Sewanee Benefits

Medical & Pharmacy

Medical and pharmacy coverage work together to support both routine care and larger health needs. This page is here to help you understand what your coverage includes, how it works, where to go next, and what to do when something becomes more complicated.

Start here

Not sure where to begin? Start with the option that best matches what you need right now.

What’s included

Medical Coverage

Sewanee offers three medical plan options to help employees choose the balance of paycheck cost and out-of-pocket cost that fits them and their families best.

Prescription Coverage

Prescription coverage is part of your health benefit, but is administered separately. That means your medical and pharmacy coverage work together, even though some questions, tools, and ID cards may be handled by different partners.

Preventive Care

Preventive care is meant to help you stay healthy and catch concerns early. In-network preventive care is often covered differently than diagnostic care, so it helps to understand the difference before your visit.

Telehealth, Network Access, and Ongoing Support

Your benefit also includes tools to help you find care, use telehealth, manage prescriptions, and navigate larger needs such as imaging, specialty medications, chronic conditions, prior authorization, and billing questions.

How it works

Paycheck Deduction
This is the amount that comes out of your paycheck for coverage.
Deductible
This is the amount you may need to pay before the plan starts sharing certain costs.
Copay
A copay is a fixed amount you pay for certain services, such as office visits or prescriptions, depending on the plan.
Coinsurance
Coinsurance is your share of the cost after the plan begins paying a portion.
Out-of-Pocket Maximum
This is the most you pay for covered services in a plan year before the plan pays more fully, subject to plan rules.
In-Network
Using in-network providers and pharmacies usually lowers your cost and simplifies claims processing.
Formulary
A formulary is the plan’s list of covered drugs and the level at which they are covered.
Prior Authorization
Some services and medications need approval before they are covered. It is worth confirming this before care whenever possible.
Step Therapy
Some drugs require you to try another appropriate medication first before a higher-cost medication will be covered.
Specialty Medication
These are often higher-cost medications that may require special handling, special pharmacies, and additional review.

Compare the medical plans

HSA-Eligible Plan

This option is often the best fit for employees who want a lower paycheck deduction and the ability to save pre-tax dollars in a Health Savings Account.

Good fit if: you want a lower paycheck cost, want to contribute to an HSA, and are comfortable with a deductible-first structure.
Base PPO

This option is often a middle ground for employees who want some predictable copays while keeping paycheck cost more moderate.

Good fit if: you want balance between paycheck cost and what you pay when you use care.
Buy-Up PPO

This option is often the best fit for employees who expect to use more care and would rather pay more through payroll in exchange for lower cost when receiving services.

Good fit if: you expect more medical use and want lower out-of-pocket exposure when care is needed.

Before you…

Before you receive care
Confirm the provider or facility is in-network.
Ask whether prior authorization is required.
Ask for an estimate if the service may be high-cost.
Confirm whether imaging, surgery, infusion drugs, or hospital-based care needs additional review.
Contact Benefits if you are not sure where to start.
Before you fill a prescription
Check whether the medication is covered.
Review the formulary tier.
Confirm whether prior authorization or step therapy applies.
Ask whether a lower-cost alternative is available.
Compare retail, mail order, and specialty options when relevant.
Before you pay a bill
Wait for your Explanation of Benefits (EOB).
Compare the EOB to the provider bill.
Make sure the claim processed correctly.
Call the provider or carrier before paying if something looks wrong.
Keep notes, dates, and names if you are resolving an issue.

Common questions

Click a section below to view common questions and next steps.

Getting started
Start here if you need the basics
How do I know which medical plan I enrolled in?
Start with Employee Navigator or your enrollment confirmation. You can also check your BCBST account or contact the Benefits team if you are unsure.
Where do I get my medical ID card?
Start with your BCBST member portal. You can print or order a physical ID or download a digital ID for use before the card arrives.
Where do I get my pharmacy ID card?
Start with your MedImpact member portal. You can print or order a physical ID or download a digital ID for use before the card arrives.
Do I need separate ID cards for medical and pharmacy?
Yes. Medical and pharmacy benefits work together, but are administered separately.
What if I never received my ID card?
Contact the Benefits team.
How do I find an in-network doctor or facility?
Use BCBST's provider search tool and confirm both the provider and the facility before you schedule care.
What is the difference between medical coverage and pharmacy coverage?
Medical coverage usually handles office visits, imaging, hospital care, and other services. Pharmacy coverage handles prescriptions, though some medications may process under medical instead.
Choosing and using care
Start here if you are trying to use care wisely
I need a primary care doctor. What should I do?
Use BCBST's provider search tool to identify in-network doctors who are accepting new patients, then call the office directly to confirm availability.
I need a specialist. Do I need a referral?
No; however, even when a referral is not required, it is still smart to confirm the specialist is in-network and that any needed authorization is in place.
When should I use primary care, urgent care, telehealth, or the emergency room?
Primary care is usually the best place to start for routine needs. Urgent care and telehealth can be good options for many non-emergency concerns. Emergency rooms are generally best for true emergencies.
How do I use telehealth?
To use telehealth, register for Teladoc Health through your BCBST member portal and have your member ID card ready when you set up your account. Once registered, you can talk with a doctor by phone or video any time for non-emergency care through the BCBST app, the Teladoc website, or by calling 1-800-TELADOC.
How do I know if a visit is preventive or diagnostic?
Preventive care is generally routine care intended to help prevent illness or catch concerns early. Diagnostic care usually means a symptom, condition, or concern is being evaluated.
Why was my annual visit billed differently than I expected?
If other concerns were addressed during the visit beyond routine preventive care, part of the visit may have processed differently.
How do I price shop before scheduling care?
Confirm the provider is in-network, ask for an estimate, and compare the cost at different locations. Where you access care can make a significant difference.
Why can the same service cost more at a hospital than at a physician office?
The same service can cost more in a hospital-based setting because hospitals often bill not only for the professional service itself, but also for the facility, staffing, equipment, and overhead tied to that location. That means a routine visit, imaging service, or outpatient procedure may cost more at a hospital outpatient department than at an independent physician office or freestanding center, even when the care looks very similar to you. When it is appropriate, asking where the service will be performed and whether there is a lower-cost setting can help you avoid unnecessary expense.
Advanced imaging and higher-cost services
Start here if a larger service has been ordered
My provider wants me to get advanced imaging done. What do I do next?
Before scheduling, confirm the imaging center is in-network, ask whether prior authorization is required, ask who is submitting that authorization, and request an estimate if the service may be high-cost.
How do I know if an MRI, CT, PET scan, or other imaging requires prior authorization?
All advanced imaging outside of an emergency setting requires prior authorization. High-cost imaging may have additional review requirements.
Who is responsible for prior authorization for imaging?
Usually the ordering provider or facility submits the request, but you should not assume. Ask directly who is handling it and how you can confirm approval.
How do I confirm the imaging center is in-network?
Use the provider search tool and then confirm with the facility directly. It is wise to verify the exact location, not just the provider name.
Can the same imaging cost very different amounts at different places?
Yes. Independent imaging centers and hospital-based locations can have very different prices for the same service.
What should I ask before scheduling advanced imaging?
Before scheduling, confirm the imaging center is in-network, ask whether prior authorization is required, and make sure you know who is responsible for submitting it. It is also wise to ask for a cost estimate in advance, because advanced imaging can be expensive and costs can vary widely by location. If you have options, ask whether the same scan can be done at a lower-cost independent imaging center rather than a hospital-based location. Many imaging centers will also work with you on pricing or may match a competitor’s cash price, so it is worth asking before you schedule.
What if the imaging authorization is denied?
Ask your provider what the reason was, whether more clinical information can be submitted, and whether an appeal or peer-to-peer review makes sense. If you are unsure where to start, contact Benefits.
Chronic condition diagnosis and ongoing care
Start here if care will be ongoing
I was just diagnosed with a chronic condition. Where do I start?
Start by understanding your treatment plan, your providers, your medications, and which parts of care may need authorization. A simple written record can make everything easier to manage.
How do I understand what my plan will cover for ongoing treatment?
Look at specialist visits, labs, imaging, prescriptions, and supplies together. Then think about where you are relative to the deductible and out-of-pocket maximum.
How do I coordinate care across visits, labs, imaging, and prescriptions?
Keep track of what has been ordered, who is handling authorizations, where services are being scheduled, and which medications are being prescribed. Even a simple note on your phone can help.
How do I estimate what recurring care may cost me this year?
Think about visits, testing, imaging, prescriptions, and equipment as a whole. If you expect ongoing care, total annual cost usually matters more than just paycheck cost.
What if I need durable medical equipment or supplies?
Ask whether the supplier is in-network, whether prior authorization applies, and what documentation is needed from your provider before anything is ordered.
When should I contact the Benefits team for help navigating ongoing care?
Contact Benefits when you are not sure which partner handles what, when approvals or claims are getting tangled, or when costs are becoming hard to interpret.
Prescriptions, formulary, mail order, and specialty drugs
Start here if you are filling or managing a prescription
My provider prescribed a new medication. What should I do before I fill it?
Check whether the drug is covered, review the formulary tier, see whether prior authorization or step therapy applies, and ask whether a lower-cost alternative may be available.
How do I review whether a drug is covered?
Use the formulary or covered drug list through MedImpact. It's the fastest way to confirm whether the medication is covered and at what level.
What do the drug tiers mean?
Drugs are often grouped by cost and coverage level, such as generic, preferred brand, non-preferred brand, and specialty. Your cost may vary based on the tier.
How do I estimate what I will pay for a medication?
Check the tier, ask whether there is a price tool, and compare retail, mail order, and specialty options if relevant.
How does mail order pharmacy work?
Mail order is often used for ongoing maintenance medications. It can sometimes improve convenience and may allow longer fills depending on the drug and plan rules.
How do I transfer a prescription to mail order?
Start with MedImpact. They can usually tell you whether a transfer is possible or whether your provider needs to send a new prescription.
What is a specialty medication?
Specialty medications are usually higher-cost drugs that may require special handling, a specialty pharmacy, prior authorization, or extra clinical review.
Where can specialty medications be filled?
Often through a designated specialty pharmacy. Do not assume any retail pharmacy can fill a specialty medication the same way.
What if my drug is very expensive?
Start by checking what tier the drug is on and whether there is a lower-cost covered option that may work for the same condition. Then confirm whether prior authorization or step therapy is affecting the cost, and contact MedImpact to walk you through any lower-cost options, including covered alternatives, preferred drugs, or ways to fill the prescription more affordably.
Prior authorization, step therapy, denials, and non-covered services
Start here if something needs approval or was denied
What is prior authorization?
Prior authorization means the plan wants certain services or medications reviewed and approved before they are covered.
How do I know if a service needs prior authorization?
Check the plan materials, ask the provider, and confirm with BCBST or MedImpact if needed. For larger services or high-cost care, it is usually worth asking early.
Who submits the prior authorization request?
Usually the provider or facility, though sometimes the pharmacy or specialty pharmacy may be involved for medications. Always ask who is handling it and how you can verify status.
What is step therapy?
Step therapy means the plan may require a clinically appropriate lower-cost medication to be tried first before covering another drug.
What if I already tried another medication before joining the plan?
Tell your provider. Previous treatment history may matter, and the provider may be able to submit supporting information if step therapy is being applied in a way that does not fit your situation.
What does “not covered” mean?
It can mean the service or drug is excluded, not medically necessary based on the information submitted, out-of-network in a way the plan will not cover, or subject to other plan rules.
What should I do first if something is denied?
Find out why it was denied, then ask whether more information can be submitted, whether an appeal is appropriate, or whether there is a covered alternative.
Who should I contact first if something is denied?
It depends on the issue. Start with BCBST for medical services, the MedImpact for prescriptions, and your provider if more clinical information may be needed. If you are unsure, the Benefits team can help you sort it out.
High-cost drugs, copay cards, and patient assistance
Start here if a medication cost feels too high
My medication is expensive. What should I do next?
Start by confirming the drug’s tier, whether a covered alternative exists, whether prior authorization or step therapy is affecting cost, and whether the pharmacy administrator can show lower-cost options.
What are manufacturer copay cards?
Copay cards are programs sponsored by some drug manufacturers that may reduce what eligible members pay for certain brand-name drugs.
What is patient assistance?
Patient assistance programs are separate support programs, often offered by manufacturers or foundations, that may help eligible people access costly medications.
Who can help me find copay cards or patient assistance?
Your provider’s office, the specialty pharmacy, and sometimes the drug manufacturer’s support program can help. The Benefits team can also help you review the options available.
What if I still cannot afford the medication after insurance?
Ask about lower-cost alternatives, covered options in a different tier, patient assistance, or ask the Benefits team to assist you in exploring other options the plan may provide.
Claims, EOBs, and bills
Start here if a bill or claim does not make sense
What is an EOB?
An Explanation of Benefits shows how a claim processed.
Why did I get both an EOB and a bill from the provider?
The EOB explains how the plan processed the claim. The provider bill is the provider’s request for payment. Review both together before paying.
How do I read my EOB?
Focus on the billed amount, allowed amount, what the plan paid, and what your responsibility is. If the provider bill does not line up, pause before paying.
Why are the billed amount and allowed amount different?
The billed amount is what the provider charged. The allowed amount is the amount recognized under the plan’s network agreement or claim rules.
What should I do before I pay a large bill?
Compare the bill to your EOB, make sure the claim processed correctly, and call the provider or carrier if something does not line up. Do not rush to pay if the bill looks wrong.
What if the provider billed me before insurance finished processing?
Ask the provider’s billing office whether the claim is still pending and whether they can place the account on hold until processing is complete.
What if the provider says I owe more than the EOB shows?
Ask the provider’s billing office to explain the charge and compare it to the EOB. If needed, call BCBST and keep notes on dates, names, and reference numbers.
What should I keep if I am disputing a bill?
Keep the EOB, the bill, dates of service, names of people you spoke with, phone numbers, and any reference numbers you received.
Emergencies, hospital stays, and major care
Start here if care was urgent or hospital-based
What should I do after an emergency room visit?
Save any paperwork you received, wait for the claim and EOB to process, and review follow-up care needs. If the bills seem unusual, compare them carefully before paying.
Why did I get multiple bills for one hospital visit?
It is common to receive separate bills from the hospital, physician, radiologist, anesthesiologist, or other providers involved in care.
What should I confirm before a scheduled surgery or procedure?
Confirm the surgeon and facility are in-network, ask whether prior authorization is approved, request an estimate, and ask whether any hospital-based providers may bill separately.
What if a hospital-based provider is out-of-network?
Ask the hospital or provider billing office for an explanation, review the EOB carefully, and contact the carrier if the bill appears inconsistent with emergency or facility-based protections.
Life events and coverage changes
Start here if coverage needs to change
When can I add or remove a dependent from coverage?
Most changes outside Open Enrollment require a qualifying life event and timely action. Review the life event checklist page and contact HR as soon as the change happens.
How soon do I need to report a life event?
Life events usually have a deadline for action. It is best to contact HR as soon as the event occurs rather than wait.
What happens if I lose other coverage?
Loss of other coverage is often a qualifying event, but it must be reported within the required time period. Contact HR promptly so you do not miss the window.
What if my child ages out of eligibility?
Review the eligibility rules and contact HR if you need help understanding timing and next steps for coverage changes.
What happens to my coverage while I am on leave or if I leave Sewanee?
Coverage treatment depends on the type of leave or employment change. Reach out to HR and Benefits early so you understand timing, costs, and any continuation options.

Who handles what?

Medical Carrier
Medical claims
Provider network
Medical ID cards
Coverage questions for medical services
Pharmacy Administrator
Prescription claims
Formulary coverage
Pharmacy ID cards
Mail order and pharmacy pricing
Provider or Facility
Clinical treatment decisions
Submitting authorizations
Coding and medical records
Estimates for care
Benefits Team
Help understanding your options
Guidance on where to start
Support when something is confusing
Escalation help when needed

Need help?

If you are not sure where to begin, or something about your care, prescription, authorization, or bill does not make sense, please reach out. It is often easier to sort things out early than after the fact.