Out of Area Benefits

At WVU, we know that there is no “one size fits all” option when it comes to health insurance. Benefits-eligible employees at WVU have several options to choose from. For benefits-eligible employees who reside outside of the state of West Virginia and bordering counties of surrounding states, PEIA PPB plans A, B, or C are the best options. PEIA PPB Plan D is available only to West Virginia residents, and The Health Plan options are limited to West Virginia and some counties in surrounding states. For more information on health insurance options at WVU, including premium information, visit the PEIA Shoppers Guide.

The PEIA PPB Plans provide care through several networks of providers, and the benefit level depends on whether the care is provided inside West Virginia and on whether the out-of-state care is approved in advance by UMR, if necessary. In West Virginia, any properly licensed health care provider who provides health care services or supplies to a PEIA participant is automatically considered a member of the PEIA network.

Outside West Virginia, PEIA uses the UnitedHealthcare Choice Plus PPO to provide care for members of PEIA PPB Plans A, B and C. To locate a network provider, use PEIA's Find a Healthcare Provider tool, call UMR at 1-888-440-7342, or visit UMR.com. Care provided outside West Virginia, even by network providers, costs more.

Outside West Virginia, even with the discount contracts PEIA has in place with network providers, PEIA cannot control its costs as it can inside West Virginia. Therefore, your out-of-pocket costs will likely be higher for out-of-state services. Please note that not all providers in the UnitedHealthcare Choice Plus PPO network may participate with PEIA. Kings Daughters Medical Center in Kentucky remains out-of-network for PEIA, regardless of their network status with the PPO network. Also, PEIA does not use the PPO network in Washington County, Ohio, (including Marietta Memorial Hospital) or Boyd County, Kentucky. PEIA reserves the right to remove providers from the network, so not all providers listed in the network may be available to you.

PEIA offers several health insurance plan options, some of which have defined “service areas”. These service areas define which plans are available to you based on where you live.

PEIA PPB plans A, B, and C do not have a defined service area and are options for benefits-eligible WVU employees regardless of where they reside.

PEIA PPB Plan D has a service area of West Virginia, so is only available to West Virginia residents.

The Health Plan HMO also has a service area of West Virginia, but also includes some counties in surrounding states. Check the PEIA Shoppers Guide for a detailed listing of the Health Plan HMO’s service area.

PEIA distinguishes between services rendered “out-of-state” and those rendered “in-state”. Out-of-state refers to services rendered outside of the state of West Virginia and bordering counties of surrounding states. For example, services rendered in Fayette County, Pennsylvania would be considered “in-state” and not “out-of-state”, as Fayette County is a bordering county in a surrounding state. Whether a service is rendered “in-state” or “out-of-state” may impact the level of coverage for the service.

The PEIA PPB Plans A, B & D require that certain services and/or types of services be reviewed to determine whether they are medically necessary and to evaluate the necessity for Complex Condition Care. Some services require “precertification,” and other services require “notification.” Precertification is performed to determine if the admission/service is medically necessary and appropriate based on the patient’s documented medical condition.

Your address on file with or recorded with PEIA will be used when determining out-of-area coverage approvals.

For PEIA PPB Plans A and B participants who reside outside the state of West Virginia (beyond the bordering counties of surrounding states), PEIA has made special arrangements. Participants who live more than one county outside the state may seek care from any network provider without obtaining prior approval. Care from network providers will be covered at the highest out-of-state benefit level.

For PEIA PPB Plan C participants who reside outside of West Virginia, (beyond the bordering counties of surrounding states), care from network providers does not require prior approval, and that care will be covered at the in-network benefit level (typically 80%). Precertification of inpatient stays and certain outpatient procedures is still required for PEIA PPB Plans A, B, and C. Visit the PEIA Summary Plan Descriptions for more information.

For PEIA participants who reside in WV or bordering counties of surrounding states, coverage and out-of-pocket costs will depend on whether the provider is in-network or out-of-network, and whether approval was obtained by the participant from UMR prior to receiving the service. Consult the PEIA Summary Plan Description for your plan for additional information on coverage levels and obtaining approval. PPB Plan participants traveling out-of-state have coverage for urgent and emergency care. In an emergency, seek treatment at the nearest facility that is able to provide the needed care, and that care will be paid at the in-network benefit level as an emergency. For non-emergency, urgent care, call UMR at at 888-440-7342 for a referral to a network provider, or for approval to see an out-of-network provider where you are.

Prescription drug coverage is included in all PEIA health insurance options. The prescription drug program is administered by Express Scripts. PEIA prescription drug benefits pay for a wide range of medications, with differing copayments and coverage depending on where you purchase those drugs, whether you purchase generic or brand-name drugs, and whether the drugs are on the WV Preferred Drug List. To get a prescription filled, simply present your medical/prescription drug ID card at a participating Express Scripts network pharmacy. Express Scripts also provides a convenient mail service pharmacy program for PEIA PPB Plan insureds. You may use the mail service pharmacy if you’re taking medication to treat an ongoing health condition, such as high blood pressure, asthma, or diabetes. The prescription drug program provides coverage for some drugs only if they are prescribed for certain uses and amounts, so those drugs require prior authorization for coverage. For more information on prescription out-of-pocket costs, prior authorization, and Express Scripts network, visit the PEIA Summary Plan Descriptions.

Out-of-area benefits are available to covered dependents who reside outside West Virginia beyond the bordering (contiguous) counties of surrounding states. If you have a dependent who lives more than one county outside of West Virginia, you must complete the Dependent Out of Area Benefits Form and return it to UMR annually to receive the highest level of out-of-state benefits for your chosen PPB Plan, without having to seek prior approval for all services. Services must be provided by UnitedHealthcare Choice Plus PPO network providers.

If you are new to the PEIA PPB Plan and have been receiving medical treatment from an out of state provider, you may be concerned that your care will be interrupted in your move to this Plan. To assist participants receiving treatment for serious medical conditions from out-of-state or out-of-network providers, PEIA has a Transition of Care (TOC) program. If you qualify for TOC, you can continue to receive medical treatment from a non-network provider during a transition period specified by UMR and be covered at the in-network benefit level. Following this transition period or after your treatment is complete your medical care must be provided by a network provider to be eligible for the higher in-network level of benefits. For more information about the Transition of Care program, visit the PEIA Summary Plan Description for your plan.

If you or a covered dependent incur medical expenses while outside the United States, you may be required to pay the provider yourself. Request an itemized bill from your provider and submit the bill along with a claim form to UMR or the prescription drug administrator. UMR or the prescription drug administrator will determine, through a local banking institution, the currency exchange rate and you will be reimbursed according to the terms of the plan you’re enrolled in.

Vacation supplies of prescription drugs are not covered unless leaving the country. If you are leaving the country and want PEIA to cover a vacation supply, you must submit documentation (copy of an airline ticket, travel agency itinerary, etc.) to substantiate your international travel arrangements. Please allow seven (7) days for processing.

Mountaineer Flexible Benefits, including dental, vision, hearing, and legal options, all utilize nationwide provider networks with no coverage level change for out-of-state care provided in-network.

Out of state undergraduate dependent children under age 26 may be eligible for up to the difference in in-state and out-of-state university tuition for a maximum of four years. Visit the WVU Dependent Scholarship page for additional eligibility details and application information, and note that in-state vs. out-of-state definitions for students differ from those of PEIA health insurance.

WVU retiree health benefits differ depending on whether the member is Medicare-eligible. Non-Medicare retiree health coverage follows the same out-of-area guidelines and restrictions noted above for active employee coverage. Medicare-eligible members enrolled in the PEIA Humana Medicare Advantage plan utilize the nationwide Humana network and benefit level does not vary based on state.

Medicare-eligible retirees who reside outside the United States will have benefits through PEIA’s Special Medicare Plan. Medicare claims will be processed by UMR, and PEIA will pay only the amount we would have paid if Medicare had processed your claim and made a payment. Prescription drug claims will be processed by Express Scripts.

Retiree Flexible Benefits, including dental, vision, hearing, and legal options, all utilize nationwide provider networks with no coverage level change for out-of-state care provided in-network.