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Quality health plans & benefits
Healthier living
Financial well-being
Intelligent solutions
Gwinnett County
Open Enrollment Benefits Review
Pre-65 Retirees
Effective January 1st, 2015
90.25.904.1 B (7/14)
Aetna: Who We Are
Quality health plans & benefits. Healthier living. Financial well-being. Intelligent solutions.
Membership facts:
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We serve 23.1 million medical members
We serve 15.3 million pharmacy members
Healthcare network facts:
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More than 1.1 million health care professionals
More than 655,000 primary care doctors and specialists
More than 5,400 hospitals
Products and programs facts:
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Wide range of insurance and employee benefits products
Programs and services to help control rising costs while
improving the quality of health care
Tools and information to help people make better-informed
decisions about their health care and financial well-being
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Benefit Plans Review
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Benefits Highlights
High-level overview of your plan designs, effective January 1st, 2015:
Benefit
Deductible (calendar year)
Coinsurance
Out-of-Pocket Limit (includes
the deductible)
Preventive Care
PCP / Specialist Office Visit
Emergency Room
Urgent Care
Ambulance
Silver Plan
Gold Plan
In-Network
Out-of-Network
In-Network
Out-of-Network
$1,800 Single
$3,600 Family
$3,600 Single
$7,200 Family
$1,300 Single
$2,600 Family
$2,600 Single
$5,400 Family
30%; after deductible
50%; after deductible
15%; after deductible
50%; after deductible
$3,750 Single
$7,500 Family
$7,500 Single
$15,000 Family
$2,000 Single
$4,000 Family
$4,000 Single
$8,000 Family
Covered at 100%
50%; after deductible
Covered at 100%
50%; after deductible
30%; after deductible
50%; after deductible
15%; after deductible
50%; after deductible
30%; after deductible (waived if admitted)
15%; after deductible (waived if admitted)
Inpatient / Outpatient Hospital
30%; after deductible
50%; after deductible
15%; after deductible
50%; after deductible
Diagnostic Lab & X-Ray
30%; after deductible
50%; after deductible
15%; after deductible
50%; after deductible
Pharmacy – Retail
- Tier 1 Generic
- Tier 2 Brand Formulary
- Tier 3 Brand Non-Formulary
30%; after deductible
30%; after deductible
30%; after deductible
15%; after deductible
15%; after deductible
15%; after deductible
Pharmacy – Mail Order
30%; after deductible
15%; after deductible
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Benefits Highlights
High-level overview of your plan designs, effective January 1st, 2015:
Benefit
Traditional Plan
In-Network
Out-of-Network
$1,300 Single
$2,600 Family
$2,600 Single
$5,200 Family
30%; after deductible
50%; after deductible
$3,500 Single
$7,000 Family
$7,000 Single
$14,000 Family
Preventive Care
Covered at 100%
50%; after deductible
PCP / Specialist Office Visit
$40 / $60 copay
50%; after deductible
Emergency Room
30%; after deductible (waived if admitted)
Deductible (calendar year)
Coinsurance
Out-of-Pocket Limit (includes
the deductible)
Inpatient / Outpatient Hospital
Pharmacy – Retail
- Tier 1 Generic
- Tier 2 Brand Formulary
- Tier 3 Brand Non-Formulary
Pharmacy – Mail Order
30%; after deductible
50%; after deductible
$15 copay
$45 copay
$70 copay
2x Retail copay
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Transition of Care
Benefit provisions to ease your transition to Aetna.
Medical Transition of Care
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If you are currently undergoing treatment for a diagnosed condition and your doctor is not
in the Aetna network, you can continue receiving treatment from the doctor at the innetwork benefit level.
This provision is available on a case-by-case basis and applies to active treatments such as –
pregnancy, transplants, chemotherapy or radiation therapy, terminal illness, surgery,
mental illness and substance abuse *Please let us know if you need a Medical Transition of
Care form.
Pharmacy Step Therapy – Transition of Care
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Requires that you try a therapeutically-equivalent, less expensive drug first,
before certain more expensive drugs on our Step Therapy list will be
covered
If you are currently on a prescription for a drug that is on our Step Therapy
list, we will automatically override Step Therapy, allowing you to fill your
prescription without any review for the first 90 days
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Value-Added Benefits
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Enhanced Disease Management
One-on-one nurse support and integrated virtual care provides you with help
in the way you want to receive it.
1:1 Nurse Support
Virtual Support
Get personalized support to
help plan and coordinate care
holistically
Get self-paced guidance from
online wellness and chronic
condition management programs
Navigate the health care system
and find the right resources
Receive timely alerts and
reminders for nurse-assigned
activities on the Personal Health
Record
Develop an individualized action plan to achieve meaningful
health goals
Learn tips to stay healthy and manage conditions
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Online Disease Management
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Provides support for wellness and managing several
chronic conditions including:
- Eat Healthier
- Be Tobacco Free
- Get Active
- Blood Pressure in Check
- Healthy Back
- Heart Healthy Cholesterol
- Sleep Well
- Living Well with Asthma
- Stress Less
- Health in a Hurry
- Weight Less
- Diabetes Life
Online
disease
management
program
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Complements work with a health coach, or can stand alone
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Provides highly-personalized, self-paced online coaching sessions
Tailored program plans specific to your unique needs including interactive tools and
resources
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Informed Health Line – 24/7 Nurse Line
24/7 toll-free access
to registered nurses
for health information:
1-800-556-1555
Access to online
health information
through award-winning
Healthwise ® Care
Management Solution
Personal follow-up
helps members better
manage their health
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Top 5 Reasons Members Call Informed Health
Line*
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5
Abdominal
pain
Fever
Back
problems
and
injuries
Respiratory
problems
What kind
of doctor
should I
see for…
*Healthwise ® Care Management Solution, 2011 data
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Aetna Pharmacy Advisor
Multiple counseling methods to help improve health outcomes
Pharmacy Advisor counseling
• Face-to-face and telephone counseling
with registered pharmacists
• Provides information about medicines
and how they work in your body
• Guidance to help you stay on track with
your prescription medicine
• Member outreach via:
o Educational brochures
o Reminder letters
Aetna Rx AutoFill
• Automatic order refills/renewals
through Aetna Rx Home Delivery
• Enroll online through www.aetna.com,
or by calling the customer service
number on the back of your ID card
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Adherence to Drug Therapy
Member Outreach Overview
~ 10 days after first fill
Welcome letter educates you
on medication, your condition
and the importance of
adherence
refill
First fill
Member experience may vary from
home delivery to retail.
~ 14 days before refill is due
~ 10 days past refill date
Members using Aetna Rx Home
Delivery®
• Refill reminder interactive voice
response (IVR) phone call or
• Refill reminder letter reminds
you that a refill is due
Member using Aetna Rx Home Delivery
• Off-therapy IVR phone call or letter
Members using retail pharmacies
• Off-therapy IVR call
Prescriber
• Off-therapy Fax
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Adherence to drug therapy addresses
conditions like:
Behavioral Health
Enlarged prostate
Diabetes
Heart Failure
High Cholesterol
High Blood Pressure
Osteoporosis
Parkinson's
Asthma
and more than 30 different drug classes
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Savings for Your Health and Wellness
Through the Aetna Discount Program, Aetna members get discounts
on millions of products and services in the following categories:
At home products
Natural products and services
(blood pressure monitors, clothing, toys)
Books
(acupuncture, chiropractic, online
medical consultations, health & wellness
products)
(books, DVDs, CDs, online videos, magazine
subscriptions)
Oral health care
Fitness
(water flossers, cavity-fighting and other
oral health care products)
(gym memberships, home fitness and
nutrition products, fitness plans)
Vision
Hearing
(eye exams, eye glasses, frames, contact
lenses, LASIK surgery)
(hearing exams, hearing aids, batteries)
LifeMart® shopping website
(travel, electronics, family care, home, auto,
wellness)
Weight management
(weight-loss programs and products,
diet and meal plans – Jenny Craig®,
Nutrisystem® and CalorieKing®
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ExtraCare Health Card
Save 20% on thousands of over-the-counter items
An easy way to save
• Welcome letter and two portable
ExtraCare Health Card key tags mail within
two to three weeks of January 1st, 2015
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Visit a CVS/pharmacy any time to activate
your discount, then save when you shop
at CVS/pharmacy retail stores or online at
www.cvs.com
• Items eligible for the discount include, but
are not limited to:
• Vitamins
• First-Aid supplies
• Baby care
• Remedies for allergies, cough and cold,
or heartburn and stomachache
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Online Tools & Resources
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Aetna Navigator – Your Secure Online Portal
http://www.aetna.com
Click to log in
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It’s Easy to Get Started
Once your health plan
is active, all you need
to do is sign up for
Aetna Navigator:
Step 1
Fill in your basic information
Step 2
Create a user name
and password
Step 3
Set your preferences
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Get the Care That’s Right for You
Use DocFind®, our provider
directory, to find a doctor,
hospital or other facility in the
Aetna network.
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DocFind
Search for your doctor online
Please select the following network:
Aetna Choice® POS II (Open Access)
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Explanation of Benefits (EOB)
You can view your EOB
for each claim to see:
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How much your health plan paid
How much you are expected to pay
How much has already been paid
How much you saved by staying
in network
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We Help You Take Care of You
Online Health Assessment
• Personalized summary of
your health status
• Work with a personal
wellness coach
Online wellness programs
‣ Create a personal wellness plan
‣ Lose weight, get in shape, eat
better, etc. — at your own pace
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Tools to Track Your Health
Personal
Health
Your
personalized
Record*History
helps you:
Health
Record
is
available
• always
View claims
dataso
you
can:health stats
• Track
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Review
youralerts
Get health
recent
Managecare
family’s
Track
healthimportant
info**
statswith
• health
Share info
• Share
info with
your doctor
your doctor
*If available as part of your health plan
**If family member is under 18 years of age or gives access to view their information
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Access Discount Programs
Save on products and
services that can help
improve your health
and well-being
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Access Discount Programs
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Aetna Mobile App
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Search for a doctor, dentist, hospital or pharmacy
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Use the Urgent Care Finder to quickly find urgent care
centers and walk-in clinics
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Secure member site:
• View your claims
• View your coverage and benefits
• View your Personal Health Record
• View your ID card information
• Contact us by phone or email
Also available on mobile web by typing "Aetna.com" into
the mobile web browser.
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iTriage® App
Search symptoms and find care
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Founded by 2 Emergency Room Physicians in 2008;
Acquired by Aetna in 2011
Comprehensive healthcare information in one app
Helps answers common consumer questions:
• “What could be wrong?”
• “Where should I go for treatment?”
Symptom-to-Provider™ Pathway
• Search symptoms
• Find possible causes
• Research diseases, procedures, tests, medications
• Decision support to find the closest and most
appropriate medical provider
• Connectivity leads to action
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Cost Information Tools
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Member Payment Estimator
in- and out-of-network cost estimates
• Real-time out-of-pocket estimates* for the most common medical, non-emergency
health care services, including those that may offer the biggest opportunity to save on
health care expenses and allow comparison shopping
• Lets you compare costs for physician office visits, surgical procedures, and diagnostic
tests and procedures at different doctors or facilities before you receive care
• Allows you to compare up to ten in-network providers or facilities at one time
• Estimates based on your actual benefits plan (including deductible, coinsurance, copays
and plan limits)
• Helps you understand the money they can save without compromising their quality of
care
*Estimated costs not available in all markets. The tool provides an estimate of what would be owed for a particular service based on the plan at that very point in
time. Actual costs may differ from an estimate if, for example, claims for other services are processed after the estimate is provided but before the claim for this
service is submitted. Or, if the doctor or facility performs a different service at the time of the visit. HMO members can only look up estimated costs for doctor and
outpatient facility services.
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Member Payment Estimator
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Member Payment Estimator - Landing Page
Provider
or medical
service is
selected via the
drop-down
menu
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Member Payment Estimator - Cost Estimate
– illustrative purposes only
Compare
providers
in-network,
up to ten at a
time plus view
how estimates
can vary
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Price-A-Drug
Cost and decision support information for prescription drugs
Click here, after you register and log in with your username and password
www.aetna.com
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Price-A-Drug
Cost and decision support information for prescription drugs
Members can
enter the drug
name to get
an estimate
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Price-A-Drug
Cost and decision-support information for prescription drugs
Select the
correct
Medication
and also view
generic alternative
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Price-A-Drug
Cost and decision-support information
for prescription drugs
Enter the
number
of times the
medication
is required
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Price-A-Drug
Cost and decision-support information for prescription drugs
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Estimated member
out-of-pocket costs
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Mail-order savings
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Drug information links
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Generic alternatives
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Thank you
Any questions??
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