If you retire from Duke, before reaching age 65 and you or a covered dependent are not eligible for Medicare, you will be able to continue your current health insurance plan as long as you are eligible to continue health insurance as a retiree.
You will remain on your current plan but will be switched to the Early Retiree group. Once you or a covered dependent reach age 65 or become Medicare eligible you will be switched over to the Duke Plus health plan.
For more information regarding the health plans available to you as an Early Retiree, a plan comparison chart and information on finding a provider, please click here.
Frequently Asked Questions
- Duke Basic
- DukeWELL Care Management
- Pharmacy Benefits
- Behavioral Health / Substance Abuse
If I am retired, may I enroll in a plan that I do not currently have?
No, if you are not currently enrolled in a Duke health or dental plan, you cannot add this coverage. Also, you are not eligible to participate in the Reimbursement Accounts.
I am an early retiree and I/my spouse just became eligible for Medicare because of disability. Do we have to sign up for Medicare?
Yes, when you are not actively employed and become eligible for Medicare due to age or disability, you are required by our plans to enroll in Medicare Part A and Part B and contact our office.
I am currently retired, will I be able to add a dependent to my health plan even if it is a Qualifying Event?
Only those family members currently covered will be eligible for continued coverage. However, if you have a marriage that occurs on or after January 1, 2020, you will have a onetime opportunity to add your spouse and any newly acquired stepchildren within 30 days of the marriage date. You will also have a onetime opportunity to add a new child within 30 days from the date of the birth, adoption, or placement for adoption.
I can't afford my medical coverage right now, can I drop it and add it back at a later time?
No. If you drop coverage, without going on another employer provided plan (as the subscriber) you will permanently lose eligibility for the retiree plans.
I am a retiree and I just got a job through another employer and will have coverage through them. Can I drop my Duke coverage?
Yes. The retiree may suspend health coverage and contributions at any time while employed and receiving benefits elsewhere*. If you drop coverage due to gaining coverage through another employer sponsored plan, you may suspend your Duke coverage, however, you must provide proof of other coverage in order to maintain your eligibility to come back to the Duke plans at a later date.
Coverage under another plan available to the individual as a retiree of another employer, through a spouse's health plan, or from service with the military does not count as an employee under another employer sponsored plan.
Does the inpatient hospital care co-pay apply to maternity?
Yes. You are required to pay the applicable inpatient co-pay. This co-pay is $450 per admission to a hospital within the Duke University Health System (Duke Hospital, Durham Regional, and Duke Raleigh Hospital) and $550 per admission for all other hospitals in-network. If your child requires admission, then an additional co-pay will be required for the newborn. Wake Med is considered in-network for only obstetrics and most pediatric admissions for Duke Select and Duke Basic.
If I get sick while I am traveling (in the U.S. or in a foreign country), what level of benefits am I eligible for and who do I need to call?
For emergencies, you should follow emergency medical care procedures, whether you are traveling in the U.S. or outside. Under Duke Select, Duke Basic, and Blue Care, any care received from a non-network provider is not covered except from an emergency room or Urgent Care center. Urgent Care facilities may require full payment up front and then you can file for reimbursement. Duke Options provides an additional choice for members who travel frequently. Under Duke Options you have access to an extended national and international network and this option also includes an out-of-network benefit. Unless pre-approved, care received out-of-network under Duke Options requires that you pay for this service and submit a claim form in order to be reimbursed.
What happens if I am enrolled in Duke Select, Duke Basic, or Blue Care and I do not choose a primary care physician (PCP)?
You are encouraged, but not required to select a PCP.
My current physician is listed as a primary care physician with a closed practice. Can I still choose him as my primary care physician?
A closed practice means that the physician is not accepting any new patients. However, if you are a current patient you may continue to see your current physician as your primary care physician.
Can I see a specialist without a referral?
Yes, all of the health plan choices allow you to see a network specialist without a referral.
Can I select an OB/GYN as my primary care physician?
An OB/GYN is considered a specialist. You should choose a physician in internal medicine, pediatrics (for your child), family practice and/or general practice as a primary care physician.
Will I have to file claims?
If you receive care within the network from any of our health plans, your provider will file claims for you. If you select Duke Options and receive care outside the network, you must pay for this service and also file a claim form. For urgent care received out-of-network, you may need to pay for this service out of pocket and file a claim for reimbursement.
My child will be graduating during the year. Will they continue to be eligible for health care coverage?
Due to National Health Care Reform, after your child turns 19, they are eligible for coverage until their 26th birthday.
My child is away at school. What do I do to ensure that he/she has health care coverage? Can I select a different health care plan for my child than I have for myself?
You and all of your dependents, including children away at school, must choose the same health care plan. Each plan offers different options for the college student:
Duke Select and Duke Basic are plans that are best used when the college student is in the Triangle area, as only a visit to the Emergency Room is covered outside this area. Follow-up care such as physical therapy or recommended scans or procedures must be done In-Network.
Blue Care is an appropriate plan for families with a college student in the State of North Carolina. The student can seek care through an In-Network provider in his/her college area.
Duke Options is the appropriate plan for families with a college student outside of the state. Blue Cross has both national and international networks through which the student can access care. You can call Blue Cross Blue Shield at 1-877-224-3305 or check the web site at www.bcbsnc.com or www.bluecares.com to identify network providers where your child attends school.
What if I have an eligible dependent who lives permanently outside my network area. Can I select a different health care option for them than I have for myself?
You and all of your dependents, including children living in another location, must choose the same health care plan. In this situation, you may want to choose Duke Options. Except for emergency care, there is no coverage for care received outside the local network under Duke Select, Duke Basic, and Blue Care; therefore, these may not be good options for you.
How do I find out if my provider is in the network?
You can access provider directories online for all of the Duke health plans by visiting Find a Network Provider. For Duke Select and Duke Basic, you can call toll-free 1-800-385-3636 or you may also contact Duke Consultation & Referral Center at 888-ASK-DUKE (888-275-3853). For Blue Care and Duke Options, you can call toll-free 1-877-224-3305 for additional assistance.
How does Duke Basic differ from Duke Select?
Duke Basic has higher co-pays than Duke Select ($25 co-pay for PCP visits and $60 for specialist). In addition, there is a combined annual $500 deductible per person ($1,500 family deductible) for an inpatient hospital admission, ambulance service, and outpatient surgery along with co-insurance amounts. The prescription drug benefit also has a $100 per person deductible before the co-pay structure begins. Participants under Duke Basic receive a Duke contribution for eligible health care expenses from $200-$600 depending on the type of coverage elected. Also, bariatric surgery and infertility services are not covered under this plan.
How do I determine if the Duke Basic health plan is the best choice for me?
Duke Basic has a very comprehensive array of benefits, but there is more cost-sharing under this plan than there is with Duke Select or Blue Care. Each individual must determine if he/she would rather have a low premium and risk higher co-payments should health services or prescription drugs be needed, or if you wish to pay a higher premium with lower out-of-pocket exposure. In addition, Duke Basic does not cover infertility or bariatric surgery.
Who administers the Duke Basic health plan?
Aetna administers both Duke Basic and Duke Select. Duke Basic also has the same network of providers as Duke Select.
What is the Duke contribution that is associated with the Duke Basic health plan?
All Duke Basic members will receive an annual taxable payment designed to help with the cost-sharing features of this plan. This payment made by Duke is based on the level of coverage selected: $200 for individual; $300 for employee/child; $400 for employee/children; $400 for employee/spouse or employee/same-sex spousal equivalent; and $600 for family.
What is DukeWELL Care Management?
DukeWELL provides supplemental care support services at no additional cost for beneficiaries of select healthcare plans, including Duke Select & Duke Basic. DukeWELL care managers work directly with patients to help with managing chronic illnesses and general health and wellness. Benefits can include $0 copays on generic medications, telehealth appointments with care managers, customized care plans, and access to resources and coaching for nutrition, fitness, stress management, and much more!
How can I enroll in DukeWELL Care Management services?
Visit DukeWELL.org and click on the self-referral link at the top of the hompage. You can also call the DukeWELL Referral Hub directly at 919-660-WELL (9355).
Who provides the authorization for the medications requiring prior approval?
Our pharmacy manager, Express Scripts consults with your provider for authorization of medications requiring prior approval.
How do I find out if the prescription drug that I am taking is on the Express Scripts formulary? If it is not on the formulary, what are my choices?
You can check to see if the prescription drug you take is on the formulary, by logging into the Express Scripts website or by calling 1-800-717-6575. If your prescription drug is not on the formulary, you can talk with your doctor to see if it would be appropriate to change to a drug that is on the formulary or to a generic in the same class. If you and your doctor agree that a change should be made, you will be required to pay the applicable co-payment (for generic drugs) or the applicable deductible and co-payment for brand formulary and non-formulary drugs.
Are injectibles, like insulin, covered under mail order?
Yes, injectible prescription drugs are covered under the mail order program with the proper written prescription.
Can I order drugs for Controlled Substances (e.g., attention deficit disorder) (Schedule II) from mail order? I am now required to present a prescription monthly for this drug.
The ability to receive controlled substances through the mail varies by state laws. You are not required to receive controlled substance prescriptions through mail order. If you choose to fill your prescriptions at the local pharmacy you will be charged the initial 90-day pricing structure. Even after 90 days you will not be charged 50% of the cost of the drug pricing, you will be charged the $10/40/$55 co-pay prices. However, if you fill your prescription through the Express Scripts mail order program you can obtain a 90-day supply and may allow you to save significantly over retail pricing for a brand drug.
Am I required to use the Express Scripts Mail Order program for my maintenance drugs?
No. You are not required to use the Express Scripts Mail Order program, however, you will have significant savings by using the Mail Order program.
I am enrolled in Duke Select, will I be subject to a deductible?
If you purchase your prescriptions through a retail pharmacy and are using either brand formulary or non-formulary drugs you will be subject to a $100 per person deductible, and then a co-pay will be applicable.
I take insulin and use other diabetic supplies. How much will I pay for these items?
Insulin and diabetic supplies are on the generic maintenance drug list. If you purchase them through a retail pharmacy you can get them for the generic co-pay of $10/month for the first 90 days, and then a co-pay of 50% of the cost of the drug (with a minimum of the cost of the drug and a maximum of $25) will apply. However, if you purchase these items through the Express Scripts Mail Order program your total out of pocket costs will be $20 for a 90-day supply.
Can I still see my dentist?
Yes, you can still continue to see any licensed dentist under our dental plans. There is a network of providers who have agreed to accept usual and customary (U&C) for covered services. You can visit www.ameritasgroup.com/duke and select the PPO-Nationwide network to find a network provider.
How do I become eligible for the additional $250 towards my annual maximum benefit in 2013?
If you were a dental plan member who had at least one visit in calendar year 2012 with less than $500 in claims expenses, you will have an additional $250 added to your annual maximum benefit in 2012. The accumulation will continue until the annual maximum has increased from $1,000 to $2,000 on Plan A, or from $750 to $1,750 on Plan B.
What is PAS and what benefit do I receive?
Personal Assistance Service (PAS) provides free short-term counseling with licensed professionals. These professionals offer assessment, short-term counseling and referrals to help resolve a range of personal, work and family problems. PAS services are free of charge to Duke Employees and their immediate family members (including retirees) for up to eight visits.
If I (or my dependents) need to be hospitalized for a behavioral health/chemical dependency admission, what should I do?
You, your behavioral health provider, or the hospital will need to contact Aetna (if your coverage is Duke Select or Duke Basic) or Blue Cross Blue Shield of NC (if your coverage is Blue Care or Duke Options) in order to receive benefits.
If I do not call prior to an inpatient behavioral health/chemical dependency admission, what will happen?
If the admission is an emergency and you are unable to call prior to the admission, you, your behavioral health provider, or the hospital should call as soon after the admission as possible, but at least within 48 hours.
Is residential treatment covered out of network?
No, only in-network residential treatment is covered.