Do I have to use a mail order pharmacy?
If you are prescribed a long-term maintenance medication, you should use Maintenance Choice or CVS/Caremark Mail Service Pharmacy by the third fill, or the prescription will be subject to a 50% co-insurance payment and the plan limit on the maximum co-payment per prescription will not apply.
Do I have to use generic medications?
If you purchase a brand-name drug when a generic equivalent is available, you will pay your generic co-insurance plus the difference in cost between the brand-name and the generic drug. The limit on the maximum co-payment per prescription does not apply for brand-name drugs when a generic equivalent is available. Please refer to your Plan Benefit Profile in the My Documents section of your Member Dashboard for specific coverage.
What is not covered under my TeamCare Prescription Benefit?
TeamCare does not cover medication or supplies ordered from outside the United States, over the counter medications, vitamins, or dietary supplements. For a complete listing of non-covered items under your Prescription Benefit, please refer to your Summary Plan Description in the My Documents section of your Member Dashboard.
How do I file a prescription claim if I didn’t use the TeamCare Prescription Benefit?
You will need to submit itemized receipts from your pharmacy to:
TeamCareConsult your TeamCare Benefit ID card and make sure that all information is accurate on the claim.
A Central States Health Plan
P. O. Box 5116
Des Plaines, IL 60017-5116
Why was my or my family member’s prescription rejected for coverage?
There are many reasons a prescription can be rejected, such as a problem with eligibility, trying to get a non-covered drug, or having other insurance. Ask the pharmacy why the prescription was rejected and contact TeamCare for assistance.
- Where do I find a form for Caremark Mail Service Pharmacy?
Will you cover a prescription from my dentist?
Yes, for covered medications.
- How do I get a copy of my prescription history?
Is there a mandatory formulary?
No, there is not a mandatory formulary. A prescription drug formulary is a list of commonly prescribed medications that have been selected by Caremark because of their combination of effectiveness and cost.
Your doctor should call Caremark or visit caremark.com to learn which drugs are covered under your Prescription Benefit. You should encourage your physician to prescribe preferred medications whenever possible, because drugs not on the formulary will not be covered and will cost you more money.
Is there an out-of-pocket maximum on injectable medications?
Yes, there is a separate annual out-of-pocket maximum that applies only to injectable medications. Once your out-of-pocket for prescription medications costs reach the annual limit of $1,000, all future injectable medication costs will be paid at 100%. Please refer to your Plan Benefit Profile to find the specific information for your injectable medication coverage and to determine exactly what your Prescription Drug Benefit covers—and doesn’t cover.
When am I eligible for my next dental appointment?
If your plan includes dental benefits, members and their covered dependents may receive oral exams once every six months. Oral exams are covered under the preventive services portion of your dental plan. For more information, review your Summary of Benefits in the My Documents section of your Member Dashboard.
Are sealants covered? If so, up to what age?
If your plan includes dental benefits, sealants are covered for children through age 13 every 18 months.
Are dental implants covered?
If your plan includes dental benefits, dental implants are covered as of January 1st, 2018 under your dental benefits up to your annual dental maximum (if applicable).
Are fluoride treatments covered? If so, up to what age?
If your plan includes dental benefits, fluoride treatments are covered for dependent children under age 26.
My procedure wasn't completed before I was laid off. Will TeamCare pay if I have the procedure completed?
If your plan includes dental benefits, the following services will be covered up to the plan limits if completed within one year:
- Dentures: full or partial, if the impression was taken while you were covered
- Fixed bridgework, gold restorations and crowns: if the tooth or teeth were prepared while you were covered
- Root canal therapy: if the tooth or teeth were opened for treatment while you were covered
Can I have a procedure predetermined?
Yes. You can have a procedure predetermined for charges of $500 or more. Predetermination of Benefits is available and recommended.
For crowns, bridges, partials and/or dentures, do you pay dental benefits on the impression date or insertion date?
Generally, benefits are paid on the date of completion/insertion. Certain eligibility conditions may warrant payment on impression or treatment start date.
When should X-rays be submitted for dental work performed or proposed?
X-rays are generally requested for major dental work. If a claim is received that requires X-ray review, TeamCare will send a request to your dentist.
My dentist does not file claims. I have to file them. Where should they be sent?
Mail claims to:
P. O. Box 5116
Des Plaines, IL 60017-5116
When you complete the claim form, consult your TeamCare ID card to ensure that all your information is accurate. This includes your ID number (your 806 number), subscriber’s name, patient’s name, and patient’s date of birth. Any incorrect information will delay the processing of claims.
Are there any dental procedures my plan does not cover?
Your TeamCare Dental Benefit is a comprehensive plan that includes coverage for most procedures. However, some procedures are not covered. You may find your benefit information by logging into your Member Dashboard.
Are periodontal services for children covered?
Typically, periodontal services are not covered for children. However, if recommended by a dentist and medically necessary, we will provide benefits for adult children aged 19 – 25.
- What is not covered under the Vision Benefit?
When am I eligible for glasses?
If your plan includes vision benefits, members and their covered dependents may receive an eye examination and glasses or contact lenses according to your Plan Benefit Profile. For more information, review your Summary of Benefits in the My Documents section of your Member Dashboard.
Does the Vision Benefit cover safety glasses?
No, TeamCare does not provide coverage for safety glasses.
Are Department of Transportation (DOT) physicals or executive exams covered under my Wellness Benefit?
No, TeamCare does not cover any work-related physicals.
Is an executive exam covered under my plan?
No. Executive exams — comprehensive exams that include preventative screening tests and examinations, lifestyle assessments, and nutritional counseling —are not covered by TeamCare.
Does TeamCare cover HIV testing and screening for sexually transmitted diseases (STDs)?
Yes. TeamCare will cover HIV testing and screenings for STDs under the Wellness Benefit.
How is a Bone Density Test covered?
A Bone Density Test conducted for preventive reasons is covered under the Wellness Benefit.
A Bone Density Test conducted as part of a medical diagnosis is paid according to your plan’s Outpatient Diagnostic X-Ray and Laboratory Expense Benefit.
Does TeamCare cover vaccines?
Yes, TeamCare covers most vaccines including the Rotavirus vaccine for children under age 26, and Gardasil for children between ages 9 and 25. There is no deductible for the Well Child Exam or immunizations for children. TeamCare does not, however, cover required immunizations for international travel. Contact TeamCare for a full list of covered vaccinations.
My doctor said I will be unable to work for six weeks. My next appointment is in six weeks, so why do I need to complete another form before then?
To qualify for continued Short-Term Disability, TeamCare requires you to be following a treatment plan prescribed by a physician. Depending on the type of disability, you may be required to submit additional documentation to support your claims. For a walkthrough on how to apply for short-term disability benefits, please visit “How to file for short-term disability."
I received the maximum benefits under my Short-Term Disability Benefit. However, I am still disabled. Are there any other benefits available to me?
Although the Short-Term Disability Benefit only provides you a weekly payment for a set number of weeks (see Plan Benefit Profile), you may be entitled for continued medical coverage for the illness that is specifically disabling you from work.Under the Extended Benefit and Extended Major Medical Benefit, you can receive medical benefits for yourself, but not your family, after your Short-Term Disability Benefit ends if you meet certain conditions. You will need to apply for this benefit, and eligibility information regarding Extended Benefits can be found under your Summary Plan Description in My Documents on your Member Dashboard.
What happens if I am disabled again after I return to work?
If your second disability is related to your first disability, you must return to active employment and work for 30 consecutive calendar days — with no break — before you can begin a new Short-Term Disability period. If your second disability is not related to your first disability, you must return to active employment and work at least one day to qualify for a new Short-Term Disability period.
Can my Short-Term Disability check be deposited directly into my bank account?
No. TeamCare does not offer direct deposit of Short-Term Disability Benefit checks.
Is my doctor allowed to charge me a fee to complete my Short-Term Disability Form?
Yes. While many doctors include this fee with their office visit charge, they can bill you separately for completing the form. Additional questions should be discussed with your doctor’s office as TeamCare does not oversee physician billing for administrative services.
Can I qualify for Short-Term Disability Benefits if I am compensated for vacation, sick, or personal days?
No. Short-Term Disability Benefits begin after the last day compensated.
How many weeks of Short-Term Disability will I receive when I deliver my baby?
The length of your disability will depend on your physician’s recommendation and your situation. A normal vaginal delivery typically allows you six weeks of Short-Term Disability. In the case of a C-Section you are typically allowed eight weeks. If you have complications either pre or post-delivery, we will need documentation from your doctor to approve additional Short-Term Disability Benefits.
Are my dependents eligible for Short-Term Disability?
No. Short-Term Disability is a member-only benefit.
Am I entitled to health benefits while on Short-Term Disability?
Some plans offer continued health benefits while you are on Short-Term Disability. Refer to your Plan Benefit Profile in the My Documents section of your Member Dashboard for details. If your Plan does not include health benefits, you and your family may qualify for COBRA coverage or you may qualify for an extension of benefits.
What happens if I don't respond to TeamCare's correspondence about my accident?
It is very important that you respond to all correspondence from TeamCare. Failure to cooperate and respond to TeamCare may place your benefit payments in jeopardy. After an accident, TeamCare may postpone benefit payments until you respond to all of our subrogation-related requests.
Can I receive monetary recovery from my accident without letting TeamCare know?
If you receive monetary recovery without TeamCare's prior approval, we may decline future benefit payments for you until TeamCare's subrogation share is reimbursed.
Family Protection Benefit
What do I have to do to qualify for the Family Protection Benefit?
To qualify, families must utilize in-network TeamCare medical providers and facilities for all non-emergency medical care during the two-year period before a member’s death.
Are the health benefits different under the Family Protection Benefit?
No, covered dependents will remain under the same TeamCare plan in place prior to your death.
How are out-of-network benefits paid under the Family Protection Benefit?
Benefits under the Family Protection Benefit are only payable for services rendered by in-network medical providers except for emergency situations. No benefits are payable to out-of-network medical providers except in emergency situations. This applies to medical benefits only. For non-medical providers such as dental and vision, your family may receive care from an in-network or out-of-network provider at their option.
Does my spouse qualify for coverage if covered under another plan or if they remarry?
No, spouses or dependents who are covered under another plan (including Medicare) would not qualify for the Family Protection Benefit since it is designed to provide coverage for those without health benefits, due to the death of our member. Additionally, coverage would end for your spouse upon remarriage. However, if your spouse remarries, TeamCare would still continue to cover eligible dependent children if they are not covered under another plan.
Could coverage extend beyond age 26 for my children since it is a 5-year benefit?
Coverage under the Family Protection Benefit will end on whichever date comes first: 5 years from the members’ death or the child’s 26th birthday.