If you have questions about any aspect of your health insurance coverage, please check the Q & A on this page. If you have a question that is not answered here, please submit your question to Jessie Moulton at email@example.com
Will I need to fill out an application for this transfer to Empire?
Excellus will transfer all enrollment data to Empire, so an application will not be necessary.
When will I receive my new insurance card(s)?
The date planned for the mailing of the cards is December 14th. If, however, the transfer of data from Excellus to Empire occurs earlier than expected, the mailing could occur a few days earlier.
Your cards will arrive in a plain, white envelope that does not have Empire’s logo. Please open all mail that you receive after December 10th, to be sure that you don’t miss it.
I currently take advantage of a program called Fitness My Way through Excellus. Does Empire offer a similar service?
Empire, through its Special Offers program, does offer a similar plan, called Active and Fit. Empire is currently attempting to recruit gyms in the area to join the program, as there are none at this time. We anticipate that the area gyms will want to participate, due to the popularity of the Excellus program. Check with your local gym for updates.
I see a specialist in Burlington, Vermont. Will they be considered “in-network” under Empire?
If a provider is in a Blue Cross/Blue Shield (BCBS) network outside of Empire’s service area, then they are considered “in-network,” since they are part of BCBS’s Blue Card national network. This also applies anywhere else in the United States and in 190 countries worldwide.
If your specialist in Burlington is currently in-network with Excellus, then they will be under Empire, as well, since both companies participate in the Blue Card program.
My doctor in Plattsburgh is in Excellus’s local network but is not in Empire’s network. Will I be covered for services provided by this doctor?
The CEWW Consortium plans cover out-of-network providers. You may need to pay your doctor directly and submit a claim to Empire for reimbursement of Empire’s allowed amount for the provided service (some out-of-network providers will submit for you, some will not). Empire will then send payment directly to you. If the amount that your doctor charges exceeds Empire’s allowed amount, the doctor could bill you for the excess amount.
Empire will contact all out-of-network providers in the area and attempt to get them to join.
Excellus does not currently require prior authorization (PA) to determine medical necessity for certain procedures. They assess this by reviewing after the procedures have occurred. Does Empire determine medical necessity in a similar manner?
Empire determines medical necessity for certain procedures prior to the initiation of care and authorizes physicians to provide the service before it begins. This “Prior Authorization (PA)” is standard procedure for many providers today and aligns with the requirements of Medicare. These authorizations are requested by your providers – you are not required to contact Empire.
If you are covered by Medicare and receive PA from them, another authorization from Empire is not necessary.
The list of procedures requiring PA is posted on this website.
I currently receive my drugs via mail order. Will I need to re-apply for this service?
This information is being transferred from Excellus to Empire’s Pharmacy Benefits Manager (PBM), IngenioRx, so a new application is not necessary. However, since the exchange of a member’s financial information is not allowed by law, you will have to contact IngenioRx after you receive your new card, to give them you credit card number for any copays associated with your prescription. You will also need to let them know if your prescription is subject to an auto-fill, as this information does not transfer from Excellus.
I am currently taking a medication that is on both Excellus and Empire’s drug lists. Will I need to get a new prescription from my physician?
Empire will get prescription drug information from Excellus, so, in most cases, a new prescription is not necessary. An exception to this would be for controlled substance prescriptions – these cannot be transferred, so your doctor would need to write a new prescription for these types of drugs.
You would also need a new prescription if you plan to switch retail pharmacies.
I am currently taking a drug that is not on Empire’s drug list. Will I be covered if I continue to take this drug?
There are two categories of drugs that are not on Empire’s drug list – Non-formulary and not covered.
Non-formulary drugs are prescription medications that are not on Empire’s list of preferred drugs, based on their safety, effectiveness and cost.
If you are currently prescribed a non-formulary drug, you will be “Grandfathered” and may continue to take this drug. However, if you are on Plan 2, you may have to pay a higher copay.
All non-formulary drugs will require the Tier 3 copay for Plan 2 members.
After January 1st, if your doctor wants to begin prescribing a non-formulary drug, this will likely require that they provide documentation showing that it is medically necessary for you to take the non-formulary drug, rather that the preferred alternative. Again, Plan 2 members will pay the Tier 3 copay for any non-formulary drugs.
Not covered drugs often are available over-the-counter (OTC). Empire has a preferred alternative for most of these drugs, but they are not covered under any circumstance. If you are currently taking one of these drugs, talk to your doctor about one of the preferred alternatives or purchase the drug OTC at your own cost.
I am on Plan 2 and take a drug that is on Tier 2 with Excellus. Will this drug also be on Tier 2 with Empire?
Although most drugs that are on both Excellus and Empire’s drug lists will match tiers, some may not. It is possible that Plan 2 members will pay either a lower or a higher copay for their prescription.
Will Prior Authorization (PA) and Step Therapy (ST) be required for certain brand named and specialty drugs for both Plan 1 and Plan 2?
Empire will require that your physician provide documentation in support of a determination of medical necessity for certain drugs. This documentation may include the results of ST with preferred alternative drugs. Empire will manage its drug list for both plans in a similar manner. Refer to the Empire drug list on this website for drugs requiring ST and PA.
If, however, you have received PA for a drug that you currently take, you will not be required to go through that process a second time.
Q. Why is the consortium changing carriers?
A. As a result of rising health care costs, the Consortium, in an effort to ensure that it is making the most effective use of its limited resources, sought to analyze alternative insurance carriers through a Request for Proposal (RFP) process. With the assistance of the Consortium’s Consultants, Segal Consulting, projected costs and services were analyzed for the incumbent, Excellus, and three other carriers that submitted proposals. Based on projected claim costs, member services and a more favorable prescription drug arrangement, the Consortium’s Board of Directors, with input from members of the Advisory Committee, made the decision to end the relationship with Excellus and to begin working with Empire Blue Cross effective January 1, 2020.
Q. Who was involved in the decision to change?
A. Consensus was reached by members of a combined committee of the members of the Board of Directors and all current and active members of the Advisory Committee after interviewing Excellus and Empire and analyzing information provided by both the carriers and Segal Consulting.
Q. Are there any changes being made to the Plans?
A. Aside from changes made effective July 1, 2019 ($100 ER copay, Telemedicine w/o coinsurance) to Platinum 2, the plans remain as they were under Excellus.
Q. Are all covered benefits of the plans going to be exactly the same as they were under Excellus?
A. No two insurance companies operate exactly the same. Most differences between Excellus and Empire exist behind the scenes, like network management and case management. There are others, like the list of covered prescription drugs, that may impact a small number of members. Empire will work directly with members and their physicians to minimize the impact and to ensure continued quality care going forward.
Q. Who is going to notify retirees of the website address?
A. Local retiree groups will be provided with the link. Retirees who are not members of these groups are encouraged to contact their active locals for the information. The link will be provided to each District in the CEWW BOCES region and they will be asked to add it to their website.
Q. Does the Consortium have stop-gap insurance?
A. No. Analysis has shown that there would have been little to no financial advantage to having this coverage for the Consortium’s plans over the past two years.
Q. What is the basis for pharmaceutical rebates?
A. These are negotiated between pharmaceutical companies and pharmacy benefit managers and then a portion is shared with the insurance provider. Rebates are marketing tools and are generally offered on high-cost drugs that are competing against other drugs that treat similar conditions.
Q.Is telemedicine available for Plan 1?
A. Yes. It is subject to the 20% co-insurance. For Plan 2, the co-insurance is waived.