Transcript Prescription Drug Benefits

Health Care Coverage for
You and Your Family!
Welcome
Agenda
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What’s new this year
Who is eligible to enroll
Plan options
Cost of health coverage
How to enroll
Enrollment support
Questions
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What’s New for 2007-2008?
• ActiveCare 1:
• Plan year deductible increased from $1,050 to $1,100 per
individual
• ActiveCare 2:
• $100 inpatient hospital copay per day ($500 maximum copay per
admission, $1,500 maximum copay per plan year)
• $100 outpatient surgery copay per visit
• $100 emergency room copay per visit (copay waived if admitted)
• Copays are in addition to deductible and coinsurance
• ActiveCare 3:
• No plan changes
• Premium increase (approximately 7%)
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Employees Eligible to Enroll
Active
contributing
TRS member?
If Yes
You may be eligible
If No
Regularly work
10 or more
hours per week?
If Yes
You may be eligible
If No
You are
not eligible
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Employees NOT Eligible to Enroll
• State of Texas employees or retirees
• Higher education employees or retirees
• Most TRS retirees, including those back at
work
• These individuals are not eligible to enroll for
TRS-ActiveCare coverage as employees, but
they can be covered as a dependent of an
eligible employee
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Eligible Dependents
• Spouse (including a common law spouse)
• Unmarried (including divorced) children under age 25
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Natural child
Adopted child
Stepchild
Foster child
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More Eligible Children
• An unmarried child under the legal guardianship of the
employee
• An unmarried child in a regular parent-child relationship
with the employee:
• The child's primary residence is the household of
the employee
• The employee provides at least 50% of the child's support
• Neither of the child's natural parents resides in that household
• The employee has the legal right to make decisions regarding
the child's medical care
• An unmarried grandchild whose primary residence is the
household of the employee and who is a dependent of the
employee for federal income tax purposes
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More Eligible Dependents
• Unmarried children (any age) mentally retarded
or physically incapacitated
• Siblings over age 25 or parents are not the children of an
employee and do not meet the definition of an eligible
dependent
• Any other dependents required to be covered under
applicable law
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Newborns
• Covered the first 31 days if employee has coverage
• To continue coverage, employee must add newborn
within 60 days after the date of birth
• However, an employee has up to one year after the
newborn’s date of birth if:
• Employee has “employee and family” or “employee and
child(ren)” coverage at the time of birth and at the time of
enrollment
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PPO Plan Options
ActiveCare 1, 2 and 3
PPO Features
ActiveCare 1, ActiveCare 2 and ActiveCare 3
• Administered by Blue Cross and Blue Shield of Texas and
Medco
• No primary care physician (PCP) required; no referrals
required to see a specialist
• Select any provider for care within the PPO network or outside
the network
• When you receive care inside the network, you receive the
highest level of benefits
• When you receive care outside the network, you still have
coverage but you may pay more of the cost
• Worldwide coverage for emergency and non-emergency care
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Network vs. Non-Network Providers
Network Providers
• Receive highest level of benefits
• No claims to file
• No balance billing
Non-Network Providers
• Receive non-network level of benefits
• Must file own claims
• May be billed for charges exceeding allowable amount
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Non-Network Providers
ParPlan Providers
• Receive non-network level of benefits
• No claims to file in most cases (ParPlan provider will
usually file the claims)
• No balance billing; ParPlan providers cannot bill for
costs exceeding the allowable amount
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Coverage Outside Texas
BlueCard PPO Program
(for enrollees living or traveling outside of Texas)
• More than 85 percent of all doctors and hospitals
contract with Blue Cross and Blue Shield Plans
• Outside of the U.S., you have access to doctors
and hospitals in more than 200 countries
• Network level of benefits
• Claims filed by providers
• No balance billing
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Deductibles (Plan Year)
ActiveCare 1
Network
Non-Network
$1,100 Individual
$3,000 Family
ActiveCare 2
Network
Non-Network
$500 Individual
$1,500 Family
ActiveCare 3
Network
Non-Network
None
$500
Individual
$1,500
Family
Deductible: The amount of out-of-pocket expense that must
be paid for health care services before becoming payable by
the health care plan
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Coinsurance
ActiveCare 1
ActiveCare 2
ActiveCare 3
Network
NonNetwork
Network
NonNetwork
Network
NonNetwork
(after
deductible)
20%
40%
20%
40%
20%
40%
Plan Pays
80%
60%
80%
60%
You Pay
(no
deductible)
80%
60%
Coinsurance: The percentage of medical expenses that you
and the health plan share
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Office Visit Copay
ActiveCare 1
ActiveCare 2
ActiveCare 3
Network
NonNetwork
Network
NonNetwork
Network
NonNetwork
20% after
deductible
40% after
deductible
$25/$35
per visit
40% after
deductible
$20/$30
per visit
40% after
deductible
Copayment (Copay): The amount paid at the time of service for certain
medical services and prescription drugs; copays depend on whether the
doctor is primary or a specialist
Specialist: Any physician other than a family practitioner, internist,
OB/GYN, and pediatricians
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Preventive Care
ActiveCare 1
Network
ActiveCare 2
ActiveCare 3
NonNetwork
Network
NonNetwork
Network
NonNetwork
40% after
deductible
$25/$35
per visit
40% after
deductible
$20/$30
per visit
40% after
deductible
No copay
Plan pays
100% up to
first $500 per
person, per
plan year
Copayment (Copay): The amount paid at the time of service for certain
medical services and prescription drugs; copays depend on whether the
doctor is primary or a specialist
Specialist: Any physician other than a family practitioner, internist,
OB/GYN or pediatrician
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Out-of-Pocket Maximum
(excludes copays and deductibles)
ActiveCare 1
Network
Non-Network
$2,000 Individual
$6,000 Family
ActiveCare 2
Network
Non-Network
$2,000 Individual
$6,000 Family
ActiveCare 3
Network
Non-Network
$1,000
per
Individual
$3,000
per
Individual
Out-of-Pocket Maximum: When you reach your plan’s of
out-of-pocket maximum, the plan then pays 100% of any
eligible expenses for the rest of the plan year.
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Preauthorization Required
• All inpatient hospital stays
• Treatment of all serious mental illness, mental health
care and chemical dependency
• Home health care
• Hospice
• Skilled nursing facility
• Home infusion therapy
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Special Beginnings
Prenatal Program
• Available now to ActiveCare 1, 2 and 3 plan
participants—at no cost
• Program is available from pregnancy
through six weeks after delivery
• Helps mothers take better care of
themselves and their babies
• Assesses pregnancy risk level and provides
close monitoring through a series of calls
from an experienced obstetrical nurse
• Call 1-800-462-3275 to enroll or ask
questions about the program
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Disease Management Programs
ActiveCare 1, 2 and 3 PPO Plans
• Voluntary programs available now to ActiveCare 1, 2
and 3 plan participants—at no out-of-pocket cost
• Designed for those diagnosed with:
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Asthma
Diabetes
Congestive heart failure
Coronary artery disease
Metabolic syndrome (high blood pressure, high
cholesterol)
• Lower back pain
• End stage renal disease
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Disease Management Programs
(Cont.)
• Enrolling in a program can help:
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Decrease the intensity and frequency of symptoms
Enhance self-management skills
Minimize missed days at work
Enrich quality of life
• Claims and pharmacy data review, preauthorization prior to a
hospitalization or a physician referral are some of the factors
that help determine if a disease management program is right
for the plan participant
• Blue Cross and Blue Shield of Texas will notify doctor by letter
if it finds that the plan participant would benefit by enrolling in
a program
• Call 1-800-462-3275 to enroll
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Disease Management Programs
What You will Receive
If severity of the Coverage for targeted preventive screenings
Seasonal mailings with educational materials related to the
condition is
condition
mild
Annual contact calls to encourage medication compliance
Tools to help better self-manage the condition
If the severity of
the condition is
moderate to
severe
Personalized self-management planning
Regularly scheduled monitoring by a registered nurse
24-hour-a-day telephone access to a specialty nurse
An audio library of topics related to the condition, available
by telephone around-the-clock
Assistance in getting durable medical equipment
Home health visits and social service consultation, if
needed
If a representative from Blue Cross and Blue Shield of Texas or
LifeMasters calls or leaves a message for you, talk to them! They are
calling to help improve your health and well being.
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Blue Access for Members
(Registration required)
• Available to ActiveCare 1, 2 and 3 enrollees
• Blue Access for Members link on TRS-ActiveCare Web site
and www.bcbstx.com/trs
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Check the status of a claim
Confirm who is covered under the plan
View and print detailed claim information (Explanation of Benefits)
Opt-out of receiving paper copies of their Explanation of Benefits
Sign up to receive email notifications of new claim activity
Request a new or replacement ID card or print a temporary member ID card
• Access to health and wellness information
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Take a Health Risk Assessment
• Confidential online survey to help you learn more
about your individual health risks
• Takes 10-15 minutes to complete
• Individualized report provided with guidance and
suggestions for next steps to improving your health
• Available through Blue Access for Members
• Click on My Health tab, then select the Health & Wellness
icon to Take a Health Risk Assessment
• Your information is kept confidential
• Information will not be released to your employer
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Prescription
Drug Benefits
ActiveCare 1, 2 and 3
Prescription Drug Benefits
What’s New
• No plan changes, no copay changes
• Retail Pharmacy Program
ActiveCare 2 and ActiveCare 3—No
changes
• Retail copays for maintenance medications
» First two fills of maintenance medication at retail =
short-term copay
» Third (3rd) fill of maintenance medication at retail =
copay increase
• Retail copays for short-term medications did not
change
• Mail order copays did not change
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Prescription Drug Benefits
ActiveCare 1
Retail
Mail Order
(up to 30-day supply)
(up to 90-day supply)
Network
Non-Network
You pay 100% of the
discounted cost at
the time of purchase
and will be
reimbursed 80% by
Blue Cross and Blue
Shield of Texas after
your deductible
You pay 100% of the
total cost at the time
of purchase and will
be reimbursed 80%
by Blue Cross and
Blue Shield of Texas
after your deductible
You pay 100% of the
discounted cost at the
time of purchase and will
be reimbursed 80% by
Blue Cross and Blue
Shield of Texas after
your deductible
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Prescription Drug Benefits
ActiveCare 2
Retail Network
Mail Order
(up to 30-day supply)
(up to 90-day supply)
Short-Term Maintenance
Generic
Preferred Brand
Non-Preferred
Brand
$10
$25
$45
$15
$35
$60
$20
$62.50
$112.50
Note: When using a non-network pharmacy, you must pay the entire cost and
submit a claim form to Medco. You will be reimbursed the amount that would have
been charged by a network pharmacy, less the required copayment.
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Prescription Drug Benefits
ActiveCare 3
Retail Network
Mail Order
(up to 30-day supply)
(up to 90-day supply)
Short-Term Maintenance
Generic
Preferred Brand
Non-Preferred
Brand
$10
$25
$40
$15
$35
$55
$20
$62.50
$100
Note: When using a non-network pharmacy, you must pay the entire cost and
submit a claim form to Medco. You will be reimbursed the amount that would have
been charged by a network pharmacy, less the required copayment.
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Prescription Drug Benefits
ActiveCare 2 and 3: Applying the Deductible
Example 1—Claim cost less than $50 Deductible
Total
Cost
Deductible
Applied
Copay
Deductible
Remaining
First Fill
$18
$18
$18
$32
Second Fill
$29
$29
$29
$3
Third Fill
$101
$3
$3 + copay
$0
• Once the deductible is satisfied, the member pays the
applicable copay
• Member-paid cost differences between a brand-name drug
and a generic equivalent do not apply to the deductible
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Prescription Drug Benefits
ActiveCare 2 and 3: Applying the Deductible
Example 2—Claim cost more than $50 Deductible
Total
Cost
Deductible
Applied
Copay
Deductible
Remaining
First Fill
$100
$50
$25
$0
Next Fill
$100
$0
$25
$0
• Once the deductible is satisfied, the member pays the
applicable copay
• Member-paid cost differences between a brand-name drug
and a generic equivalent do not apply to the deductible
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Prescription Drug Benefits
ActiveCare 2 and 3: Member pays the difference
• You pay the difference if a brand-name prescription is
dispensed when a generic is available
• You pay the generic copay plus the difference in cost between
the brand-name prescription and what the cost would be if the
generic drug had been purchased, regardless of doctor DAW
(Dispense As Written)
Example:
Full price of brand-name drug
$120
Full price of generic
$ 70
(Difference)
$ 50
Plus retail generic copay
$ 10
You pay
$ 60
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Prescription Drug Benefits
Drug Formulary
• Preferred and Non-Preferred Medications
• Copays
• Preferred Prescriptions Drug List
• Generic Medications
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Prescription Drug Benefits
Prior Authorization
• Program designed to ensure the safety of
participants and help contain costs
• May review some or all of the following
information to assure an appropriate
coverage decision:
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Patient diagnosis
Indications for prescribed drug use
Dosing
Duration of therapy
Patient drug profile
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Prescription Drug Benefits
Online Technology: www.trs.state.tx.us/trs-activecare
Online services
available prior to
enrollment
• Compare pricing and coverage for brand-name and
generic medication for both home delivery and retail
• View Retail Maintenance List
• Locate participating retail network pharmacies
• Access pharmacy benefits highlights
• Locate drug information
Additional online
services available
after enrollment
• Request refills and renewals through
mail service pharmacy
• Check status of orders
• Access health and wellness information
• Order supplies
• My Rx Choices
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My Rx Choices (Pilot Program:
replaced
Savings Advisor)
• Pilot Participant
• Initiated 12/1/2006; goes through 2/28/2007
• Features include:
• Personal assessment of cost-saving opportunities
based on the member’s prescription plan
• Best-value alternatives based upon greatest cost
savings to the member presented in order from
highest value to member
• Brand-to-generic and retail-to-mail compare
options available
• Explanation of complicated concepts in easy-tounderstand terms
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My Rx Choices
Available through 800 # or on www.medco.com
As of 3/1/2007:
 8,813 registered
TRS-ActiveCare
members
 17,129 wizard
starts
 1,694 forms
downloaded
 12% of the time
members switched
to cost saving
alternatives
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My Rx Choices
Medco can
facilitate on
generic
equivalents
received
through mail
order
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My Rx Choices
Members
may print a
kit to discuss
lower-cost
alternatives
with their
doctor
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Coverage Categories
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Employee Only
Employee and Spouse
Employee and Child(ren)
Employee and Family
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Choosing a Coverage Category
• If employee and spouse both work for a participating
entity:
• A spouse may be covered as an employee or as a
dependent of an employee
• Only one parent can cover dependent children
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Application to Split Premium
• Married couples working for different participating
entities may “pool” funds
• Optional
• Requires an Application to Split Premium form to be
completed by both employees and employers
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How to Enroll
2007-2008 Plan Year
Who needs to enroll?
• For new coverage or changes, complete an
Enrollment Application and Change Form
• If you enrolled in 2006-2007 and do not wish to make
changes to your current health benefit plan, you do
not need to submit an enrollment application
• You must complete an application if declining
coverage – even if you previously declined coverage
Complete, sign, date and submit forms
to your Benefits Administrator
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Can Changes in Coverage Be Made
After Your Application Has Been
Submitted?
• Changes can be made up to the end of your enrollment period
• Plan choices will remain in effect through August 31, 2008
unless there’s a special enrollment event such as:
• Marriage or divorce
• Birth, adoption or placement for adoption of a child
• A child marries or reaches age 25
• A court order to provide health coverage for an eligible child
• Loss of coverage
• Changes must be made within 31 days after the event date
(special rules apply to newborns)
• New application must be submitted for any change
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Cafeteria Plan Vendor(s)
• Making a change through the Section 125 vendor
does not automatically generate a change to
coverage under TRS-ActiveCare
• All changes to TRS-ActiveCare must be signed,
dated and submitted on an Enrollment Application
and Change Form
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Important Notice
Supplemental Coverage
• TRS does not offer or endorse any supplemental
coverage for any of the health coverage plans
available under TRS-ActiveCare
• To obtain information about any coverage that
claims to be a companion or supplement to any
TRS-ActiveCare plan, employees should contact:
• The organization making such offering and/or
• The Texas Department of Insurance (TDI)
http://www.tdi.state.tx.us or the TDI Consumer
Helpline (800) 252-3439
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Your TRS-ActiveCare ID card will
be mailed to your home
• ActiveCare 1 and 3
• New ID cards will not be issued to current participants
unless changing plans; new enrollees will receive new
cards
• ActiveCare 2
• All enrollees will receive new cards
• HMO plans
• All HMO participants will receive new cards (except for
Mercy Health Plans)
• Each individual covered under the plan will receive a card
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Enrollment Support
Dedicated Customer Service
• ActiveCare 1, 2 or 3
1.866.355.5999
(Blue Cross and Blue Shield of Texas and Medco)
• FirstCare Health Plans
• Legacy Health Solutions
• Mercy Health Plans
• Scott and White Health Plan
• Valley Baptist Health Plans
1.800.884.4901
1.877.410.2432
1.800.617.3433
1.800.321.7947
1.800.829.6440
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Enrollment Support
Available Online
• Enrollment guide (English and Spanish)
• Downloadable forms
(enrollment application, split premium, claim form, etc.)
• Provider locator
• Frequently asked questions
www.trs.state.tx.us/trs-activecare
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Blue Access for Members
• Available to ActiveCare 1, 2 and 3 enrollees
• BAM link now on TRS Web site and
www.bcbstx.com/trs
• Check the status of a claim
• Confirm who is covered under the plan
• View and print detailed claim information (Explanation of
Benefits)
• Opt-out of receiving paper copies of your Explanation of Benefits
• Sign up to receive e-mail notifications of new claim activity
• Request a new or replacement ID card or print a temporary
member ID card
• Take a Health Risk Assessment
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Questions
Thank you for attending