Transcript Employee and Family

2010-2011 Plan Year
Effective September 1, 2010
Your TRS-ActiveCare ID card will be
mailed to your home
 Enroll by May 19 to receive ID card by September 1
 ActiveCare 1-HD, 1, 2 and 3
– All enrollees, including existing plan participants, will receive new
ID cards
– New! Separate cards for medical and prescription drugs
• Blue Cross and Blue Shield of Texas
• Medco
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PPO Medical Plans
ActiveCare 1-HD, 1, 2 & 3 Plans
PPO Network for ActiveCare 1-HD, 1, 2 and 3
Network
There is no need to:
– Select a Primary Care Physician
– Obtain referrals for specialist care
Receive the highest level of
benefits:
– Pay less for care
– No balance billing
No claim forms
– Provider files claim for you
New for 2010-2011: The allowable
amount for non-contracting providers
will be limited to 50% of billed charges
Always verify provider network status
Non-Network:
 You pay more of the cost
of out-of-network benefits
– Higher deductibles,
coinsurance
 You may need to
file your own claim
 You could be
balance billed
for amounts
over allowed
amount
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PPO Plan Overview (Network Level of Benefits)
Plan Features
ActiveCare 1-HD
ActiveCare 1
ActiveCare 2
ActiveCare 3
Deductible
(individual/family)
$2,400/$2,400
$1,200/$3,000
$500/$1,500
None
$3,000/$5,000
$2,000/$6,000
$2,000/$6,000
$1,000 per
individual
80% / 20%
80% / 20%
80% / 20%
80% / 20%
Out-of-Pocket
Maximum
(does not include
deductibles)
Coinsurance
(Plan pays/participant
pays)
New Deductibles
for 2010-2011
(per IRS rules)
ActiveCare 1-HD
and ActiveCare 1
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PPO Plan Overview (Network Level of Benefits)
Services
Office Visit Copay
Preventive Care
 Routine physicals*
 Well-woman exams*
 Routine
mammograms*
 Eye exams*
 Well-baby exams
 Immunizations
 Hearing exams
 PSA screenings
 Colorectal
screenings
 Osteoporosis
screenings
* Services
limited to one
per person per plan year
ActiveCare 1-HD
ActiveCare 1
ActiveCare 2
ActiveCare 3
20% after deductible
$30 for primary
$50 for specialist
$20 for primary
$30 for specialist
$0 copay up to $500
per person, per plan year
$30 for primary
$50 for specialist
$20 for primary
$30 for specialist
Remaining charges subject to
deductible and coinsurance
Includes all
preventive care
services billed
with an office visit
by a network
doctor
Includes all
preventive care
services billed with
an office visit by a
network doctor
New Copays
for 2010-2011
ActiveCare 2
Coinsurance
applies when no
office visit is billed
or when services
are performed
outside the office
(deductible
waived)
Coinsurance
applies when no
office visit is billed
or when services
are performed
outside
the office
(no deductible)
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ActiveCare 1-HD vs. ActiveCare 1
Plan Features
ActiveCare 1-HD
ActiveCare 1
Meets IRS definition of High
Deductible Health Plan
Yes, for all coverage
categories
(employee only, employee and
spouse, employee and
child(ren) and employee and
family)
Yes, for employee-only
coverage
No, for other coverage
categories
Deductible
$2,400 for employee only
$2,400 for family
$1,200 per individual
$3,000 per family
Maximum Coinsurance
$3,000 for employee only
$5,000 for family
$2,000 per individual
$6,000 per family
Out-of-Pocket Maximum
(includes deductibles)
$5,400 for employee only
$7,400 for family
$3,200 per individual
$9,000 per family
Lower premium than
ActiveCare 1
in all coverage categories
except employee and family
Higher premium than
ActiveCare 1-HD in all
coverage categories except
employee and family
Monthly Premium Cost
New for 2010-2011: Deductible and out-of-pocket maximum
amounts increased per IRS guidelines
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Blue Distinction Centers for Bariatric Surgery
Important:
Bariatric surgery procedures for weight loss, such as lap
band and gastric bypass, must be performed at one of the
Blue Distinction Centers for Bariatric Surgery or the
procedure will not be covered by TRS-ActiveCare
 List of Blue Distinction Centers for Bariatric Surgery is
subject to change
 Refer to the Doctors and Hospitals section of the Web site,
www.bcbstx.com/trs or call Customer Service for most
current list
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How to Enroll
2010-2011 Plan Year
Enrollment
 Enrollment Periods for 2010-2011 Plan Year:
– April 21,22,23 (HISD Spring Enrollment)
– August date TBA (HISD Summer Enrollment)
 Preexisting condition exclusion applies to those that
previously declined coverage; may be reduced by prior
creditable coverage
 All employees must attend enrollment to:
–
–
–
–
Change TRS-ActiveCare plan option
Add or drop dependents
Cancel and/or decline coverage
Enroll for TRS-ActiveCare coverage with a different
participating district/entity
– Change name or address or correct date of birth or Social Security number
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Eligible Dependents
 Spouse (including a common law spouse)
 Unmarried children under age 25
–
–
–
–
Natural child
Adopted child
Stepchild
Foster child
 Other eligible dependents listed in
Enrollment Guide
– Grandchildren (unmarried)
– Disabled children
(unmarried, of any age)
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Special Eligibility Situations
 If employee and spouse both work for a participating
district/entity:
– A spouse may be covered as an employee or as a dependent of
an employee
– Only one parent can cover dependent children
 A child (under age 25) employed by a district/entity and a
contributing TRS member cannot be covered as a
dependent
 The child must be covered as an employee
 If the child is not a contributing TRS member, the child
may be covered as a dependent
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Preexisting Condition Waiting Period
and Creditable Coverage
 Pre-x does not apply to employees that initially enroll when the
district/entity begins participating in TRS-ActiveCare or to new hires
who enroll within 31 days after their actively-at-work date
Exception: If a participant has been covered by TRS-ActiveCare at any
time since 2002, pre-x may apply if employee is hired by another
participating district/entity (or rehired by same district/entity)
 A 12-month pre-x condition waiting period may apply due to:
– A special enrollment event
– A future plan enrollment period (to be determined by TRS for each
plan enrollment period)
– A transfer to another participating district/entity (or rehire) if the
employee or any covered dependent has any remaining preexisting
waiting period or a gap in coverage of 63 or more consecutive days
 Pre-x waiting period may be reduced by creditable coverage
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Cost for Health Coverage
2010-2011 Plan Year
Monthly Cost
for Coverage
 See page 27 of
Enrollment Guide
 $225 in district/entity
and state funds to
help pay for coverage
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Cost of Coverage (Cont’d)
PPO Plans
ActiveCare 1-HD
ActiveCare 1
Your Cost
Your Cost
Employee Only
$37
$72
Employee and Spouse
$417
$452
Employee and Child(ren)
$184
$249
Employee and Family
$615
$521
Family Deductible
$2,400
$3,000
Family Out-of-Pocket
Maximum
$7,400
$9,000
Coverage Category
Employee and family coverage for ActiveCare 1-HD is more expensive than
ActiveCare 1 because the deductible and out-of-pocket maximum amounts for
family are less and the plan may begin paying 100% benefits sooner
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Cost of Coverage (Cont’d)
PPO Plans
Coverage Category
ActiveCare 2
ActiveCare 3
Your Cost
Your Cost
Employee Only
$171
$308
Employee and Spouse
$676
$988
Employee and Children
$405
$625
Employee and Family
$766
$1,109
Family Deductible
$1,500
None
Family Out-of-Pocket
Maximum
$7,500
$1,000 per individual
New Copays for 2010-2011 (Active Care 2) $30 for an office or preventive
care visit for primary and $50 for specialist.
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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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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, 2011
unless there’s a special enrollment event such as:
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–
–
–
–
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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Newborns
 Covered first 31 days if employee has coverage
 Must add newborn within 60 days after the date of
birth or up to one year after the 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
 Not necessary to wait for newborn’s Social Security
number
– Submit application without SSN to enroll
– Re-submit another form after SSN is issued
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Blue Access® for Members
Online member management tool
 Check claim status, view claim
summaries and print EOBs
(Explanations of Benefits)
 Order additional ID cards,
and print temporary ID
 Monthly health articles
 Links to health information
and wellness tools and
resources, including the
Personal Health Manager
Send secure e-mail messages to BCBS Customer Advocates
available Monday thru Friday, 7 a.m. to 10 p.m. (CT)
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www.bcbstx.com/trs
Available online
Enrollment Video
Application Form
Enrollment Guide
Benefits Booklet
24/7 Nurseline,
Lifestyle and
Condition
Management and
Special Beginnings
phone numbers
Blue Care Connection®
Total Care Approach to Health and Wellness
 Whether you decide to skip fast food, quit smoking,
or walk more, every day decisions can have a positive
impact on your health; Blue Care Connection
offers guidance at every level of health
Well Members
Low- Risk
Moderate- Risk
High-Risk
Complex / Catastrophic
< < < Wellness > > >
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Condition Management
If you have a chronic condition, we offer support.
• Support from Blue Care Advisors—clinical
professionals who can help you manage
chronic health conditions such as: asthma,
diabetes, coronary artery disease,
congestive heart failure, chronic obstructive
pulmonary disorder and other health
conditions
• Understanding and following your
physician’s orders
• Review medications, side effects,
compliance, refills and current services
1-800-462-3275
• Establish goals with you and caregivers,
scheduling follow-ups as appropriate
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Tobacco Cessation and Weight Management
Self-Paced Approach
• Online program and resources
available in the Personal
Health Manager
• Secure e-mail outreach to keep
members on track
Lifestyle Management
Support
• Counseling and coaching with
licensed Wellness Coaches
• 24/7 Nurseline
• Referrals when appropriate
1-800-462-3275
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Special Beginnings®
Special Beginnings helps expectant mothers and
their babies get off to a healthy start by providing
prenatal and postnatal health education and guidance
at no additional cost
Once enrolled in the program, plan participants receive:
• Pregnancy risk assessment and ongoing
communication/monitoring
• Educational material covering pregnancy and infant care
topics
• Frequent, personal contact with program staff from early
pregnancy through six weeks after delivery
• Assistance in managing high-risk conditions such as
gestational diabetes and preeclampsia
Program components are available in English and Spanish
1-888-421-7781
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24/7 Nurseline
Advice anytime.
Round-the-clock health
and the wellness advice
from licensed
professionals
Advice isn’t just needed
from 9 to 5.
24/7 Nurseline is here to help.
 Nurses provide health advice and
information about high fevers, earaches,
cuts and bruises and more
 Audio health library on topics such as
kicking the smoking habit and ways
to get a good night’s rest
24/7
1-800-581-0368
Available in English and Spanish
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Personal Health Manager (PHM)
Your online wellness experience begins
with the Personal Health Manager
Features include:
 Lifestyle Management tools:
 Weight Management
 Tobacco Cessation
 Fitness and Nutrition Plans
 Stress Reduction
 Health Risk Assessment
 “For Your Health” features
 Blue PointsSM Rewards
 “Ask-A” feature – health and
wellness questions via
secure e-mail
 Online health encyclopedia
 Interactive symptom checker
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Personal Health Manager – Home Page
Read secure
messages
Take a Health Risk
Assessment
Review
member
alerts
Access Member
Care Profile
Use the
Interactive
Symptom
Checker
Explore
topics in the
Health
Information
and Care
Center
Ask a Question to a
certified Nurse,
Trainer, Dietitian or
Life Coach
Read the latest
health news, search
for specific health
topics or explore the
prescription drug
index
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“Ask A” Online Advisor
Ask the experts.
Expert advice from
licensed professionals
via the Personal Health
Manager
Expert advice at your fingertips.
Our “Ask A” feature is here to help.
Ask A Nurse:
Interact online with a Blue
Care Advisor on nonemergency, healthrelated questions using
the secure “Ask A Nurse”
feature.
Ask A Trainer,
Dietitian or
Life Coach:
Send questions about
fitness, nutrition, or
managing stress.
Confidential and Secure – Receive an
e-mail response within one business day
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Health Risk Assessment – Easy To Use
1
2
Choose your
assessment topic:
• Health & well-being*
• Sleep
• Stress management
• Nutrition
• Fitness & physical
activity
• Back & joint health
Complete the
assessment in
as little as
10 to 15 minutes
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Receive Personalized
report and next steps:
• Report provides member
with summary of health
risks and areas where they
could improve
• Recommended ‘next steps’
and suggestions to make
positive changes to your
lifestyle.
*We recommend completing
the Health & Well-being
assessment first.
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Health Risk Assessment (HRA)
Be informed about your overall health and well-being
A Health Risk Assessment helps
assess your health risks, interests
and readiness to change
 Examines your overall health
and well-being
 Provides a detailed report with overall
health and well-being score and
sub-scores for:
 Medical health, job satisfaction,
life load, risk and lifestyle, mood, nutrition,
sleep, stress, pain and body weight
 Recommends areas for improvement
 Confidential and secure (results are not
shared with employers)
Earn Blue PointsSM
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Blue PointsSM Incentives
Stay motivated.
Earn Blue Points in the
Personal Health Manager
TRS-ActiveCare PPO plan
participants and their covered
dependents accumulate Blue Points
in the Personal Health Manager
 Complete designated health and
wellness activities
 Report completed activities in the
Personal Health Manager
 Track your available balance
 Redeem earned Blue Points for
a variety of items!
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Prescription Drugs
ActiveCare 1-HD,1, 2 & 3
Your Medco Prescription Drug Plan
 Medco administers your prescription drug
plans on behalf of TRS
– ActiveCare 1-HD, 1, 2, and 3 plans
 Benefit includes both a retail and mail
component
 Medco has its own mail-order pharmacy
– Medco By Mail – where specialist
pharmacist focus on compliance and
lower cost options for the patient, and the
automated filling system ensures the
prescription is filled accurately.*
• Medco’s mail-order pharmacies fill about 2 million prescriptions per week through a highly automated process that is 99.9997% accurate and is 23
times more accurate than a retail pharmacy
“Dispensing Error Rate in a Highly Automated Mail-Service Pharmacy Practice”; Nov. 2007, Pharmacology, a peer-reviewed journal of the American
College of Clinical Pharmacy
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Prescription Drug Benefits - Network Level
Features
Drug Deductible
(per person, per plan year)
ActiveCare 1-HD
ActiveCare 1
ActiveCare 2
ActiveCare 3
Subject to plan
year deductible
Subject to plan
year deductible
$50
$50
$10
$25*
$45*
$10
$25*
$40*
$15
$35*
$60*
$15
$35*
$55*
$20
$62.50*
$112.50*
$20
$62.50*
$100*
Retail Short-Term
(up to 30-day supply)
Generic/Preferred Brand/NonPreferred Brand
Retail Maintenance
(after second fill, up to
30-day supply)
Generic/Preferred Brand/NonPreferred Brand
Medco by Mail
(up to 90-day supply)
Generic/Preferred Brand/NonPreferred Brand
20% coinsurance
after deductible
* If you obtain a brand-name drug when a generic equivalent is available, you are responsible for the generic copayment plus the cost difference
between the brand-name drug and the generic drug. Chart illustrates benefits when network pharmacies are used. Non-network benefits are also
available; see Enrollment Guide for more information.
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Specific Rx Benefit Information
 Retail pharmacies are ideal for acute (short-term) and new
medication you may be trying for the first time
In compliance with SB 0704, 81 (R) Texas Legislature, TRS will make
available through Medco a retail maintenance network effective
September 1, 2010. Retail pharmacies who choose to participate in
this network will be able to dispense up to a 90-day supply of
medication. Please contact Medco customer service for more
information on pharmacies that may choose to participate in the retail
maintenance network. Medco is in the process of soliciting this
network. We will not know which pharmacies will choose to
participate until later this summer.
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Specific Rx Benefit Information
 If you are taking a long-term medication, filling your
prescriptions through Medco’s mail-order pharmacy
provides several benefits:
– You can receive up to a 90-day supply of your medication at a lower
copay
– Prescriptions are delivered directly to you and you can order refills
online and check the status of your orders
– You have access to specialist pharmacists
• Specifically trained in specific conditions
• Review all of your incoming prescriptions for potential safety issues
and will contact you and your doctor to discuss any issue
– Medco only buys medication from the most reputable
suppliers
You have access to specialist pharmacists whether you fill your
prescription at a retail pharmacy or at Medco By Mail.
Your medication questions can be answered by calling 1-866-355-5999
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My Rx Choices®
Your online savings tool
 Lower your cost for prescriptions with My Rx Choices®
– Features include:
• Personal assessment of cost-saving opportunities based on your
prescription plan and the medications you use
• Print a kit to help your doctor better understand the economic
impact of different medication alternatives
• Alternative medications are based upon greatest cost savings to
you presented in order, starting with the highest value
• Brand-to-generic and retail-to-mail comparisons are shown
• The average amount saved by My Rx Choices® users is $294!
 Simply visit www.medco.com/save. You’ll need to take a
moment to register before using this service. You can
also call 1-866-355-5999
 You have to shop your benefit. Prices can vary at
different retail pharmacies
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My Rx Choices®
Available through Customer Service or on www.medco.com
 The My Rx Choices® home
page allows the user to:
– Select a patient within a
household (prepopulated with all under
age 18 dependents and
spouse information will
be shown if
authorization has been
given)
– Select a drug to
compare from a prepopulated list of
prescriptions for the
user.
 Your potential savings are
clearly presented
 Members may print a kit to
discuss with their doctor
 Generic alternatives are
provided
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Information Resources
 TRS Web site – www.trs.state.tx.us/trs-activecare
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Pharmacy Benefit Highlights
List of maintenance medications
FAQs
Download forms
 Medco Member Web site – www.medco.com
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–
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Prior authorization list
Formulary information
Locate a participating pharmacy
Health and wellness information
My Rx Choices® / Price a Medication
Online ordering
Order Medco By Mail refills
Download forms
Medco widget
 Customer Service 1-866-355-5999
 Benefits Booklet
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What if I Have Questions?
Personalized Service
 Call TRS-ActiveCare customer service for:
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Claim questions/status
Network provider information
Membership and eligibility
Medical coverage questions
Inquiries (telephone and e-mail)
ID card requests
Transition of care information
Help with online tools!
Customer Service
1-866-355-5999
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Thank you for attending