New Preferred Drug List for WVCHIP members

The West Virginia Children’s Health Insurance Program is changing to a new Preferred Drug List (PDL), effective January 1, 2006. Due to rising drugs costs a new drug list was created by focusing more on generic use to contain costs. Adoption of this change is estimated to bring a total savings of more than $1 million to the program. Unlike the current PDL, non-preferred drugs will no longer be covered. After this January 1, 2006 effective date, if a provider chooses to prescribe a drug not listed on the formulary it will be a 100% retail cost to the patient. Co-payments for drugs on the new PDL will remain the same. Click here for the new preferred drug list. Questions concerning drugs covered by WVCHIP should be directed to Express Scripts, Inc. (ESI) at 1-877-256-4689.  Click here to see a copy of the letter mailed out to WV CHIP families.

Who can I call or where can I go to ask questions?

How long does my child’s coverage last?

Are there annual enrollment fees or deductibles?

Are there co-payments required for certain services and prescriptions?

What doctors and dentists are in my area?

How can I understand my child’s insurance card?

I lost my child’s insurance card, what do I do?

Do I need to renew my child’s coverage?

My income has changed. What do I do?

I have other insurance for my child through my job now. What do I do?

I just had a baby and I want to add him/her onto CHIP. How do I do this?

I moved. What do I need to do?

I am getting a bill because a claim is not being paid. Do I have to pay this?

My child is going to college this fall. Is he or she still covered?

Are there benefit limits under the WVCHIP Plan?

Are there benefit limits for some special services?

What do I need to do if my child needs medical services outside West Virginia?

Do I need to file claims for medical or prescription services?

Who do I contact about pre-certification or pre-authorization?

Who do I contact about drug interactions or drug comparisons?

What happens to CHIP coverage when a child moves out of state?

Q. Who can I call or where can I go to ask questions?

A. The toll-free helpline welcomes calls from members and non-members. Please call 1-877-982-2447. Customer service representatives are available 24 hours a day to take your call.

You can also go to the closest primary care center in your area. Staff at these sites can answer questions and help families complete applications. Click here to find a center near you.

Q. How long does my child’s coverage last?

A. Your child’s coverage lasts for 12 months, unless your child turns 19 or gets other health coverage (including Medicaid) during that time. Children are only eligible for CHIP through the end of the month they turn 19 (For example, if your child’s birthday falls on August 1, they are covered until August 31). If your child gets other insurance, please call the DHHR change center at 1-877-716-1212 to cancel your CHIP coverage.

Your child’s health coverage begins the first day of the month in which the application was approved.

Q. Are there annual enrollment fees or deductibles?

A. No.

Q. Are there co-payments required for certain services and prescriptions?

A. Yes. Click here for a list of co-payments.

Q. What doctors and dentists are in my area?

A. Providers do not have to a member of WVCHIP to provide services to a child who has health coverage through CHIP. They only need to accept the reimbursement amount or rate provided by CHIP. To ensure that a doctor or dentist accepts CHIP, you will need to contact their office directly.

Q. How can I understand my child’s insurance card?

A. Call Express Scripts (ESI) at 1-877-256-4689 for an explanation on any part of your child’s insurance card.

Q. I lost my child’s insurance card, what do I do?

A. Call Express Scripts (ESI) at 1-877-256-4689 to replace a lost card.

Q. Do I need to renew my child’s coverage?

A. Yes. CHIP will send you a reminder to renew and a request for current income information when your child’s year of coverage is almost over. Do not forget to renew at this time so that there is no break in your child’s coverage. If you do not get a reminder and an application, please call the WVCHIP toll-free helpline at 1-877-982-2447.

Q. My income has changed. What do I do?

A. You do not need to report income changes since your child's insurance is good for 12 months. After 12 months you will complete a renewal form and notify CHIP of any income changes at that time.

Q. I have other insurance for my child through my job now. What do I do?

A. Children covered by other insurance cannot also be covered by WVCHIP. Please call the DHHR change center at 1-877-716-1212 to report the new coverage. We can cancel your WVCHIP coverage the day before your new coverage starts so that your child does not go without coverage at any time.

Q. I just had a baby and I want to add him/her onto WVCHIP. How do I do this?

A. Please call the DHHR change center at 1-877-716-1212 to report the change in your family's number of household members.

Q. I moved. What do I need to do?

A. Please call the DHHR change center at 1-877-716-1212 to give us your new address and other contact information.

Q. I am getting a bill because a claim is not being paid. Do I have to pay this?

A. Please call WVCHIP’s third party administrator, Acordia National at 1-800-356-2392 to speak with someone about your claim.

Q. My child is going to college in the fall. Is he or she still covered?

A. Your child will only be covered by WVCHIP until he/she turns 19.

Q. Are there benefits limits under the WVCHIP Plan?

A. Yes. Having some limits on what the Plan can pay helps keep WVCHIP available to as many children in West Virginia as possible. The Plan has two major benefit limits on the amount of medical claims it can pay for each child. One is a lifetime limit and one is an annual limit for the benefit year starting January 1 and ending December 31.

Lifetime Limit: $1,000,000 per child
Annual Limit: $200,000 per child

Q. Are there benefit limits for some special services?

A. Yes.

Q. What do I need to do if my child needs medical service outside West Virginia?

A. You must call Acordia National at 1-800-356-2392 to get prior approval that the medical claim will be paid.

Q. Do I need to file claims for medical or prescription services?

A. Usually medical claims for a child covered by WVCHIP will be filed by the health provider. If you need to file a medical claim, use the WVCHIP medical claim form and mail the completed form and a copy of the itemized bill to:

Acordia National
PO Box 2451
Charleston, WV 25329-2451

If you get your child’s prescription filled at a pharmacy that participates with Express Scripts, Inc., your claim will be filed electronically for you by the Pharmacist. Most national drug stores and supermarket chains participate in the network. To find out if the pharmacy you use is a member of the network, you may call member services at 1-877-256-4689. If you are using a non-network pharmacy, you will have to pay for the full-cost of the prescription at the time it is purchased. To be fully reimbursed, you must submit a prescription claim form along with a receipt or itemized bill. The completed form should be mailed to:

Express Scripts, Inc.
PO Box 390873
Bloomington, MN 55439-0843

Q. Who do I contact about pre-certification or pre-authorizations?

A. Call Acordia National at 1-800-356-2392.

Q. Who do I contact about drug interactions or drug comparisons?

A. Call Express Scripts, Inc. at 1-800-824-0898

Q. What happens to WVCHIP coverage when a child moves out of state?

A. It is the parent’s responsibility to report this information to the DHHR change center at 1-877-716-1212. The child will lose coverage in this state and must reapply in their new state. Claims will not be paid for non-state residents. Click here for a list of other state programs.

For more information about benefits, click here for the summary benefit plan and WVCHIP's Notice of Privacy Practices.

WVCHIP Insurance Card

Your insurance card will come separately in the mail within a few weeks of receiving your welcome kit. It will look like one of the mock-ups shown below and you may want to check to see that the name is shown correctly.