, your employer or Member Services Department of your plan can answer this for you.

Can I go to the chiropractor or do I need a referral from my doctor?

The need for a referral depends on your employer's group plan. If you are in an HMO, it is possible you will need to see your Primary Care Provider before going to any specialist, including a chiropractor.

Your coverage may include a limited number of visits to a chiropractor. You should always confirm your benefits before seeking treatment to avoid higher out-of-pocket expenses. There Your Member Handbook, your employer or the Member Services Department of your Plan can answer this for you.

An insurance company can offer many different kinds of coverage under many different kinds of plans. So, even if you and someone else you know deal with the same insurance company, the kinds of chiropractic benefit for each of you can be very different. Do not expect that the provider will know what your chiropractic coverage is.

What is coverage like for an out–of-state school for child?

Coverage for your child attending an out-of-state school is determined by your individual employer's benefit plan. Variables for this coverage may include the age of your child, as well as other factors. Consult your Member Handbook, contact your employer, or call the Member Services Department of your plan.

What happens if I am traveling and I have an emergency?

To avoid unwanted surprises, always confirm your insurance coverage BEFORE you travel out of the area since your coverage while traveling is determined by your employer's benefit plan. The extent of time you will be away from home or work and the availability of network or contracted healthcare providers are just two of the many factors that can affect your benefits. In addition, co-payments and co-insurance will apply when you seek care out of the area.

To get the maximum benefit allowed under your plan, you should let your insurance company know if you receive treatment in an emergency room while you are traveling. There is a Primary Care Physician or a qualified medical professional who covers a medical practice and who is available 24 hours a day. Verify coverage information before you leave your home area.

It is always frightening to have a health problem when you are not in familiar surroundings, but not every illness is an emergency.

An emergency is the sudden onset of severe or painful symptoms that require immediate medical attention because they would place a patient in serious jeopardy.

In the event of a life-threatening emergency, patients should go to the nearest emergency room for treatment. Prior authorization from an insurance company is not required, but patients in managed care should notify their primary care provider or the Insurance Plan within 24 hours, or as soon as is reasonably possible, so that appropriate, coordinated care can be arranged. Emergency care is not the same as urgent care. (See below for a definition of urgent care)

Urgent Care is needed to minimize the severity of and complications from an unexpected illness or injury that is not an emergency or life-threatening. Urgent care is not the same as emergency care. (See above for a definition of emergency care)

Most Insurance Plans, but not all, cover emergency services while you are traveling. Some Plans require a co-payment for emergency room care and will put that financial information on your insurance card. It is recommended that you notify your insurance company if you receive treatment in an emergency room setting.

In states with a Prudent Layperson Law, an insurer must pay for an emergency room visit if a prudent, sensible, layperson, who is acting reasonably, would think that an emergency medical condition existed. However, it is important to know that some Insurance Plans will not cover an emergency room visit if the symptoms appeared more than 24 hours earlier.