You are not required to designate a PCP or obtain a referral to a specialist under COVA Care. You may visit any PCP or specialist in the Anthem network. A PCP is defined as a family or general practitioner, pediatrician, or internist. Select a PCP or specialist from the network using the Commonwealth of Virginia and The Local Choice Provider Directory. This directory is available from your Benefits Administrator, or you may view the directory at www.anthem.com/cova. The directory on the Web site is updated continuously. 

You may also call Anthem Member Services at 1-800-552-2682 to find out if a particular doctor participates in the Anthem network. You may want to confirm with the doctor's office that you will be accepted as a patient.

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Yes. While you no longer must designate a PCP or obtain a referral to a specialist, it is a good idea to have a primary doctor who coordinates your care and knows your medical history. You must seek care from physicians and facilities that are in the Virginia provider network or participate in the Anthem BlueCard PPO network outside the state (see question 4).  Employees and family members will pay the $25 PCP copayment when seeking care from a physician in the provider network who is in general or family practice, pediatrics or internal medicine. The $35 specialist copayment appliesto office visits at any other in-network provider. Unless you have separate out-of-network coverage, you have no benefits under the basic plan when using a non-participating provider except for emergency care.

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COVA Care includes the Anthem BlueCard PPO network, which allows you and your covered family members to use PPO network providers and facilities outside Virginia. To receive the highest level of benefits if you live or travel outside Virginia, you should receive care from providers who participate in a Blue Cross and Blue Shield company's BlueCard PPO network. Blue Cross Blue Shield PPO network providers who participate in the BlueCard PPO will accept your plan copayment or coinsurance instead of requiring full payment at the time of service. These providers or facilities will file your claim for you, and have agreed to accept the allowable charge established by their local Blue Cross and/or Blue Shield plan as payment in full for their services. If you go to a non-participating provider, the basic plan will pay for care only in an emergency. To find providers outside Virginia in the BlueCard PPO network, visit www.bcbs.com or call 1-800-810-BLUE (2583).

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An emergency is the sudden onset of a medical condition that manifests itself by symptoms of sufficient severity, including severe pain that without immediate medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine to result in: 

• serious jeopardy to the mental or physical health of the individual;
• danger of serious impairment of the individual’s body functions;
• serious dysfunction of any of the individual’s bodily organs; or
• in the case of a pregnant woman, serious jeopardy to the health of the fetus.

Action: Go to the nearest hospital or medical facility. Be sure to obtain Hospital Admission Review if admitted by calling Anthem at 1-800-242-7277.

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In addition to the Hospital Admission Review process, the COVA Care plan requires that selected services be reviewed to determine if they are medically necessary. Some examples of these services include:  elective ambulance services; non-routine dental and oral surgery services covered under your medical benefits; diabetic education; medical equipment, devices, appliances and supplies; spinal manipulations in conjunction with physical therapy; and morbid obesity treatment.

COVA Care recommends completing the medical necessity review process in advance of actually receiving services so that you will know beforehand whether or not the services meet the medical necessity criteria.  Services that do not meet the medical necessity criteria are not covered.  If you do not complete the medical necessity review process prior to receiving services, the review will be completed at the time the claim is processed.

For more information on medical necessity review, contact Anthem Member Services at or 1-800-552-2682.

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Routine wellness care is covered for children through age 6 and for children and adults age 7 and over. There is no deductible, copayment or coinsurance for the member to pay before the plan pays for routine wellness coverage. Routine well child care through age 6 covers at no cost office visits at specified intervals, immunizations, routine lab tests and x-rays at facilities and doctors’ offices. Routine well adult care age 7 and older includes a routine annual wellness check-up at no cost, as well as routine lab tests, immunizations and x-rays at facilities and doctors’ offices.

Preventive care benefits include for specified ages at no cost an annual gynecological exam or prostate exam, and the following services once per calendar year: a Pap test, mammography screening, prostate specific antigen (PSA) test and colorectal cancer screening.

See the COVA Care Member Handbook for more details.

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The COVA Care plan covers medical supplies, equipment and education for diabetes care for all diabetics. Your prescription drug benefit covers blood glucose test strips and home glucose meters at no deductible and 20 percent coinsurance. You pay the applicable drug tier copayment for insulin, syringes and lancets. Coverage for the following is included under medical services:

• Insulin pumps and associated supplies
• Lancet devices and calibrator solution;
• Outpatient self-management training and education performed in person; including medical nutrition therapy when provided by a certified, licensed or registered health care professional.

There is no charge for diabetic education. You pay 20% coinsurance for diabetic supplies and equipment after you have met your deductible, and the plan pays the remainder based on the allowable charge.

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This is a special treatment by which therapeutic agents are supplied to the patient through the vein or directly through the intestines. The most common use for this type of therapy is to supply medication directly into the bloodstream, or to deliver nutrients through a tube into the gastrointestinal tract. This is a covered medical service under your COVA Care plan.

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Your outpatient hospital copayment covers the charge by the facility for outpatient surgery and the emergency room.

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The COVA Care Basic plan does not include out-of-network coverage. You must elect the out-of-network option to have coverage for the services of facilities and providers outside of the medical or behavioral health networks that accept COVA Care. The out-of-network benefit is the in-network benefit less a 25 percent reduction in the allowable charge paid by the plan. You will also be responsible for any deductible or copayment that applies. Remember that if you elect the out-of-network option and use a non-network provider, you will be responsible for any amount charged by the provider that is more than the plan's allowable charge.

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Yes. ValueOptions, Inc. will administers  behavioral health services.  It is strongly recommended that COVA Care members obtain pre-authorization for mental health and substance abuse services. If an employee fails to obtain pre-authorization, but goes to a participating provider, ValueOptions will pay as long as the service is medically necessary. However, if pre-authorization is not obtained and care is sought at a non-participating provider, there will be no benefit.

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COVA Care members have only one individual or family (as appropriate) deductible to meet under the plan. Any covered service or supply for which the deductible is applied will accrue against that plan year requirement, whether it is medical (Anthem) or behavioral health (ValueOptions).

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Like the deductible, the out-of-pocket expense limit under COVA Care applies to applicable medical and behavioral health expenses.

• If you are the only one covered, or if you have Employee Plus One membership, the most each of you will pay out of your pocket is $1,500 per plan year for covered services. Once you have reached this amount, your expense for covered in-network services is $0. Remember, drug, dental, vision and hearing copayments, if covered, do not apply toward the out-of-pocket expense limit nor are they paid at 100 percent if the out-of-pocket limit is met.
• If three or more people are covered by the plan, the combined limit is $3,000. However, no family member will pay more than $1,500 toward the limit. Then your expenses for covered in-network services are $0.
• For those with the out-of-network option: Remember that out-of-network providers may bill for amounts above the plan's allowable charge, and payment is your responsibility.

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Dental benefits are administered by Delta Dental Plan of Virginia. The COVA Care basic plan pays up to $2000 per plan year for diagnostic, preventive and primary services once the plan year deductible is met ($50 single, $100 dual, $150 family). In addition, the Expanded Dental option provides complex restorative and orthodontic services. Expanded Dental also provides up to $2000 per member per lifetime for orthodontic coverage.

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The Expanded Dental option covers restorative and orthodontic services, with 50% coinsurance after the plan year deductible is met.  The services are in addition to the basic COVA Care dental benefits.  Complex restorative dental services include inlays, onlays, crowns, dentures, bridges and implants.  The plan will pay up to $2,000 per member each plan year for the preventive, diagnostic, primary and complex restorative dental services under this option. Orthodontic services are covered up to $2,000 per member per lifetime.

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The Out-of-Network option gives you access to providers who are not in the network, but the payment for covered services is generally reduced by 25 percent.  You are still responsible for any applicable deductible, copayment or coinsurance, and any balance above the allowable charge.  Payments for out-of-network claims are paid directly to you rather than to the provider.

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There is no waiting period for hearing benefits under the Vision, Hearing and Expanded Dental option. Hearing coverage includes an exam from a hearing specialist ($35 specialist copayment) and $1200 per member every 48 months for hearing aids and hearing aid related services.

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Yes. Vision coverage under the Vision, Hearing and Expanded Dental option provides a benefit every 24 months for an eye exam and lenses or eyeglass frames. You did not receive an additional 24 months when enrolling in the COVA Care plan with Vision, Hearing and Expanded Dental benefits.

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Stainless steel crowns are covered under the COVA Care Basic plan at 80 percent, once the plan year deductible is met.  These are considered temporary crowns, often used for children to protect against shifting due to missing teeth.  Coverage for permanent crowns is provided at 50 percent only under the Expanded Dental option.

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The Expanded Dental option may be added to COVA Care Basic coverage for an additional premium.

• The COVA Care Basic plan covers all Diagnostic & Preventive procedures (i.e. exams, cleanings, x-rays) at 100 percent. Basic Dental Care (i.e. fillings, extractions, root canals) is covered at 80 percent once the plan year deductible is met.  The plan pays up to $2,000 maximum per member each plan year for covered benefits.
• The Expanded Dental option covers everything the Basic plan covers, but in addition covers Major Dental Care (i.e. crowns, bridges, dentures) at 50 percent after the deductible is met and Orthodontics at 50 percent with no deductible.  The plan pays up to a $1,500 maximum per member each plan year for covered benefits.  The plan has a lifetime maximum of $2,000 per member for Orthodontics.

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Yes.  You can receive dental care from any licensed dentist.  However, you will receive the highest level of benefits by seeing a network provider. Remember that if you see a non-participating provider, you:

• May be required to pay for the entire bill in advance;
• May be required to complete claim forms and submit them to Delta Dental yourself; and
• May be balanced billed for the difference between the non-network dentist's charges and Delta Dental's payment for covered benefits.

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The COVA Care plan year (the period in which benefits are administered) runs from July 1 - June 30. There is a deductible each plan year under COVA Care of $200 per person, up to a maximum of $400 per family. This is the amount you must pay for certain covered services before the plan will pay. The deductible applies to medical equipment and supplies, diagnostic tests and lab services. It does not apply to wellness, preventive, dental or drug benefits.

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The maximum amount you pay out-of-pocket under COVA Care is $1,500 per person, up to $3,000 per family. Expenses that count toward the out-of-pocket limit include your annual deductible, copayments and coinsurance. Additional information on the out-of-pocket limit is available in your COVA Care Member Handbook.

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Medco Health Solutions administers the prescription drug program under COVA Care. Under the three-tier prescription drug program, medications are divided into categories, or tiers, based primarily on cost. The first tier is typically generic drugs; the second tier is typically lower to middle-cost brand name drugs and some generics; and the third tier is typically higher cost brand name drugs. You pay for your prescription drug based on the tier in which it falls.

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Yes. Each 34-day supply requires a copayment. You may pay multiple network retail pharmacy copayments to purchase more than a 34-day supply. You may also purchase up to a 90-day drug supply at less cost, only twice your retail copayment, through Medco By Mail (mail service) pharmacy. Under the three-tier drug program, there is no longer a specific copayment for purchasing a 35-to-90 day supply at a retail pharmacy.

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Many COVA Care plan members wish to have early refills of prescription drugs before going on vacation or out of the country. If you will be away from home for an extended period of time, participating retail pharmacies and the Medco by Mail pharmacy service can provide one early refill (up to a 34-day or 90-day supply, as appropriate) to accommodate your travel. However, for a more extended travel period, you should complete a Prescription Drug Refill Exception Request Form available on the Web or from your Benefits Administrator. Complete the form online, print and send the signed form by fax to (804) 371-0231 or mail it directly to the Department of Human Resource Management. Allow at least two weeks for processing your request. See the form for additional information.

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To find out what drugs are in the three tier categories, visit the Medco Web site at www.medco.com (also see the Medco Health link on this site under COVA Care, Contact the Plan Administrators). You may also contact Medco at 1-800-355-8279.

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Medco Health By Mail , which manages the Commonwealth's prescription drug mail order benefit, has developed special processes for the handling and shipping of some medications that are sensitive to temperature extremes. Medco has identified those medications that may lose potency when exposed to extreme temperatures. In Medco pharmacies, medications that are sensitive to heat are kept in refrigerated areas and when mailed, are placed in special insulated packages with gel packs designed to maintain the correct temperature. The packaging is designed to keep these prescriptions within the proper temperature range throughout the day of delivery. For medications that require a higher degree of special handling, Medco may also call you to arrange a convenient delivery time. For more information, visit the Medco Health Web site at www.medco.com.

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Some medications are covered by COVA Care only for certain uses or in certain quantities. Visit the Medco Web site link through the Open Enrollment section on the DHRM Web site at www.dhrm.virginia.gov to determine if the medication you are purchasing requires prior authorization. You, your doctor, or your retail pharmacist may call 1-800-753-2851 toll-free to initiate a coverage review. When you use the Medco By Mail Medco Health will call your doctor to start the coverage review process. Your doctor will receive a Coverage Management Review Fax Form to complete and return by fax to Medco. You and your doctor will receive a letter (usually within two business days of receiving necessary information) confirming whether or not coverage is approved. 

There are several reasons why a drug may require prior authorization, including:

• Patient safety - Some medications can be dangerous if prescribed or used incorrectly. While physicians are solely responsible for correctly prescribing medications, prior authorization is an additional step to help safeguard the health of members and ensure appropriate use of some medications.
• Limited uses -- Some drugs are FDA-approved for only a small number of situations. These drugs may be untested, dangerous or simply ineffective if used in ways not approved by the FDA. Prior authorization helps guard against the inappropriate use of these drugs.
• Price - Some drugs have an extraordinarily high cost. These drugs may require prior authorization to ensure that they are used only when necessary and only in appropriate amounts.

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Your physician, pharmacist or a Medco Member Services representative can tell you if a drug requires prior authorization. Be sure that your physician requests approval for drugs that require prior authorization directly from Medco on your behalf.

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Start by discussing your problem with a Member Services representative to gain an understanding of why your claim was not paid. Visit the Contact the Plan Administrators link for the telephone numbers of each administrator:  Anthem (medical benefits), Medco (prescription drugs), Delta Dental (dental benefits) or ValueOptions (behavioral health and the Employee Assistance Program). Should you decide further action is necessary, you may appeal the decision. The Member Services representative can help you start the appeal process. You must file your appeal within either 15 months of the date of service or 180 days from the date you were notified of the adverse benefit determination, whichever is later.

Appeals may  be sent to the administrators in writing or provided to a Member Services representative over the phone. Please include the following information:

• the patient's name, address and telephone number;
• your identification and group number (as shown on your identification card); and
• the name of the professional or facility that provided the service, including the date and description of the service provided and the charge.

If you disagree with the administrator's final decision and wish to appeal further, you may send your appeal in writing to the Director of the Department of Human Resource Management within 60 days of the decision. For more information about the appeal process, see your COVA Care Member Handbook.

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A summary of benefits begins on page 1 of your COVA Care Member Handbook.  There is also a copy of the summary on this site under the COVA Care Plan Summary of Benefits link.

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If you have questions about your health plan benefits, such as what is covered and not covered, or the status of a claim, call the individual administrators (see contact information under Contact the Plan Administrators). Member Services representatives are responsible for helping you with benefit and claims questions. Member Services cannot answer questions about eligibility.

If you have a question about eligibility, such as who you can enroll under your coverage, or qualifying mid-year events, contact your Benefits Administrator.

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Coordination of benefits applies only when you have coverage through other group health plans in addition to COVA Care. Since there is more than one plan, your benefits are coordinated between the plans.

You are required to notify Anthem that you are enrolled under another health plan(s). There are special rules that determine which plan will be responsible for the primary payment of claims. These rules are described in the COVA Care Member Handbook.

It is very important that you provide Anthem with complete information about any other health care coverage. This assures that your claims are paid correctly. If Anthem overpays benefits because it is discovered that you have other coverage, Anthem may recover the excess payment from you, the other insurance company, or any other organization as appropriate.

If you cover dependents under your plan, annually you will receive a postcard in the mail asking you to update information about the plans in which you are enrolled. Be sure to complete and return this card when you receive it. Claims will not be paid until you respond. Contact Anthem Member Services anytime you need to update information about your coverage under another plan. Call Anthem Member Services 1-800-552-2682.

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When an individual has more than one health plan, the benefits are coordinated among the plans. One plan is designated to pay benefits first (or primary) and the other(s), when benefits are payable, to pay second (or secondary). Here are examples of how the COVA care coordination of benefits (COB) would work for dental and for orthopedic medical services.

Example 1: Dental Crown

The primary carrier (ABC Health Care Plan) has a $50 deductible and pays 50% coinsurance for services. COVA Care has no dental deductible and pays 50% coinsurance.

Example 2: Orthopedic Surgeon for Broken Ankle

The primary carrier (ABC Health Care Plan) requires the member to pay a $30 copayment for services. The secondary carrier (Anthem) requires a $35 copayment.

If you are a Commonwealth of Virginia employee participating in the COVA Care health plan, your primary carrier for medical (or optional vision and hearing) benefits is Anthem. Your primary carrier for dental benefits is Delta Dental; for behavioral health, ValueOptions, and for prescription drugs, Medco. If your spouse is covering you under another health plan, his or her plan would be your secondary carrier. If you are the covered spouse of a State employee, and you are covered under your employer's plan, your employer's plan is the primary carrier and the individual administrator of the benefits under COVA Care is secondary. For additional information on how primary and secondary coverage is determined for dependent children, see page 51 of the COVA Care Member Handbook.

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There may be an advantage to coverage under two separate health plans if the secondary plan has a higher level of coverage or provides benefits not available under the primary health plan.

Example 1: Orthopedic Surgeon for Broken Ankle

The primary carrier (ABC Health Care Plan) requires the member to satisfy a $2,000 deductible before any claims are paid. The secondary carrier (Anthem) requires a $35 copayment.

Example 2: Dental Crown

The primary carrier (ABC Health Care Plan) does not provide coverage for crowns. The secondary carrier (Delta Dental) pays 50% coinsurance for crowns, not subject to a dental deductible.