- Will UHA cover over-the-counter medications?
- Can I change between UHA benefit plans at any time?
- Why is the co-pay different for prescription drugs?
- Does UHA have any pre-existing condition clause?
- What do I do if I have a pre-existing condition and would like to continue my treatment plan?
- My prescription plan has an annual maximum benefit. When do my benefits reset and begin again after the maximum is reached?
- I filled a prescription recently and paid the full cost for my drugs, although I was just supposed to pay a co-payment. How do I get reimbursed?
- Who is responsible for notifying UHA regarding hospital outpatient or inpatient services?
- Who do I notify if I have an urgent authorization request?
- My physician has referred me to a mainland specialist. May I receive coverage for these services?
- I would like to get a second opinion from a mainland provider. Is it a covered benefit? What about any follow-up care or surgery?
Q. Will UHA cover over-the-counter medications?
A. UHA no longer covers over-the-counter (OTC) medications.
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Q. Can I change between UHA benefit plans at any time?
A. Once you select a plan, you must remain in the plan until your group's next open enrollment period. Open enrollment periods occur annually. See your company's human resource director for your open enrollment periods.
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Q. Why is the co-pay different for prescription drugs?
A. Depending on your drug plan, your co-payment for prescription drugs from a participating pharmacy can vary as follows:
- generic drug - member pays $0 to $7
- preferred brand - member pays $10 to $20
- non-preferred brand - the member pays $15 to $40
- prescription, generic or brand, with ingredient costs over $125, $150 or $200 - member pays 20% of the allowable ingredient cost
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Q. Does UHA have any pre-existing condition clause?
A. Our benefit plans do not limit coverage for pre-existing conditions.
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Q. What do I do if I have a pre-existing condition and would like to continue my treatment plan?
A. If you are a new member to UHA and are currently on a treatment plan, have your physician contact Health Care Services to discuss a treatment program to ensure there is no lapse in your medical services.
Also, ask your Human Resources Director for a UHA Transition Coverage Questionnaire. Completing and submitting this form will ensure continuation of your care during the transition period.
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Q. My prescription plan has an annual maximum benefit. When do my benefits reset and begin again after the maximum is reached?
A. Benefit plan maximums are based on the calendar year. Accumulation towards the maximum begins on January 1.
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Q. I filled a prescription recently and paid the full cost for my drugs, although I was just supposed to pay a co-payment. How do I get reimbursed?
A. There are some situations in which you may be asked to pay for the full cost of your drugs at the pharmacy. Either the pharmacy you have chosen is not a participating pharmacy with UHA, or your enrollment form is still being processed.
In these situations, have the pharmacy complete a Prescription Drug Claim form and submit it to UHA for reimbursement to you. Your claim must be filed within 90 days from date the prescription was filled.
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Q. Who is responsible for notifying UHA regarding hospital outpatient or inpatient services?
A. Physicians are responsible because they have the necessary information to complete the referrals, i.e., diagnosis and procedure codes.
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Q. Who do I notify if I have an urgent authorization request?
A. Contact Health Care Services.
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Q. My physician has referred me to a specialist on the mainland. May I receive coverage for these services?
A. Your physician must submit an Out-of-State Services Request Form at least 2 weeks in advance.
We advise that you do not make travel arrangements until the review is completed and you and your referring physician receive written confirmation from us that the service will be covered. Benefit coverage information will be provided only after the review is completed. Airfare and lodging are not covered benefits.
Contact Health Care Services with any questions.
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Q. I would like to get a second opinion from a mainland provider. Is it a covered benefit?
A. Providers outside of Hawaii are not contracted with UHA, therefore, non-participating provider benefits will apply. This means UHA will pay only up to our eligible charge for non-participating providers, which is based on our rate for similar services performed in Hawaii. You are responsible for the difference between UHA's payment and the provider's actual charge ("balance billing"), which can be substantial. See your medical benefits guide for the eligible, non-participating provider level amount.
Members are encouraged to obtain their second opinion within the State of Hawaii, which is covered at 100% of the eligible charge. If you are considering out-of-state services, please contact Health Care Services to discuss your options.
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