Insurance Benefits Plan
Montana University System
July 1, 2007 – June 30, 2008
• The Traditional Plans have been remodeled to:
Plan A - $400 Deductible
Plan B - $600 Deductible
• Plan A will have preferred hospitals. In Billings, the preferred hospital will be
St. Vincent Healthcare. Plan B will not have preferred hospitals.
• The premiums for these Plans have been restructured.
• ALL employees currently on a Traditional Plan MUST complete a new enrollment form.
• If you do NOT complete a new enrollment form, you will default to
Plan A - $400 Deductible as Employee Only.
• There are no major changes to the structure of the Managed Care Plans.
Anyone considering a managed care option should carefully research the plan’s network providers.
Going outside the network can have serious consequences.
• Children will be eligible for coverage on both the basic and premium Plans.
• Orthodontics coverage for children and adults will be available
July 1, 2007. There is a $1,500 per person lifetime maximum.
• Dental claims will be reimbursed on a schedule of benefits rather than a percentage model.
• The new Vision Plan provider is EyeMed.
– Eye exam every 12 months.
– Frames every 24 months.
– Corrective lenses or contacts every 12 months.
• The premium structure has changed with this Plan.
• Allegiance Benefit Plan Management will continue as the Traditional Plan Third Party Administrator
(TPA) for 3 more years (with two renewal options) starting July 1, 2007.
• There will be two newly-structured Traditional Plans, Plan A and Plan B, replacing the present $400
and $575 deductible plans.
• Plan A - $400 Deductible will have preferred provider hospitals (St. Vincent Healthcare in Billings, St.
Patrick Hospital in Missoula, ) with “steerage” provisions. An enrolled plan member will get a discount
on expenses and receive better benefits when they go to the preferred hospitals in these cities.
• Plan B - $600 Deductible will NOT have preferred hospitals. An enrolled plan member can go to any
hospital but the premium rates for coverage will be moderately higher.
• If you are currently enrolled in either of the Traditional $400 or $575 Deductible Plans, you must make
an active plan choice this year. Your previous medical election will NOT carry forward.
• If no specific election is made, you will default into the Traditional
Plan A - $400 Deductible with the Employee Only option.
• The plan is returning to the preferred provider service model to assure discounts when two or more
service providers of equal quality are available within a specific city.
• Plan A - $400 Deductible will “steer” you to St. Vincent Healthcare, Plan B - $600 Deductible will not.
You will pay less for the plan with “steerage”.
Managed Care Plans
• Our managed care TPAs will remain the same—New West, Blue Cross, Peak, and the Allegiance
Managed Care Plan. The Allegiance Managed Care Plan will be an available choice in all cities
(previously limited to Helena and Dillon).
• A list of providers for ALL networks is available online in the Benefit Quick Questions section on the
CHOICES website www.montana.edu/choices/.
• If you are currently in a Managed Care Plan, your choice WILL carry forward from last year.
Please pay close attention to the Managed Care network providers this year when making your medical plan
choices as some network members have changed.
• Delta Dental will be the new TPA for the dental benefit effective July 1, 2007. There will be no increase
in dental premium rates. Both the Premium Plan and Basic Plan will be available for dependent
• Plan members will have open access to providers (i.e., no network) and may visit any dentist worldwide.
• The dental plan will pay up to the amount established in the schedule of services. The benefit schedule
will be revised periodically to keep up with inflation.
• Some additional changes to understand:
– Dental choices can now be made every year - instead of every other year
– Adult and children orthodontic benefit - $1,500 lifetime per person
– New yearly benefit max (July 1 - June 30):
$1,500 Premium Plan
$750 Basic Plan per person
– Premium dental coverage now available for children and retirees
Scheduled Plan Design, Basic
(Partial sample of schedule
Maximum Allowable Charge (MAC 1) = 80th Percentile of Montana Standards)
Procedure Description MAC 1
Periodic Oral Examination $36
Comp Oral Evaluation - New/Established $62
Intra Oral - Complete Series $117
Bitewings - Four Films $52
Prophylaxis - Adult $72
Prophylaxis - Child $49
Topical Application of Fluoride - Child $21
Topical Application of Fluoride - Adult $22
Sealant - Per Tooth $38
Our Dental plan will be administered by Delta Dental as of July 1, 2007. Premium coverage for children,
retiree coverage, scheduled benefits and a new annual maximum per person are now included. You must
actively enroll yourself and your specific family members; if no specific election is made you will default to the
Basic Plan – employee only option.
• There are no changes to the current pharmacy benefit managers (PBMs), PharmaCare and Ridgeway
• The structure of current retail deductibles, retail co-insurance and mail order co-payments will remain
• The plan will introduce a new PharmaCare “ProtoCall” Specialty Drug Program for high-cost
medications for certain chronic illnesses (such as rheumatoid arthritis, hepatitis, transplant, MS,
oncology, Parkinson’s, HIV/AIDS, among others).
• With one phone call, affected plan members will enjoy these advantages:
– Free delivery of 30-day supply to home or doctor’s office
– No co-payment and no deductible for ProtoCall Specialty Drugs
– 24/7 access to trained specialists plus educational materials and home instruction
– Free supplies such as syringes and needles
• Our pharmacy plan will not change except for the addition of the “ProtoCall” Specialty Drug Program
for the purchase of specialty drugs at no cost to the member.
Prescription Drug Benefit
Note: All medical insurance choices have the same Prescription Drug Benefit administered by PharmaCare.
For pharmacy customer services, call 1-888-442-9780.
Network Pharmacy: Thru Mail Order Specialty
After a $100/person and/or PharmaCare or Pharmacy
$200/ Ridgeway ProtoCall Specialty
Family deductible, you pay: you pay: Drug Program, you
Generic: The greater of $10 or $20, 90-day supply
20%, 30-day supply
Brand Name Formulary: The $40, 90-day supply
greater of $20 or 30%, 30-day
Non-Formulary: The greater $60, 90-day supply
of $30 or 40%, 30-day supply
ProtoCall Specialty Drugs: Not Covered $0
The greater of $40 or 50%, 30-
The benefit year out-of-pocket maximum on pharmacy charges only (excluding deductible) is $800/person
There is no deductible or out-of-pocket maximum on mail order charges.
EyeMed will be the new Vision Provider effective July 1, 2007.
In Network and Out-of-Network Benefits available
• EyeMed network includes Pearle Vision, Sears, Shopko, among others. You can lookup EyeMed’s
current network of providers and/or nominate your provider at http://www.montana.edu/choices/.
• To participate in the optional vision benefit, you must actively enroll for the coming plan year - last
year’s election will not carry forward.
• The premium rates for the vision benefit will depend on which family members you choose to include.
You must actively enroll yourself and your specific family members. Last year’s vision benefit
election will not carry forward.
The enrollment requirement is due to the Vision Provider change and a new premium structure
for the vision benefit, effective July 1, 2007.
EyeMed Vision Care
Vision Care Services Member Cost
Exam with Dilation as
$10 Copay $45
Contact Lens Fit & Follow-
$20 copay, paid-in-full, fit and 2
Standard follow-up visits
$20 copay, 10% off retail price,
Premium then apply $35 allowance
Frames: Any available frame $125 allowance, 20% off balance
at provider location over $125 $47
Standard Plastic Lenses
Single Vision $20 Copay $45
Bifocal $20 Copay $55
Trifocal $20 Copay $65
Contact Lenses: Allowance
covers materials only $0 Copay, $125 Allowance, 15%
Conventional off balance over $125
$0 Copay, $125 Allowance, plus
Disposable balance over $125
Medically Necessary $0 Copay, Paid-in-Full
Plan Yr 7/1 -
Examination Once every 12 months
Plan Yr 7/1 -
Frame Once every 24 months
Lenses or Contact Lenses Once every 12 months
Plan Yr 7/1 -
MUS Benefits Plan Overview
• The eight campuses and community colleges of the MUS operate a
self-funded insurance plan by paying their own costs and setting the plan structure for its members.
• The Inter Unit Benefits Committee (IUBC) and the Director of Benefits, with help from our plan
consultant, Mercer Health and Benefits, manage the plan.
• We hire TPAs to do the claims work for us - essentially paying the claims from the MUS checkbook.
• This year EyeMed is the new vision provider. Delta Dental is the TPA for the dental benefit.
• The present TPA service provider for our Traditional Plans, Allegiance Benefit Plan Management, has
been selected to continue.
• Our Managed Care providers will remain the same: New West, Blue Cross, Peak, and Allegiance
Managed Care Plan.
• The State contribution for the next 2 plan-years will increase, but not at the same percentage as previous
– For 2007-2008, the projected increase is $33 raising the monthly contribution to $590, an
increase of only 5.9%.
– For 2008-2009, the increase is $36, raising the monthly contribution to $626, an increase of only
• Our plan’s medical, dental, and pharmacy claims costs have increased at a rate higher than the national
average. Provider discounts have been lower over the past few years, resulting in higher claims costs.
• These factors have been taken into account by the IUBC in selecting the next TPA for our indemnity
plan, selecting a new TPA for the dental plan, selecting a new provider for the vision benefits, and in
making other changes to our overall benefit structure.
• Ask yourself:
– How might the changes affect me and my family?
– Will my current benefit CHOICES still be right for me and my family in the upcoming year?
• Be prepared to actively enroll this year for:
– Either Plan A, Plan B, or a Managed Care Plan if you are currently in the Traditional $400 or
$575 Deductible Plan
– Dental benefit
– Optional vision benefit