FAQ

General | Enrollments | Coordination of Benefits | Coverage | Out-of-State and Emergency Care | Network Providers | Pharmacy Benefits |

General

General FAQ
Q. Where can I find which health plans are offered by GatorCare?

A. Information can be found at gatorcare.org.

Q. What is the effective date of my health coverage?

A. The effective date of coverage is determined by your employer. Please contact your Human Resources office for information.

Q. When do I need to make a decision regarding the selection of health plans?

A. Please contact your Human Resources office for information.

Q. How do I find out what I have to pay for my health plan coverage?

A. Please contact your Human Resources office for information.

Q. What is a calendar-year deductible (CYD) and benefit-year deductible (BYD)?

A. A calendar-year deductible (CYD) is the amount, when applicable, that must be satisfied by the member each calendar year before any payment will be made by the group health plan.  Similarly, a benefit-year deductible is the amount that must be satisfied by the member during the plan year, i.e. GatorGradCare benefit plan year is 8/16-8/15, before any payment will be made by the group health plan.

Q. What is a per-admission deductible?

A. A per-admission deductible is an amount, in addition to the CYD, that is paid by the member upon being admitted to the hospital.

Q. What is coinsurance?

A. Coinsurance is percentage share of health expenses paid by the member for covered services after the CYD is satisfied.

Q. What is balance billing?

A. Balance billing is the amount billed to and due from the member for services received outside of the network.

Q. Whom should I contact if I have questions on the health plans?

A. GatorCare is very fortunate to have two on-site representatives from Florida Blue, the medical administrator, available to respond to medical coverage questions. In Gainesville, please contact Kelly Maloney at (352) 594-3354 or Kelly.Maloney@bcbsfl.com; In Jacksonville, please contact Kelley Thomas at (904) 244-9130 or Kelley.Thomas@bcbsfl.com. Magellan Rx Management administers the pharmacy benefits and can be contacted at (800) 651-8921.

Q. I haven’t received my ID card. What should I do?

A. Members normally receive their GatorCare ID cards between one week prior to the effective date of coverage or immediately following the coverage effective date. It is important to ensure your home address is up to date. If you have not received your GatorCare ID card is immediately following the effective date of coverage, you can order an ID card directly from Florida Blue by logging on to www.FloridaBlue.com and signing in. Click on my account, and choose the ID Card Services. A temporary card also can be printed from this site. Members may also call Florida Blue customer service at 1-800-664-5295 or the on-site GatorCare representatives from Florida Blue (Jacksonville 904-244-9130 or Gainesville 352-594-3354). The health and prescription card are one card and members will not have a separate card for prescriptions.

FB CARD 2

Q. The GatorCare ID cards that I received are not in my dependent’s name. What do I need to do to request additional cards for my spouse and children?

A. GatorCare subscriber IDs include only the name of the contract holder (subscriber), but any family members enrolled are included in this membership. Providers can swipe the card to determine eligibility electronically or they will call Florida Blue for the information. Additional cards can be ordered, but each card will contain only the subscriber name. This does not present a problem for the membership. Providers verify active eligibility at point of service.

Q. During the past Open Enrollment Period, I added dependents to my health plan. Will I receive a new GatorCare ID card?

A. GatorCare subscribers who change plans will receive new GatorCare ID cards; if a member remains in the same plan and adds dependents, additional cards may be requested, and will have the subscriber’s name.

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Enrollments

Q. Whom should I contact regarding the enrollment process?

A. Please contact your Human Resources office for information. Human Resource contact information can be found on the Contact Us page.

Q. If I decide I want to change to another health plan offered through GatorCare, when can I make the change?

A. You may change to another health plan that your employer is offering during a future open enrollment period or when a qualifying event occurs. Open enrollment will be scheduled each year during the fall. Please contact your Human Resources office for more information.

Q. What is a “qualifying” event?

A. A qualifying event is either a “work” or “life” event that permits a change to your benefits during the plan year. Common qualifying events include, but are not limited to: marriage, birth of a child, divorce, adoption, change of employment status or the death of a covered dependent. You must notify your Human Resources office within 30 days of an event.

Q. Am I required to enroll into one of the health plans being offered?

A. Normally, employees have the option to enroll. Please contact your Human Resources office if you want to opt out; they may require proof of having alternative coverage.

Q. My dependent child is age 26. How long can he remain covered on a health plan through GatorCare?

A. GatorCare provides health coverage for dependent children to the end of the calendar year in which the child turns age 26.  Contact your Human Resources office to apply for health coverage for a disabled dependent over age 26.

Q. What do I do about health insurance upon my retirement?

A. Employees moving to a retiree status should contact their Human Resources office to discuss continuation of health coverage 60 days prior to retirement. If you are eligible to continue health coverage following retirement, you will be responsible for paying the premiums. Depending on your age at retirement, the coverage may be secondary to the Medicare Parts A and B. It will be necessary for you to coordinate your enrollment in Medicare Part B to coincide with your retirement date.

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Coordination of Benefits

Q. How do I know if my or my spouse’s insurance is primary?

A. If you are the employee, your GatorCare coverage is primary for you. Your spouse’s policy is primary for him/her and secondary for you provided you also are covered by your spouse’s policy. If you have children covered on both plans, except in the case of separation or divorce, the plan of the parent whose birthday excluding year of birth, falls earlier in the year, is the primary coverage. For more information on how your other coverage coordinates benefits, please contact that plan provider.

Q. How will GatorCare coordinate with my other health insurance?

A. GatorCare follows a standard Coordination of Benefits (COB) process. It is the member’s responsibility to inform Florida Blue of any duplication of benefits or other health plan coverage. When GatorCare is your primary health plan, covered services are reimbursed without regard to coverage under the other plan. When GatorCare is not your primary health plan, covered services are reimbursed based on what the other insurance did not pay only up to the Florida Blue allowed amount under their contracted rates with providers.  In the event the primary payer’s insurance exceeds the allowed amount, no payment will be made for such services.

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Coverage

Q. Are chiropractic services covered?

A. Yes, chiropractic care is a covered service with GatorCare. Florida Blue has partnered with American Specialty Health Group (ASH) for management of chiropractic services for the plans offered through GatorCare. Chiropractors who are participating in the ASH network are covered with specialist copays. Chiropractors who do not participate with the ASH network are considered to be Tier 3 providers and services are covered only on the Premium Plan and are subject to a calendar-year deductible and coinsurance and may balance bill the member for charges over the allowance. Chiropractic manipulations are limited to 26 per calendar-year.

Q. How is massage therapy covered?

A. Massage therapy is covered under the outpatient therapy benefits and reimbursed based on the participation of the rendering providers. Massage therapy must meet medical coverage guidelines to be covered. There is a 75-visit limit per benefit period; this includes cardiac, massage, occupation, physical and speech therapies.

Q. How is maternity covered?

A. You will be charged a specialist copay during the first OB visit to confirm your pregnancy.  Subsequent prenatal visits and the delivery services are billed by your physician after you deliver.  Those charges as well as the charges for your hospital services are subject to the calendar-year deductible and coinsurance of your plan. Benefits are determined by the plan you are enrolled in and the participating level of the physician and hospital.

Q. Do I need a referral to see a specialist?

A. No referral is needed on GatorCare plans to see a specialist, however, it is always a good practice to coordinate your care with your primary care provider.

Q. Will I have to meet three different calendar year deductibles if I use three different benefit tiers?

A. It is possible that you may have to meet the calendar year deductible (CYD) if you use three different benefit tiers on the Premium plan, or two different benefit tiers on the Prime Plus plan within the same year. However, any amount applied to your CYD on a higher tier also will be applied on the lower tiers. The amount applied to your CYD on a lower tier will not be applied to the higher tiers. For example, if you are covered on the Premium plan and received services from Tier 3 providers in the beginning of the year, any amount applied to your Tier 3 CYD also will apply to the Tier 2 and Tier 1 CYD, and any amount met at Tier 2 will apply to the Tier 1 CYD. This also is true on the Prime Plus plan. If you have met any or all of your Tier 1 CYD and then go to providers in Tier 2 or 3, nothing from the Tier 1 CYD will apply towards those tiers.

Q. What will it cost me to take my child to routine wellness visits?

A. Please refer to the Summary of Health Plan Benefit documents.

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Out-of-State and Emergency Care

Q. What happens if I am out of the state and need medical care?

A. As a GatorCare member, if you need emergency care for a life-threatening problem and you are travelling outside of Florida or internationally, you have access to an extensive network of Tier 2 providers through Florida Blue’s BlueCard program. Please see the Where to Go for Care document for help finding options when you travel.

Within the United States, you can take advantage of savings the local Blue Plan has negotiated with doctors and hospitals in the area.  For covered emergency care services received from a BlueCard PPO provider, you should not have to pay any amount above these negotiated rates.  Just follow these simple steps:

  1. Always carry your current GatorCare ID card.
  2. In a life-threatening emergency, go directly to any hospital.
  3. To find doctors and hospitals outside of Florida, call the BlueCard Customer Service Center at 1-800-810-BLUE(2583) or visit BCBS.com to access the Blue National doctor and Hospital Finder.
  4. If you are hospitalized, the hospital should cal Florida Blue for prior authorization at 1-800-955-5692, the number on the back of your GatorCare ID card – it is different from the number above.

Outside of the United States, you have access to covered emergency care services from doctors and hospitals in more than 200 countries and territories around the world through the BlueCard Worldwide Program.  Just follow these simple steps:

  1. Verify your international benefits by calling Florida Blue Customer Service at 1-800-664-5295 before leaving the United States.  Coverage may be different outside the country.
  2. Always carry your current GatorCare ID card.
  3. In a life-threatening emergency, go directly to any hospital.
  4. To find doctors and hospitals around the world, call the BlueCard Customer Service Center at 1-800-810-BLUE(2583) or call collect to 1-804-673-1177 24-hours a day, seven days a week.  An assistance coordinator, in conjunction with a medical professional, will help arrange a doctor’s appointment or hospitalization, if necessary.
  5. If you are hospitalized, you should call Florida Blue for prior authorization at 1-800-955-5692, the number on the back of your GatorCare ID card – it is different from the number above.
  6. Call the Blue Card Customer Service Center if you need inpatient care.  In most cases, you should not need to pay up front for inpatient care at participating hospitals, except for the usual out-of-pocket expenses.  The hospital should submit the claims on your behalf.
  7. You will need to pay up front for care received from a doctor and/or non-participating hospital.  Then, complete an international claim form and send it with the bill(s) to the BlueCard Worldwide Service Center address on the form – look online at BCBS.com/bluecardworldwide.

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Network Providers

Q. How do I know if my doctor is a Tier 1 GatorCare provider or a Network Blue provider?

A. The list of GatorCare Tier 1 providers is located on the GatorCare website, www.GatorCare.org as well as UF Health’s Bridge under Human Resources. The Tier 2 Blue Options provider directory can be accessed from the link located at www.gatorcare.org under the Network Provider tab. The list also can be accessed on www.FloridaBlue.com

Q. Which urgent care centers are considered Tier 1?

A.There are several GatorCare Tier 1 participating urgent care centers in Gainesville and Jacksonville and they are listed below. Additional Tier 1 urgent care centers throughout the state of Florida can be found in this listing.

Q. What if I need an urgent care center and I am outside of Florida?

A. A list of Network Blue – Tier 2 participating Urgent Care centers is available on the Florida Blue website. When searching in the Florida Blue online provider directory, please use “BlueOptions” to find providers that qualify for Tier 2 coverage under the GatorCare health plan.

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Pharmacy Benefits Frequently Asked Questions

Q. Whom do I call concerning my prescriptions?

A. Magellan Rx Management is the administrator for GatorCare’s pharmacy benefits. The GatorCare dedicated-toll-free- number is (800) 651-8921.

Q. The prescription plan has 5 tiers of coinsurance. How can I find out the tier for the medication being prescribed?

A. Magellan Rx Management has a look-up tool for our GatorCare members.  The tool is user friendly and offers useful and important information. After navigating to this page, enter the name of the drug on the left hand side. After several seconds, possible matches appear on the right side of the screen. The tier to which the drug is offered through the GatorCare formulary is found along with other alternative drugs and information. By clicking on the ‘find alternative drugs’ link, a member can determine if an alternative medication for the drug may be available on the formulary on a lower tier, reducing the member’s out-of-pocket expenses.

Q. How can I find out the expected cost for a prescription?

A. Members should establish an account on the MagellanRx portal.  Once the account has been set up, there is a “Price a Drug” function.  Members can also contact the GatorCare dedicated line at Magellan Rx Management at 1-800-651-8921. If the call is being made prior to the effective date of coverage, please advise the GatorCare customer representative that your policy is still not active, but you expect it to begin at a later date.

Q. What is a pharmacy deductible?

A. Beginning January 1, 2017, GatorCare members enrolled in the Prime, Prime Plus, Premium, Healthy Rewards HRA, and Options plans and beginning August 16, 2017, members enrolled in GatorGradCare will be required to satisfy a prescription drug deductible for purchases of all Tier 2-5 prescription drugs before the plan’s prescription benefits apply. The deductible amount is $100 per covered person, with a deductible cap of $400 per family. Each member will pay the deductible plus any applicable coinsurance, up to the cost of the drug. For drugs that cost less than $100, members will pay the cost of the drug, until the $100 prescription drug deductible is met. The deductible applies regardless of whether you purchase your prescription from a retail or mail order pharmacy. For more information, visit gatorcare.org/pharmacy.

Q. Are the Shands pharmacies considered in-network?

A. The Shands Pharmacies in Gainesville are in-network and offer GatorCare members a discount on prescriptions.

UF Health Pharmacy – Shands Cancer Hospital

1515 SW Archer Road Gainesville, FL 32608

Main Phone: 733-0890 Fax: (352) 733-1291

Hours: Monday – Friday: 8:30 a.m. – 7:00 p.m.

Located next to the Adult Emergency Department and behind the Opus Café in the UF Health Shands Cancer Hospital.

UF Health Pharmacy – Shands Hospital

1600 SW Archer Road Gainesville, FL 32608

Main Phone: (352) 265-0405 Fax: 265-0133

Hours: Monday – Friday: 7:00 a.m. – 7:00 p.m. Saturday, Sunday and holidays: 9:00 a.m. – 1:00 p.m.

Located next to the UF Health Shands Hospital Atrium behind Opus Café.

UF Health Pharmacy – Medical Plaza

2000 SW Archer Road Gainesville, FL 32608

Main Phone: (352) 265-8270 Fax: 265-8276

Hours: Monday – Friday: 8:30 a.m. – 5:00 p.m.

UF Health Pharmacy – Ayers Plaza Pharmacy

720 Southwest 2nd Avenue Gainesville, FL 32601

Main Phone: (352) 733-0090 Fax: 733-0098

Hours: Monday – Friday: 8:30 a.m. – 5:00 p.m.

Q. Are there other pharmacies that are considered in-network?

A. The Magellan Rx Management network includes more than 60,000 retail pharmacies. All major chains are included (Shands, Walgreens, CVS, Publix, Winn Dixie, Target, Kroger, etc.). Members can verify if a pharmacy is in-network on the Magellan website or by calling customer service at 800-651-8921.

Q. Am I required to use the Shands Gainesville Pharmacy?

A.All members are encouraged to use the Shands Pharmacies.  The Shands Pharmacies offer GatorCare members a discount when filling preferred medications.  In certain cases of specialty medications, GatorCare members from the Shands Healthcare organization may be required to fill specialty medications through the Shands Pharmacy. Magellan Rx Management should be contacted at (800) 651-8921 in the event a member has a question about pharmacies in the network.

Q. Am I required to use a mail-order service for my maintenance drugs?

A. Members are not required to use mail order service, but it is encouraged.  Members can fill their Tier 1, Tier 2, or Tier 4 maintenance medications at retail in a 90-day supply for the same mail order coinsurance if they choose. (Some restrictions apply to controlled medications.) *Note: Beginning 8/16/2017 for the GatorGradCare plan and 1/1/2018 for other plans, all Tier 1 and Tier 2 maintenance medications must be filled at a 90-day prescription, after filling up to two 30-day fills.

Q. How do I order 90-day mail order prescriptions?

A. All members, excepts the Shands Healthcare members in Gainesville, can order through Walgreens Mail Order at (800) 999-2655 or www.walgreens.com.  All members can also contact the Shands Medical Plaza Pharmacy at (888) 345-8270 or (352) 265-8270, and ask for a 90-day supply. Orders can either be picked up or delivered free of charge to the members’ address. Shands Healthcare employees and dependents are required to use the Shands pharmacies for mail order services.

Q. If I currently order 90-day prescriptions through my prior carrier, will the refills transfer? What do I need to do to get this done?

A. As long as there are refills available, and the medication is not a controlled substance, the prescription can be transferred from one pharmacy to another. In order to have remaining 90-day refills transferred to Walgreen’s Mail Order, non-UF Health Shands members may call (800) 999-2655 and a representative will assist in having the prescriptions transferred and filled; UF Health Shands members may contact the Shands Medical Plan Pharmacy at (888) 345-8270 or (352) 265-8270 and request assistance in having the prescriptions transferred and filled through the Shands Pharmacy.

Q. If my physician prescribes a medication that has a generic equivalent, will the plan allow me to have the prescription filled as written and not require me to accept the generic?

A. The pharmacy benefits permit a member to have the prescription filled as written, but the member is required to pay the brand copay plus the difference in cost between the brand and generic if you choose a brand product when a generic equivalent is available.

Q. If I am allergic to a generic or if my physician has determined that I cannot take a generic drug, what process must I follow to receive an exception?

A. To request an exception, an appeal with clinical documentation must be submitted to Magellan Rx Management.

Q. I am a new member. What is required to have a prescription filled or refilled at the pharmacy I’ve been using for years?

A. The GatorCare ID card includes pharmacy information. To have a prescription filled or refilled at retail pharmacies or through mail order, please provide your updated prescription information found on the ID card. This new information is required by the pharmacy; otherwise, your request to have a prescription filled will be rejected. Many pharmacies use SSN’s thinking that is a valid default, and in the case of GatorCare, it is not. The member must provide the new ID. For more information, please contact Magellan Rx Management at 1- 800-651-8921.

Q. I need to have a prescription filled and I do not have my new ID card. What should I do?

A. If you need a prescription filled and have not received your GatorCare ID card, please contact Florida Blue. There are two on-site representatives to assist you, or you can call the toll-free number.

  • Kelley Thomas – Florida Blue On-Site Representative in Jacksonville 904-244-9130
  • Kelly Maloney – Florida Blue On-site Representative in Gainesville 352-594-3354
  • Florida Blue GatorCare Customer Service – 1-800-664-5295
Q. What is the process to have a prescription filled that requires a prior authorization?

A. If a prior authorization is required for your medication, provide your prescriber with the prior authorization form located here or have them call 1-800-651-8921 to request your prior authorization as soon as possible. Magellan Rx Management will notify you and your prescriber if the prior authorization is approved or denied. If approved, your medication will be covered at the appropriate co-payment or coinsurance under your plan. If denied, you can either purchase the drug for the full price or discuss alternatives with your doctor.