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Health insurance

University faculty and staff eligible for benefits may enroll themselves and their eligible dependents in the Community Blue PPO health plan, administered by Blue Cross Blue Shield of Michigan (BCBSM).

Summary of Benefit Changes-Effective January 1, 2012

The following benefit changes pertain to AAUP faculty, POA employees, and benefits-eligible non-bargaining employees with the exception of Aviation Associates and R3 Research Staff. They also pertain to WMU Retirees, excluding those retired from the AFSCME and MSEA bargaining units: or .

Your Benefit Guide

Issued by BCBSM, Your Benefit Guide provides information on how to use the Community Blue PPO, benefits and services covered by the plan, and ways you can minimize out-of-pocket medical costs. Details of your prescription drug, dental, and vision coverage are also included in this guide.

To access Your Benefit Guide:

• Go to www.bcbsm.com.
• Under Member Secured Services, enter your user name and password; click login. Tip: for first-time login, have your PPO plan card handy to establish your user identity.
• Scroll down the Manage My Plan page and click Benefits to open Your Benefit Guide.

Community Blue PPO network providers

Members can find Community Blue PPO network providers on BCBSM's Where You Can Go For Care Web page. Search for physicians, hospitals, and other health care providers in the PPO network. Members can also search for providers who participate in BCBSM's traditional network.

Coverage varies by provider type as follows. Par providers are those who participate with BCBSM.

In-Network Vs Out-of-Network Coverage: Par Vs Non-Par
Provider Type	PPO In Network	Traditional BCBSM, out-of-network, with referral	Traditional BCBSM, out-of-network, no referral	Non-Par BCBSM, out-of-network, with referral	Non-Par BCBSM, out-of-network, no referral
Coverage	100% after in-network deductible	100% after in-network deductible	75% after out- of-network deductible	100% of approved charge, after in-network deductible; employee liable for balance	75% of approved charge, after out-of-network deductible; employee liable for balance

On-campus health care

Health care services are also available on campus at Sindecuse Health Center and WMU Unified Clinics to members of the Community Blue PPO through the WMU Health Services Plan.

Prescription drug coverage

Your prescription drug benefit is provided through BCBSM's 90-day retail prescription drug program. Under this program, members are able, with proper prescription, to obtain a 90-day supply of a medication for two copays at a participating retail pharmacy, and for a single copay at Sindecuse Health Center pharmacy.

The benefit has the following provisions:

• The copay is determined by the three-tier structure of generic ($15), formulary brand ($35), and non-formulary brand ($55). These co-payments are $10, $30, and $40, respectively, at Sindecuse
• The member may continue to obtain a 30-day supply of a medication from a 90-day retail network provider.
• The written prescription must specify a quantity greater than an 83-day supply, up to a 90-day supply. Claims for supplies of 35 to 83 days will be rejected.
  
  Mandatory MAC
  If you obtain a brand name drug when a generic equivalent is available, you must pay the difference in cost between the brand name drug dispensed and the cost of the generic drug plus your brand name copay regardless of whether you or your doctor requests the brand.  However, the cost differential between brand name and generic is waived if your doctor documents medical necessity for the brand name drug instead of the generic.  Your doctor must contact Blue Cross Blue Shield of Michigan pharmacy services for the exception.

Your Benefit Guide contains detailed information about your prescription drug coverage (see above for access). You may also find the following Web links helpful:

BCBSM 90-day Retail Prescription Program

BCBSM Approved Drug Lists (Formularies)

Sindecuse Pharmacy

Submitting claims

Typically, in-network providers submit your claim for you; some out-of-network providers may also do so. For claims that you must submit yourself, send them to:

Attn: WMU Claims
Blue Cross Blue Shield of Michigan
PO Box 230555
Grand Rapids, MI 49523-0555

Pre-addressed claim envelopes are available for pick-up in Human Resources.

Need help?

Contact Blue Cross Blue Shield of Michigan for coverage and claims information concerning the Community Blue PPO:

• BCBSM Customer Service: (800) 879-1945
• A BCBSM representative is available to meet with employees in Human Resources each Thursday. Please call Human Resources to make an appointment.

Additional resources

The Health Insurance Portability and Accountability Act (HIPAA) establishes certain privacy rights regarding employees' personal health information. Detailed Information is located in the Human Resources Policies and Procedures Manual's Health Insurance Portability and Accountability Act (HIPPA) Section.