Transcript Out-of-Pocket Maximum

Health Coverage for You and Your Family
PPO Plan Overview
ActiveCare 1-HD, 2 and 3 Plans
2013-2014 Plan Year
New Deductible and Out-of-Pocket
Maximum for ActiveCare 1-HD
• ActiveCare 1-HD meets IRS definition of a high deductible health
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plan for all coverage tiers
May contribute pretax dollars into a health savings account
(HSA) to help pay for current health expenses and save for future
qualified medical and retiree health expenses on a tax-free basis
Individuals can establish an HSA with banks and credit unions
2012-2013 Plan Year
Deductible
(employee only/family)
2013-2014 Plan Year
AC1
AC1-HD
AC1-HD
$1,200/$3,000
$2,400/$2,400
$2,400/$4,800
$2,000/$6,000
$3,000/$5,000
$3,850/$4,200
Out-of-Pocket
Maximum
(employee only/family;
does not include
deductibles)
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New Deductible and Out-of-Pocket
Maximum for ActiveCare 2
Deductible
(individual/family)
2012-2013 Plan Year
2013-2014 Plan Year
ActiveCare 2
ActiveCare 2
$750/$2,250
$1,000/$3,000
$2,000/$6,000
$4,000/$8,000
Out-of-Pocket Maximum
(individual/family;
does not include deductibles)
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Family Deductible Illustration
Amy covers spouse and three dependents
Amy Ted Bob Sue Chris
ActiveCare 1-HD with $4,800 family deductible
•The family deductible may be met by one or more
people
•Plan pays benefits once entire $4,800 is met ̶ there is
no individual deductible to meet
$4,800
ActiveCare 2 with a $1,000 individual deductible and a $3,000 family deductible
• Plan pays benefits for an individual as his/her deductible is met
• Everyone helps to meet the family deductible, but no one person pays more than
the individual amount
Amy
Ted
Bob
Sue
Chris
$1,000
$800
$600
$400
$200
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Out-of-Pocket (OOP) Maximum Illustration
Amy covers spouse and three dependents
Amy Ted Bob Sue Chris
ActiveCare 1-HD with $4,200 family OOP maximum
•The family out-of-pocket maximum may be met by one
or more people
•Plan pays benefits once entire $4,200 is met ̶ there is
no individual amount to meet
$4,200
ActiveCare 2 with a $4,000 individual and $8,000 family OOP maximum
• Plan pays benefits for an individual as his/her OOP maximum is met
• Everyone helps to meet the family OOP maximum, but no one person pays more
than the individual amount
Amy
Ted
Bob
Sue
Chris
$4,000
$2,000
$1,000
$600
$400
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PPO Network for ActiveCare
1-HD, 2 and 3
Network
Statewide (all 254 counties)
No need to:
– Select a Primary Care Physician
– Obtain referrals for specialist care
Receive highest level of benefits:
– Pay less for care
– No balance billing
No claim forms
– Provider files claim for you
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)
Deductible
Out-of-Pocket
Maximum
(does not include copays
or deductibles)
ActiveCare 1-HD
ActiveCare 2
ActiveCare 3
$2,400 employee only
$4,800 family
$1,000 individual
$3,000 family
$300 individual
$900 family
$3,850 employee only
$4,200 family
$4,000 individual
$8,000 family
$1,000 per individual
80% / 20%
80% / 20%
80% / 20%
20% after deductible
$30 for primary
$50 for specialist
$20 for primary
$30 for specialist
Coinsurance
(Plan pays/
participant pays)
Office Visit Copay
Primary means care provided by family practitioners, internists, OB/GYNs and pediatricians.
All other physicians are specialists.
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PPO Plan Overview
(Network Level of Benefits)
Preventive Care Clarification
Services
Preventive Care
ActiveCare 1-HD
ActiveCare 2
ActiveCare 3
Plan pays 100%
(deductible waived)
Plan pays 100%
(no copay required)
Plan pays 100%
(no copay required)
20% after deductible
$30 for primary
$50 for specialist
$20 for primary
$30 for specialist
Routine eye exam
(one per plan year)
Hearing exam
• 100% coverage for certain age- and gender-specific preventive
care services when network providers are used
• Must be billed by provider as “preventive care”
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PPO Plan Overview
(Network Level of Benefits)
Benefits (continued)
Services
High-tech
Radiology
(CT scan, MRI,
nuclear medicine)
Inpatient Hospital
Emergency Room
Outpatient Surgery
ActiveCare 1-HD
ActiveCare 2
ActiveCare 3
20% after deductible
$100 copay per
service, plus 20%
after deductible
$100 copay per
service, plus 20%
after deductible
20% after deductible
$150 copay
per day, plus 20%
after deductible
($750 max copay per
admission; $2,250
max/year)
$150 copay
per day, plus 20%
after deductible
($750 max copay per
admission; $2,250
max/year)
20% after deductible
$150 copay, plus 20%
after deductible
(copay waived
if admitted)
$150 copay, plus 20%
after deductible
(copay waived
if admitted)
20% after deductible
$150 copay
per visit, plus 20%
after deductible
$150 copay
per visit, plus 20%
after deductible
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New!! Effective Sept. 1, 2013
Help get benefits information
and find network providers for:
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MRIs
CAT or CT Scans
Endoscopy procedures
Colonoscopy procedures
Back or spinal surgery
Real-time access to
current cost and
quality transparency
Appointment
scheduling
Clinical decision
support tools
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Knee surgery
Benefits
Shoulder surgery
Hip or joint replacement surgery
Bariatric surgery
Value Advisor
Understanding
benefits and
how to best use
them
Referrals to condition
management programs
Preauthorization
coordination
One-Call Solution: 1-866-355-5999 Customer Service
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Prescription Drugs
ActiveCare 1-HD, 2 & 3
2013-2014 Plan Year
Your Prescription Drug Plan
• Express Scripts administers your prescription
drug plans on behalf of TRS
– ActiveCare 1-HD, 2, and 3 plans
• Benefit includes both a retail and mail
component
• Express Scripts has its own mail-order
pharmacy where specialist pharmacists focus
on compliance and lower cost options for the
patient, and the automated filling system
ensures the prescription is filled accurately.*
Express Scripts buys medication from the
most reputable suppliers
*Express Scripts’ 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 2
ActiveCare 3
Subject to
plan year deductible
$0 generic;
$200 brand
$75
$20
$40*
$65*
$15
$35*
$60*
$25
$50*
$80*
$20
$45*
$75*
$45
$105*
$180*
$45
$105*
$180*
$200 per fill
$200 per fill
Retail Short-Term
(up to 31-day supply)
Tier 1 (Generic)
Tier 2 (Preferred Brand)
Tier 3 (Non-Preferred Brand)
Retail Maintenance
(after first fill, up to
31-day supply)
Tier 1 (Generic)
Tier 2 (Preferred Brand)
Tier 3 (Non-Preferred Brand)
20% coinsurance
after deductible
Mail Order and
Retail-Plus
(up to 90-day supply)
Tier 1 (Generic)
Tier 2 (Preferred Brand)
Tier 3 (Non-Preferred Brand)
Specialty Medications
(retail or mail)
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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New ID Cards for ActiveCare
Plans 1, 1-HD and 2 Participants
• All current ActiveCare 1 participants will receive replacement
cards for the new plan option in which they are enrolled.
• ActiveCare 1-HD and ActiveCare 2, participants will be mailed
replacement prescription ID cards reflecting the upcoming
changes to benefit design.
• The effective dates printed on the cards will be the more recent of
either the participant’s effective date with the plan or 9/1/10.
• Participants should expect to receive new cards around mid- to
late-August.
• Participants making changes after the replacements have been
mailed will result in a second set of cards being sent.
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Specialized Care is the Key to
Quality Outcomes
Specialization and participant engagement are critical components
to controlling health care costs and driving quality clinical outcomes:
• Specialist pharmacist
• Online Tools
• Closing gaps in care
• My Rx Choices®
• Mobile App
• Other available resources
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Specialist Pharmacists are an integral
part of the healthcare continuum
97% of
patients
Extremely Satisfied/Very Satisfied
with overall counseling experience
Specialist Pharmacists are specially trained to
counsel patients about their conditions and
connect with physicians and healthcare
coaches
• Average patient call lasts 12 minutes
• Calls are monitored and recorded for training
• Pharmacists spend their time focused on a
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single condition
“We strive to have our
pharmacists deliver the level of
patient care that any of us would
want for our families.”
Advanced tools let pharmacists see the
“whole patient” along with their drug
regimen across prescribers and pharmacies
Glen Stettin, M.D.,
Express Scripts’ Chief Medical Officer
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Express Scripts’ online tools and mobile apps
help connect patients and their caregivers
Online prescription management:
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Refills, renewals and order status
Worry-free Fills ®
Transfer to mail
Claims, balances and history
Locate a pharmacy
Preferences
Benefit education and management:
 Benefit highlights
 Forms and cards
 Pricing and coverage details
 New! Accessibility features
Gap In Care Alerts
Omission
Not Using Controller
Medication for Asthma
Help participants identify
and address potential safety issues with their
prescriptions
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Pharmacy Care Online Alerts
Adherence
Omission
On track
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Close-up: Sample Alert Message
Information about
the alert and why
it’s important
Video clips
relevant to
each alert
Ability for patients
to self-close gaps
as appropriate
Links to
additional
resources
Access to
email Express
Scripts pharmacists
Printable
information to take
to the doctor
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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
• Simply visit www.express-scripts.com. 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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Managing prescription with ease: Transfer
to mail online conversion program
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New! Accessibility Features
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Innovation that can help participants make
better decisions for healthier outcomes
Boost compliance and
adherence
Improve care
Manage Refills and
Renewals
Update in real-time
Save money
Enable informed decisions
Auto populate with
personalized information
Unique functionality not available anywhere in healthcare today
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Information Resources
• TRS Website – www.trs.state.tx.us/trs-activecare
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Pharmacy Benefit Highlights
List of maintenance medications
FAQs
Download forms
• Express Scripts Participant Website – www.express-scripts.com
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Prior authorization list
Formulary information
Locate a participating pharmacy
Generics Rx Advantage
My Rx Choices® / Price a Medication
Health and wellness information
Mobile App
Check prescription status
Order mail order refills
Download forms
Express Scripts widget
• Customer Service – 1-866-355-5999
• Benefits Booklet
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FirstCare Health Plans
HMO Plan Option
Company Overview
• We have been part of the TRS-ActiveCare program since 2003
and currently cover more than 13,000 school employees and their
dependents
• We are a hospital-based health plan, founded in 1985 and are
owned by Covenant Health System in Lubbock and Hendrick
Medical Center in Abilene
• We focus exclusively on the Texas market and have offices in
Abilene, Amarillo, Lubbock, and Waco
• FirstCare’s mission is to provide members with comprehensive
health care coverage at an affordable price
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Rate Overview
• The national average increase for health insurance premiums is
9 to 11 percent per year
• For plan year 2013, the overall rate increase is less than
2.5 percent
Coverage Category
2013 - 2014
Employee Only
$391.50
Employee and Spouse
$985.06
Employee and Child(ren)
$622.62
Family
$994.84
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Benefit Highlights
• No referrals to network specialists
• No routine claim forms
• No pre-existing limitations
• College-age dependents living outside our
service area have full coverage (address
must be on file)
NOTE: Care must be accessed through our affiliate
provider networks
• Secure online access to membership and
claim information at www.firstcare.com
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Medical Benefits for 2013-2014
No Plan Changes!
2013 - 2014
Deductible
$600 per individual
$1,500 per family
Out-of-Pocket Maximum
$4,000 per individual
$8,000 per family
Office Visit
Primary Care – $25
Specialist – $60
Inpatient / Outpatient
25% after deductible
(member share)
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Rx Benefit Comparison for 2013-2014
2013 - 2014
Deductible
$100 per Individual
$300 per Family
Rx Yearly Maximum
Unlimited
Copayment
Tier 1 (Generic) – $10
Tier 2 (Preferred Brand Name) – $30
Tier 3 (Non-Preferred Brand Name) – $60
Tier 4 (Specialty)* – 20%
*After $4,000 member out-of-pocket expense, cost is
covered 100% by FirstCare
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Service Area – 93 Counties
Across Texas
TRS-ActiveCare
Service Area
To be eligible to enroll in FirstCare,
you must live, reside or work in one
of the shaded counties.
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Why Choose FirstCare?
• We have experience with TRS-ActiveCare benefits. In fact, we
cover more than 13,000 school employees and their dependents.
• We are a hospital-based health plan that supports our local
communities.
• Medical decisions are made locally by physicians who understand
how health care is delivered in your area.
• A local FirstCare representative is available in your area to
answer questions.
• Dedicated email address for TRS-ActiveCare members and
Benefit Administrators – [email protected]
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Contact Us
You may submit your questions or comments
via email to [email protected]
You can also write or call customer service at:
FirstCare Health Plans
1901 West Loop 289
Suite #9
Lubbock, TX 79407
800-884-4901
http://www.trs.state.tx.us/trs-activecare
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How to Enroll
How to Enroll
2013-2014 Plan Year
Who is Eligible to Enroll?
To be eligible for TRS-ActiveCare coverage, you must:
• Be employed by a participating district/entity and
– Be an active, contributing TRS member or
– Be employed 10 or more regularly scheduled hours each week
Health care coverage for public school employees and their families
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Employees NOT Eligible to Enroll
• State of Texas employees or retirees
• Higher education employees or retirees
• TRS retirees, receiving or who declined coverage under
TRS-Care
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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Dependent Eligibility
Spouse, including common law spouse
A child under age 26: a natural child, an adopted child (or a child who is
lawfully placed for legal adoption), foster child, or child under legal
guardianship of the employee
“Any other child” under the age of 26 (unmarried) in a regular parent-child
relationship with the employee – Must meet residency and support criteria
A grandchild under age 26
Unmarried disabled dependent (age 26+) – Must live with employee
• A dependent does not include a brother or sister of an employee unless the
sibling is an unmarried individual under 26 years of age who is either:
(1) under the legal guardianship of the employee, or (2) in a regular parentchild relationship with the employee and meets the “any other child” criteria
• Parents and grandparents of the covered employee do not meet the
definition of an eligible dependent
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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 26) 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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Three Steps to Enroll
2 Complete an
Enrollment
Application and
Change Form
1 Choose your
health plan
Available from
your Benefits
Administrator
3 Sign, date and
submit form to
your Benefits
Administrator
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Enrollment
• Enrollment Periods for 2013-2014 Plan Year:
– April 22 – May 24 (Spring Enrollment)
– August 1 – August 31 (Summer Enrollment)
• No pre-existing condition exclusion applies except for those who
previously declined coverage (may be reduced by prior
creditable coverage)
• Passive enrollment – If no plan or coverage changes, then no
form required
Exception: If an employee is enrolled in ActiveCare 1, he or she will be
automatically enrolled in ActiveCare 1-HD effective September 1, 2013,
unless he or she submits an Enrollment Application and Change Form to
select a different TRS-ActiveCare plan option or terminate coverage
• Premium adjusted to reflect any rate change, effective
September 1
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Enrollment Application and Change Form
Who needs to submit a form?
• New hires
– Enrolling or declining TRS-ActiveCare coverage
– Enrolling for TRS-ActiveCare coverage with a different participating
district/entity
• ALL current employees:
– In an effort to get everything correct from the start, everyone must complete
a new enrollment form; even if you decline coverage.
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Enrollment Application and Change Form (Cont’d)
Enrolling for the first time:
• Forms due to the Benefits Administrator before:
– The end of the plan enrollment period, or
– 31 calendar days after the employee’s actively-at-work date, or
– 31 calendar days after a special enrollment event
• New hires may choose their effective date of coverage
– Actively-at-work date, or
– First of the month following their actively-at-work date
Full premium for the month will be due if choosing actively-at-work date;
premiums are not pro-rated
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Pre-existing Condition Exclusions
• Pre-existing condition exclusions will not apply:
– To any individual under the age of 19
– To employees that initially enroll when the district/entity begins participating
in TRS-ActiveCare
– To new hires who enroll within 31 days after their actively-at-work date
– To HMO enrollees
Exception: If a participant has been covered 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 waiting period may apply to employees or
dependents enrolling in the ActiveCare PPO plans due to:
– A special enrollment event
– A transfer to another participating district/entity (or rehire by the same
participating district/entity), if the employee or any covered dependent has
any remaining pre-existing waiting period or a gap in coverage of 63 or
more consecutive days.
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Making Changes/Special Enrollment Events
Enrollees may be able to enroll for coverage, change plan
options, or change the dependents he or she covers during the
plan year within 31 days after a special enrollment event occurs
• New dependent
– Marriage, birth, adoption or placement for adoption
– Special rules apply to newborns
• Loss of other coverage
Changing districts/entities is not considered a special enrollment event
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Newborns
• Covered first 31 days if employee has coverage
– Does not apply to newborn grandchildren
• 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
• Plan changes must be made within 31 days after the newborn’s
date of birth
• 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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Cost for Health Coverage
2013-2014 Plan Year
Cost of Coverage
Funding to Help Offset the Cost of
TRS-ActiveCare Coverage
District/Entity (minimum)
State of Texas
Total Per Month
$198.33
$75
$273.33
Funding applies to active, contributing TRS members
Cost charts illustrate the monthly gross premiums
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Monthly Cost for Coverage
• See page 17 of
Enrollment Guide
• $273.33 in
district/entity
and state funds to
help pay for coverage
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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
• Form available online
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ID Cards (mailed to your home)
• PPO plans (ActiveCare 1-HD, 2 and 3)
– Separate cards for medical and prescription drugs
• Blue Cross and Blue Shield of Texas
• Express Scripts
– BCBSTX will reissue ID cards to existing plan participants transitioning from
AC1-HD to ActiveCare 1 (medical plan ID cards do not expire)
– Prescription drug ID cards will be reissued by Express Scripts for
ActiveCare 1-HD and ActiveCare 2 plan participants
• HMO plans
– All HMO participants will receive new cards
– Each individual covered under the plan will receive a card
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Online Enrollment Support
Available online – www.trs.state.tx.us/trs-activecare
and www.bcbstx.com/trs
• Enrollment guide
• Summary of Benefits and Coverage (SBC)
• Downloadable forms (application and change form,
application to split premium, claim form, etc.)
• Provider locator
• Enrollment presentation
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Blue Access for
Members
Enrollment Info
www.bcbstx.com/trs
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Blue Access for MembersSM
Online member management tool
• Research health conditions
• View claims history and print
Explanation of Benefits (EOB) statements
EOBs are available online; you must log in
and elect to receive paper copies
Send secure
email messages
to BCBSTX
Customer
Advocates
Monday thru Friday
7 a.m. to 10 p.m. (CT)
• Locate a network doctor or hospital
• Order additional ID cards,
or print a temporary ID
• Take a confidential health assessment
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Blue Access Mobile
SM
Blue Access for Members
SM
Secure Site – Log-in Required
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•
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ID Card
My Coverage – Benefits / Eligibility
Visits and Claims
Health and Wellness – Diabetes, Obesity, Nutrition, Fitness, Metabolic
Syndrome, Maternity Care, Member Care Profile
• User Profile
• Register for Blue Access for Members
Public Site – No log-in required
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Health Care 101
Find a Doctor or Hospital
Blue Access for Members Log-in
Contact Information
Provider Finder App
For iPhone® and Android® phones
Text Messaging
Static – One-Way SMS
Messaging Diabetes
Management, Claim Status
Notification Alerts
Dynamic
– Two-Way
Messaging member initiates
text with keyword (ID Card
Management)
A claim has been paid. Please
log in to Blue Access for
Members for details.
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What if I Have Questions?
Personalized Service
• Call TRS-ActiveCare customer service for:
– Claim questions/status
– Network provider information
– Membership and eligibility
– Medical and Rx coverage questions
– Inquiries (telephone and email)
– ID card requests
– Transition of care information
– Help with online tools!
Customer Service
1-866-355-5999
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