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Medical Plan

​The Medical Plan includes comprehensive medical coverage administered by Highmark Blue Cross Blue Shield. The plan also includes prescription drug benefits, administered by OptumRx; vision benefits, administered by VSP; an Employee Assistance Program (EAP); and the well-being initiative Call to Health.

PPO and EPO Options

Your medical coverage option(s), based on your employer’s selections, and coverage-level costs are available on Benefits Connect during annual enrollment.

Teaching elders in Pastor’s Participation must be enrolled for medical coverage in the PPO (preferred provider organization) on a non-contributory basis (the employer pays 100 percent of the cost of coverage), regardless of family status.

The PPO, administered by Highmark Blue Cross Blue Shield (BCBS) (and OptumRx for prescription drugs), provides access to the national BCBS network of physicians, hospitals, and other healthcare providers. Under this medical option, you can seek care from any eligible, licensed provider; however, your out-of-pocket costs are typically lower when using network providers.

Other teaching elders and other employees may be eligible for medical coverage through the PPO option and/or the EPO (exclusive provider organization) option. One or both of these medical coverage options may be available to these employees based on their employer’s decision.

The EPO, also administered by Highmark BCBS (and OptumRx for prescription drugs), includes network medical benefits only and a specific list of brand and generic medications that are covered. Prescription drugs that are not on the preferred drug list (formulary) are not covered under the EPO.

For more information about the PPO and EPO, see 2018 Key Provisions: PPO & EPO.

Medical Coverage Costs

If you are eligible for the Medical Plan in 2018, you will see your medical option(s) and coverage-level costs on Benefits Connect during annual enrollment.

In menu options, medical coverage costs are expressed in flat dollar amounts by coverage level (Member-only, Member + Spouse, Member + Child(ren), Member + Family).

Employers are required to pay at least 50 percent of the cost of Member-only coverage for the lower-cost option they offer. Employees may be asked to pay up to 50 percent of Member-only coverage in the option they elect and up to 100 percent of the incremental cost of coverage for their eligible family members.

In Pastor’s Participation, employers pay the entire cost of medical dues — 25 percent of annual effective salary (subject to minimum and maximum dues rates).

Waiving Coverage

Menu options: If you are in menu options, you may waive medical coverage for yourself and any family members.

If you are considering waiving medical coverage, you should carefully consider the following:

  • If you are married, your spouse's employer may offer medical coverage. However, some employers allow employees to enroll a spouse only if the spouse does not have access to other medical coverage. If your spouse's employer has this rule and you are offered coverage through the Medical Plan, you would not be eligible to enroll in your spouse's employer plan. In addition, some employers impose an additional charge for spouses enrolled in their plan who have coverage available elsewhere. Before waiving Medical Plan coverage, you should confirm whether you are eligible to enroll in your spouse’s plan and the cost.
  • If you waive Medical Plan coverage, you may be assessed shared responsibility payments under the Affordable Care Act if you do not obtain coverage elsewhere. Potential coverage sources include a spouse’s or parent’s employer; government programs such as Medicare, Medicaid, and TRICARE; and the federal Health Insurance Marketplace (healthcare.gov) or a state’s health insurance exchange.
  • If you are offered coverage through the Medical Plan, you cannot qualify for a subsidy for coverage obtained through the federal Health Insurance Marketplace (healthcare.gov) or a state’s health insurance exchange.

If you waive medical coverage for yourself and/or family members, you will not be able to elect medical coverage until the next annual enrollment (unless you have a qualifying life event).

Pastor’s Participation: You may not waive medical coverage for yourself, but may waive medical coverage for eligible family members. If you waive coverage for family members, your employer is still responsible for paying the full 25 percent dues amount; family member participation does not affect dues.