Medical / Prescription Drugs
HOW THE PLANS WORK
Choosing the right medical plan is an important decision. When choosing which plan is best for you, consider the following:
WELLNESS
If you completed an annual preventive exam by October 31, 2024, you will NOT pay the non-wellness surcharge in 2024.
If you did not complete an annual preventive exam by this date, you will be assessed a non-wellness surcharge of $25 per month ($300 per year) in 2024. If your spouse did not complete an annual preventive exam by this date, you will be assessed an additional non-wellness surcharge of $25 per month ($300 per year). Surcharges are applied to medical premiums.
Preventive care is covered at 100% for KAG medical plan members, so this visit will be no cost to you!* If you need help finding a primary care doctor, call Anthem’s member service line on the back of your ID card.
The Benefits Department will receive a report to indicate who has completed the preventive exams in order to avoid being assessed the surcharges in the following year. All personal health information is completely confidential, and KAG will not receive any information regarding your visit other than the date it took place.
*Some services are generally not considered preventive if you get them as part of a visit to diagnose, monitor, or treat an illness or injury. Please be aware that you will be responsible for the cost of any non-preventive care services you receive at your preventive care exam based on your plan design.
Medical Plan Options
The Kenan Advantage Group, Inc. offers two medical plan options through Anthem.
Both plans offer in- and out-of-network benefits, providing you the freedom to choose any provider. However, you will pay less out of your pocket when you choose a network provider. Locate an Anthem network provider at anthem.com.
The table below summarizes the benefits of each medical plan. The coinsurance amounts listed reflect the amount you pay. Please refer to the official plan documents for additional information on coverage and exclusions.
Know where to go for care
Where you go for medical services can make a big difference in how much you pay and how long you wait to see a health care provider. Use the chart below to help you choose where to go for care.
AFFORDABLE CARE ACT INDIVIDUAL MANDATE
You and your family members may be required to have health insurance in 2024. Mandates and penalties vary by location. Learn more about the Affordable Care Act requirements at healthcare.gov.
SURGERY CENTERS OF EXCELLENCE
If you are enrolled in an Anthem medical plan through KAG, you have access to SurgeryPlus®—a comprehensive surgical program that provides a personalized concierge experience from dedicated Care Advocates and access to quality-centric health care through a network of credentialed surgeons.
Care Advocates will help you navigate the surgical process, including assistance scheduling appointments and reviewing and eliminating medical bills related to your care.
When you use SurgeryPlus for a covered procedure, you will pay significantly less out of your pocket.
- If you are enrolled in the Choice plan, all surgery costs will be waived.
- If you are enrolled in the Consumer plan, all surgery costs will be waived after you satisfy the IRS minimum deductible ($1,600 for individuals and $3,200 for families in 2024).
No fees will be collected up-front; instead, SurgeryPlus will conduct a reconciliation at year-end and notify you of any out-of-pocket expenses, if applicable.
Covered procedures include:
- Joint replacement/ revision
- Spine
- Bariatric
- Orthopedic
- Hernia
- Gallbladder
- Thyroid
- Gynecology
- Cardiac
- Ear, nose, and throat
- Gastroenterology
- Diagnostic and preventive colonoscopy
- Pain management
- Minor general
- Urology
To learn more, call 833-423-1001 or email kag@surgeryplus.com.
VIRTUAL PHYSICAL THERAPY
If you are enrolled in an Anthem medical plan through KAG, you and your covered dependents have access to Hinge Health, a virtual physical therapy program that helps prevent injury, reduce chronic pain, and helps eliminate the need for surgery in some cases. This resource is available to you AT NO COST.
With Hinge Health, you receive personalized care from a dedicated physical therapy team and the following tools:
- Meet one-on-one with a licensed doctor of physical therapy (DPT) and health coach to identify your needs from the comfort of home via text, phone, or email.
- Your DPT will create and adjust a custom care plan that includes guided 15-minute at-home sessions 3 times a week to help you reach your therapy goals, reduce chronic pain, and improve overall mobility.
- Utilize Hinge Health’s free wearable sensors for movement accuracy, tracking your progress, and live feedback during your exercises.
To enroll in Hinge Health, call 855-902-2777 or email hello@hingehealth.com.
Virtual Primary Care
You have access to virtual primary care services through the Sydney Health app. Save time and money by connecting 24/7 with a team of doctors for health issues, such as allergies, a cold, or the flu. A doctor can even order prescriptions, if needed.
Or, schedule an appointment for routine care such as preventive exams, prescription refills, and ongoing care for chronic conditions such as asthma and diabetes.
Download the Sydney Health app from the App Store or Google Play to get started.
BLUE DISTINCTION SPECIALTY CARE
The Blue Distinction Specialty Care program recognizes health care providers for their quality care and patient results.
- Blue Distinction Centers: Demonstrate quality care, treatment expertise, and better overall patient results.
- Blue Distinction Centers+: Demonstrate more affordable care in addition to quality care, treatment expertise, and better overall patient results.
Covered services include:
- Transplants
- Maternity care
- Cancer care
- Substance use treatment and recovery
Visit the Blue Distinction Center Finder to locate a Blue Distinction provider.
BREAST RECONSTRUCTION SURGERY
All of your medical plan options comply with the Women’s Health and Cancer Rights Act of 1998 by providing benefits for mastectomy-related services, including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy (including lymphedema).
Contact the Benefits Department at 800-675-1092 for more information.
PRESCRIPTION DRUG COVERAGE
If you are enrolled in one of the Anthem medical plans, you will automatically have prescription drug coverage through CVS Caremark.
You can utilize any of the 64,000 retail pharmacies that participate in the CVS Caremark network, including numerous chain and independent pharmacies. To check for participating pharmacies, submit mail order prescriptions, or request refills, visit caremark.com or call 888-202-1654.
CONSUMER PLAN
If you enroll in the Anthem Consumer Plan, you will pay the entire cost of your services and prescriptions, until you meet your deductible. Once you meet your deductible, you will pay 20% for all services and prescriptions until you meet your out-of-pocket maximum. Once you meet your out-of-pocket maximum, all services will be covered at 100%.
MAINTENANCE MEDICATIONS–90-DAY SUPPLY AND MAIL ORDER
The prescription plan requires the use of mail order after you have purchased more than two 30-day supplies of a prescription, which is classified as a maintenance medication. You can either use the mail order service or obtain your 90-day supply from any CVS pharmacy. To get started, take advantage of CVS Caremark’s Fast Start program. Contact CVS Caremark at 800-875-0867 and they will contact your doctor to obtain the 90-day prescription.
STEP THERAPY
The step therapy program is designed for members who take medications to treat ongoing health conditions such as arthritis and high blood pressure. Using lower-cost options, like generic alternatives, as the first step in treating your condition can help save you money.
STEP 1: This first step requires the use of a generic medication before Step 2 is considered. For many people, generic medications provide the same health benefits as brand-name medications, but at a lower cost.
STEP 2: If a Step 1 medication is not right for you, you may be moved to a brand-name medication. As always, treatment decisions rest solely with you and your doctor.
HELLO HEART
KAG has partnered with Hello Heart to give you access to a free heart health tracker. This benefit allows you to track blood pressure, cholesterol, medications, heart rate, and activity levels in one place—all from the privacy of your own phone. The Hello Heart app is easy to use, personalized, and fun!
Sign up for Hello Heart today by visiting join.helloheart.com/kag
PRUDENTRX PROGRAM
CVS Caremark has partnered with PrudentRx to make obtaining your specialty medications even more affordable. If you are enrolled in the Anthem Choice Plan, when you enroll in the PrudentRx Program, your out-of-pocket costs for covered specialty medications will be $0. If you are enrolled in the Anthem Consumer Plan, when you enroll in the PrudentRx Program, you will still be required to meet your deductible; however, once your deductible has been met, your out-of-pocket costs for covered specialty medications will be $0. Copays paid while enrolled in PrudentRx will not count toward your deductible.
If you currently take one or more specialty medications included in the PrudentRx Program Drug List, you will receive a welcome letter and phone call from PrudentRx that provides specific information about the program and how to enroll. You may opt out of this program at any time.
To enroll, contact CVS Caremark at 888-202-1654 or visit caremark.com.
ADVANCED CONTROL FORMULARY/ADVANCED CONTROL SPECIALTY FORMULARY
The Advanced Control Therapy program is designed to guide members and health care providers within select therapeutic categories of drugs.
If you are prescribed a non-preferred product, CVS Caremark will contact your doctor to request consideration of a drug list product or generic equivalent. An established evidence-based protocol must be met before a non-preferred drug will be covered. Please contact the CVS Caremark customer care team for assistance at 888-202-1654. The 2024 preferred formulary drug list is available on the KAG Roadmap.
The list contains the preferred formulary drugs along with the list of excluded drugs and the preferred option(s). The advanced control therapy program will require that you choose one of the preferred options or cover the entire cost of the excluded drug.
CVS CAREMARK SPECIALTY PHARMACY
Specialty medications include high-cost injectables and infused, oral, or inhaled drugs used to treat chronic diseases. To obtain specialty medications, you will first need prior authorization from CVS Caremark. Most specialty drugs will need to be obtained through the prescription plan and the CVS Caremark Specialty Pharmacy. The CVS Caremark Specialty Pharmacy provides personalized pharmacy care management services including:
- Access to an on-call pharmacist 24 hours a day, seven days per week.
- Coordination of care with you and your doctor.
- Convenient delivery directly to you or your doctor’s office.
- Medication and disease-specific education and counseling.
- Online support including disease-specific information and areas to submit questions to pharmacists and nurses.
For more information, visit caremark.com/manage-prescriptions/specialty.html or call CaremarkConnect at
800-237-2767 from 6:30 a.m.–8:00 p.m. (CST), Monday through Friday.