NY UFT insurance for dummies 101

amother

OP ↓

Thu, Feb 02 2023, 5:02 pm

I'm assuming there must be some DOE employees here... I'm sure I could figure this out myself except I really don't have the bandwidth, I'm very overwhelmed with life right now. Recent imamother topics made me realize there's a lot I should know about my health coverage and don't.

Such as, what's my deductible and what counts toward it? Do I have any coverage for out of network therapists? How much will it cost to give birth?

I have emblem ghi ppo which I was told is the best one that all the frum DOE people go for. And the pharmacy and dental are straight through UFT. So far I'm not impressed, I'm paying a ton at the pharmacy because normal things are inexplicably not covered and the rest have so many copays...co-pays...

Anyway if anyone here is good at this stuff and can save me a lot of time and headache by summarizing what is most important to know about this stuff, it would be a huge chessed!

amother

Azure ↓

Thu, Feb 02 2023, 5:15 pm

There is no deductible for in network. There is some out of network coverage. If you signed up for the rider it increases the amount of out of network coverage you get. Otherwise it's really minimal and there is a deductible for out of network maybe $500 for the family. Giving birth is a few hundred dollars I don't recall exactly, it's the amount charged for the hospital stay. Copays for a reg doc is $15 specialist maybe $20 or $30.

You shouldn't be paying that much for prescriptions its a decent plan. Maybe you need to get the generic? Things that you need for long term you need to use express scripts for and it's cheaper.

For dental you need to find the dentists that fully participate and then you should only be charged the listed amounts which isn't too much.

There is a frum doe watsapp group and Facebook group which are both very good resources too.

amother

↑ OP ↓

Thu, Feb 02 2023, 5:31 pm

Thanks.
The pharmacy denials were after trying both brand and generic. I asked the pharmacy and doctor if there was any way to appeal and they said no (for one medication they said they tried and were denied, the others I didn't try as hard because we were able to get something else) that's for the thing that was denied outright but when we tried a different medication for the same issue they said it was covered but my copay would be something like $80 for a week's worth of medicine because it was a more expensive drug than the one that wasn't covered at all! So I said never mind and paid out of pocket for the original one which was more like $30 in total. A different medication, also generic, they didn't give me any problems covering but they'll only approve 3 days worth at a time. So I'm constantly at the pharmacy and even though the copay for that is only $3 it adds up when you have to keep doing it.

How does it work with out of network therapists? Does the therapist need to be willing to bill them or do they reimburse you for paying out of pocket?

amother

↑ Azure ↓

Thu, Feb 02 2023, 5:51 pm

amother OP wrote:

Call express scripts with your prescription questions. Ask to speak to a supervisor and maybe someone can help you with finding it the cheapest way.

Out of network usually works that you submit paperwork and they reimburse you according to their amounts. If you pay for the rider you get back more money. There is a form on the emblem health website to fill out.

nicole81

Thu, Feb 02 2023, 5:54 pm

See if there are any options to cover more medication at a time under express scripts. For maintenance medication, they only cover a minimal amount, and for a larger copay, when you purchase at the pharmacy. But if express scripts can take it over as a mail order pharmacy, you'll get more for less money.

Regarding the $80+ copays, are you sure theyre not meant to be covered under the pica card?

Also, have you looked at the formulary to see if any version is on there? My husband's doctor once prescribed him something in a double dose bc it was cheaper, and told him to cut the pills in half. It's nuts but it's what we have to do.

Also, sometimes the liquid version of a pill can be more expensive. So I'd check out the list and see what's on there and go from there. It's all Google-able and on the UFT website

amother

↑ OP ↓

Thu, Feb 02 2023, 6:00 pm

nicole81 wrote:

What is a pica card and how would I know what it covers?

I didn't personally check any formulary but my pharmacist is amazing and I'm sure he would have let me know if there was any option. He has been helpful like that a few times. So when he says no they're just not covering this, I just believe it

amother

↑ Azure ↓

Thu, Feb 02 2023, 6:03 pm

Just gonna also say that health insurance now is a fortune. You would be paying at least 2.5k a month for a family for this plan not counting the uft benefits. Sometimes I do pay some out of pocket but I feel like I am still coming out way ahead as I am not paying for the insurance or for coinsurance or having to meet large deductibles which is pretty common.

icedcoffee

Thu, Feb 02 2023, 6:09 pm

I know a lot of people recommend GHI but I highly recommend the HIP Prime HMO. I seriously pay nothing to see anyone. A specialist is typically a $10 copay but if you choose a "preferred" primary care person, they waive the copay so it's $0 for all specialists. I paid $150 to give birth, I believe. Or maybe $300. Either way it was so nominal and I didn't pay anything else all pregnancy. The downside is you need to get a referral from your PCP before seeing a specialist, but it's never been a problem for me - I just call and they send the referral. Some people find that to be a pain in the neck. No deductible, also.

Not sure what's going on with the prescriptions. I usually either pay nothing or a few dollars. Did you enroll in the uft welfare fund?

amother

↑ OP

Thu, Feb 02 2023, 6:49 pm

icedcoffee wrote:

Yes my prescriptions are through uft welfare I think.
Your plan sounds great, I wonder why it seems emblem ghi is so much more popular. Maybe it's a ppo vs hmo thing? Is hmo more limited with out of network?

amother

↑ Azure

Thu, Feb 02 2023, 7:57 pm

amother OP wrote:

Hip doesn't have out of network benefits. Many people also find the referrals annoying. And that you are limited to your pcp....I personally like to have the option to go to different pa's because my kids get sick often. But I know people who are happy with it and save a lot of money with the no copays. So it's a personal choice.

amother

Jean

Thu, Feb 02 2023, 7:58 pm

You definitely should not be paying so much for prescriptions. Are you sure that the pharmacy is using the welfare fund card and not your regular medical insurance card? Also, you need to get any long term meds through express scripts. They send you a 3 month supply. But if you try to fill it at a regular pharmacy it won't be covered (you get 1 initial fill and then 2 refills, after that it needs to be through express scripts). My DH is on some pricey meds and we only ever paid a few dollars for them, the rest was covered.

In regards to out of network therapists, you pay the therapist and then you need to submit to insurance for reimbursement. Just a warning though, they don't cover very much Sad

. When I submitted for my daughter's therapy I think we got back about $50-$60 per session. It adds up over time but relative to the $200 charged per session by the therapist it's not much.

With GHI you have no deductible, minimal co-pays ($15 pcp, $30 specialists). I paid $300 for my hospital births. No referrals are needed to see specialists, which is nice as it's one less thing to worry about.