presented by: joannie nilan

11

Presented by: Joannie Nilan

HIGHHIGHOPTIONOPTION

22

How We Change for 2012How We Change for 2012Section 2. Page 10Section 2. Page 10

Weight Management Program Managed by CIGNA/CareAllies:

1-800-582-1314 - Prompt 6o No participation requirements

o $0 copay for in-network office visits to a registered Dietician/Nutritionist

o Health and Wellness Coaches to assist with individual needs and guidance

o Workbook and Tool Kit to keep you on track and motivated

33

How We Change for 2012How We Change for 2012Section 2. Section 2. (continued…)(continued…)

Plavix has been added to the list for Pharmacogenomic Testing for prescription drug therapies for certain conditions.o Anti-platelet drug used to assist in blood clotting

Out-of-Network Routine Gynecological visits for pap testo One annually

o Standard out-of-network rate

44

How We Change for 2011How We Change for 2011Section 2. Section 2. (continued…)(continued…)

Routine Sigmoidoscopy screenings starting at age 50 – no longer limited to every 5 years

Routine Colonoscopy screenings starting at age 50 – no longer limited to once every 10 years

55

FactsFactsSection 1. Page 8Section 1. Page 8

FFS / Non-PPOo Fee For Serviceo Standard benefitso World wide coverageo Do not discount serviceso Do not agree to accept the Plan allowanceo Higher deductibles, coinsurance, and out-of-pocket

PPOo Preferred Provider Organizationo Vendor negotiated contractso Agree to accept discounted fee for serviceso Always accept the Plan allowance (contracted

allowance)o Lower deductibles, coinsurance, copayments, and out-

of-pocket

66

FactsFactsSection 1. Page 9Section 1. Page 9

Vendors o CIGNA – Medical PPO Vendor and

Precertification Vendor• 6,100 hospitals• 815,000 providers • Precert

o ValueOptions - Mental Health and Substance Abuse Vendor

• 4,000 facilities • 62,000 providers • Precert

77

FactsFactsSection 1. Section 1. (continued…)(continued…)

Medco – Prescription Drug Vendor

○ 66,000 pharmacies

○ RX

○ Personalized Medicine

○ Specialty Drugs

○ Precert some drugs

88

How to Get CareHow to Get CareSection 3. Page 11Section 3. Page 11

ID Cards/Health Benefits Election Form / Electronic Confirmation Letter

Precertificationo Inpatient Stayso Surgeries

• Cosmetic, Transplants, Morbid Obesity, Organic Impotence

o Rehabilitative Therapy (PT/OT/ST)

99

How to Get CareHow to Get CareSection 3. Section 3. (continued…)(continued…)

o Infusion and Growth Hormone Therapy

o Nursing Visits

o DME

o High Tech Radiology/Imaging

o Mental Health and Substance Abuse

o Some Drugs

1010

Your CostYour CostSection 4. Page 18Section 4. Page 18

Cost Benefit PPO Non-PPO

Copayments(co-pays)

Office VisitRoutineHospital Admit

$18.00 $18.00$0/coinsurance

Coinsurance

$300 fee + coinsurance

Deductible Must meet Individual or Family deductible; whichever comes first

$275 Individual$550 Family

$500 Individual$1,000 Family

Coinsurance(Coins)

Benefits with Coins 10% Member90% Plan

30%* Member70% Plan

Out-of- Pocket

Co-pays and Coins only(Deductibles and non covered charges are not included)

$4,000 $10,000

*Of plan allowance and any difference between our allowance and billed amount

1111

BenefitsBenefits Section 5. Pages 28Section 5. Pages 28

5 (a). Medical Services and Supplies

Diagnostic and Treatment o Physician visits in office and other locations

o Lab, X-ray and other diagnostic tests such as…

• Blood test, urinalysis, pathology, EEG and EKG

1212

BenefitsBenefits Section 5. Section 5. (continued…)(continued…)

CT and Pet scans, MRIs, MRAs, Nuclear Medicine○ Require pre-certification; failure to do so may

result in a minimum $100 penalty

Genetic Testing for Drug Therapies○ Tamoxifen (for Breast Cancer)

○ Warfarin (anticoagulant)

○ Plavix (antiplatelet)

1313

BenefitsBenefits Section 5. Page 29Section 5. Page 29

Adult - Preventive Careo After age 12 one routine exam per person

every two calendar years

• Office visit

• Lab tests: comprehensive metabolic panel, lipid panel and urinalysis

1414


o Women age 18 or older, one routine GYN visit for Pap smear – PPO and in 2012 Non-PPO

o Member pays $18 co-payment if rendered by a PPO provider

o Non-PPO provider the member pays 30% of the Plan allowance and the difference between the allowance and the billed charge – deductible applies.

1515


Adult Routine Screenings One annual total blood cholesterol testFasting Lipoprotein once every 5 yearsOsteoporosis screeningsChlamydia infection testsColorectal cancer screenings

o Sigmoidoscopy and Colonoscopy screenings starting at age 50

1616


Prostate cancer screenings

Routine Pap smear

Abdominal aortic aneurysm screening

Routine mammograms with age restrictions

Adult immunizations recommended by the CDC

1717


Children - Preventive Careo Childhood immunizations recommended

by the American Academy of Pediatrics

o Well child physical exams and lab tests through age 12

o One screening for Amblyopia and Strabismus ages 2 – 6

o One screening of premature infants for Retinopathy

1818


Maternity Care o Delivery and Pre and Postnatalo No pre-cert required for inpatient hospital

benefits if mom and baby leave within 48 hours for a normal delivery and within 96 hours for a C-section

Infertility Serviceso Coverage for specific services see Plan

Brochureo Maximum Plan payout of $2500 annually

1919


Family Planningo Voluntary sterilizationo Surgically Implanted Contraceptiveso Injectable Contraceptives o IUDo Diaphragms

Oral contraceptives payable under Prescription Drug benefit

Non-covered: Reversal of voluntary sterilization and genetic counseling

2020

Allergy Careo Testing and treatment including materialso Allergy Shots

Treatment Therapieso Chemotherapy, Radiationo Dialysiso Respiratory and Inhalationo IV and Growth Hormone (Require Approval)• Drugs used are covered under the

Prescription Drug benefit


2121

Physical, Occupational and Speech Therapy

o Limited to 60 Combined Visits per Calendar Year

o Pre-authorization is Required

o Non-Covered: Maintenance Therapy, Exercise Programs, etc.


2222

Hearing Serviceso One exam and testing for hearing aids every

2 yearsVision Care

o Internal ocular lenses / first contact lenses to correct impairment

o Non-covered• Eyeglasses and contact lenses• Eye exercises• Refractive surgery


2323

Routine Foot Careo Only covered for a metabolic or peripheral vascular disease, such

as diabetes

Orthopedic and Prosthetic Deviceso Leg, arm, neck and back braces o Artificial limbs, eyeso External breast prostheses, surgical bras following a

mastectomyo Internal devices, joints, pacemakers and surgically

implanted breast implant following a mastectomyo Pre-authorization is recommendedo Non covered items:

• orthopedic/corrective shoes, arch and lumbosacral supports, foot orthotics, corsets, stockings, support hose


2424

Hearing Aidso No Deductibleo $1500 Benefit every 3 years

Durable Medical Equipment (DME) o Pre-certification Requiredo Covered:• Oxygen and Dialysis equipment• Hospital beds and wheelchairs• Ostomy supplies• Crutches and walkers


2525

o Non-Covered:• Whirlpool equipment• Sun and heat lamps• Light boxes• Exercise devices• Stair glides• Elevators• Air purifiers• Computer Story boards, light talkers or

other communication aids for the communication-impaired individual


2626

Home Health Services

o Preauthorization is Required

o Performed by a RN, LPN or LVN

o 25 Visit Limit per Calendar Year

o Maximum Plan Benefit of $90 per Day


2727

Chiropractic Serviceso 12 Visit Limit per Calendar Year

Acupuncture by a MD or DO


2828

Educational Programso Limited to the CIGNA Tobacco Cessation

Programo Program is 100% Voluntaryo Enhanced PPO Benefito Managed by CIGNA/CareAllieso Easy Enrollment• Telephonically or online

o Compliance Requirement• 4 Counseling sessions of 30 minutes each


2929

Tobacco Cessation Benefits

o Enhanced benefit immediately upon enrollment

o Coverage for 2 quit attempts per year

o Prescription and over-the-counter medications for Nicotine Replacement Therapy

o No Lifetime Limit


3030

5 (b). Surgical and Anesthesia ServicesSurgery

o A comprehensive range of services for operative procedures including pre and post operative care

Pre-certification required foro organ transplanto cosmetic surgeryo surgery for morbid obesity ando organic impotence

Anesthesia


3131

5 (c). Hospital or Other Facility and Ambulance

Inpatient Hospitalo Pre-certification required: • 48 hours before a scheduled admission and 48

hours after an emergency admission.• Failure to pre-cert results in a minimum $500

penalty• Member should always make sure the

hospital/doctor pre-certifies the stayo Non PPO hospital confinements have a $300

per admission feeo Calendar year deductible does not apply


3232

o Room and Board• Private rooms covered for isolation to prevent

contagiono Ancillary Services• General nursing care• Meals • Operating, recovery, maternity and other

treatment rooms• Prescribed drugs• Diagnostic lab tests and X-rays• Blood, supplies, equipment• Anesthetics


3333

o Non-covered Items:

• Any part of admission not medically necessary

• Custodial Care

• Personal Convenience Items

• Private Duty Nurses


3434

o Non-covered Facilities:

• Nursing Homes

• Skilled Nursing

• Residential Treatment

• Day and Evening Care

• Schools


3535

Cancer Centers of Excellence

o Higher level of benefits

o Member responsibility is only 5% of the Plans allowance when using a designated facility

o Managed by CIGNA/CareAllies: 1-800-582-1314


3636

Outpatient Hospital or Ambulatory Surgery Centero Operating, recovery and other treatment

roomso Prescribed Drugso Diagnostic Lab Test and X-rayso Blood and Administrationo Pre-surgical Testingo Supplies o Anesthetics


3737

Hospice Care o Annual Benefito $3,000 outpatiento $2,000 inpatiento $200 bereavement per family unit

Ambulanceo Local professional ambulance service when

medically necessaryo Ambulance service for routine transport is

not covered


3838

5 (d). Emergency Services and Accidents

Accidental Injuryo Bodily injury sustained solely thru violent,

external and accidental means o Broken Boneso Animal Biteso Poisonings

Medical Emergencyo Sudden and unexpected onset of a conditiono Heart Attacko Strokeo Sudden inability to breathe


3939

Accidental Injury: Within 24 hours our member pays

o nothing if rendered by a PPO providero only the difference between our Allowance and

the billed charge by a Non-PPO provider After 24 hours our member pays

o $18 co-pay if rendered by a PPO providero After Non-PPO deductible is satisfied, 30% of

Plan Allowance and any difference between our Allowance and billed charge

Inpatient benefits apply if admitted


4040

Medical Emergency: Outpatient Facility Charges in an Urgent Care

Center our member payso PPO facility - $40 Co-paymento Non-PPO facility – After Non-PPO calendar year deductible is

satisfied, 30% of Plan Allowance and any difference between our Allowance and billed charge

Outpatient Medical or Surgical Services and Supplies, Other Than Urgent Care Center our member payso PPO facility - After PPO calendar year deductible is satisfied,

member is responsible for 10% of Plan Allowanceo Non-PPO facility - After Non-PPO calendar year deductible is

satisfied, member is responsible for 30% of Plan Allowance and any difference between our Allowance and billed charge.

Ambulance


4141

5 (e). Mental Health and Substance Abuse

All services pre-certified through ValueOptions

The separate deductible for this benefit was eliminated in 2011

In and Out-of-Network mirror the medical benefits


4242

5 (f). Prescription Drug BenefitMedco Health Administers Our Drug PlanGeneric

o Generic is chemically equivalent to Brando Normally dispensed

Brando Prior authorization is recommendedo Higher member responsibility


4343

Non-Network Retailo 30 day supplyo 50% of the cost of the drugo $8.00 minimum

Network Retailo 30 day supplyo Generic = $8.00 co-payo Brand = 25% coinsurance with minimum of $8.00 and

$200 maximum out-of-pocketo Refill Restrictions• Only 2 fills of the same prescription• All other fills are at the non-network rate


4444

Mail Ordero 90 day supplyo Generic = $15.00 co-payo Brand = 25% coinsurance with $12.00

minimum and $600 maximum out-of-pocket

Drugs Requiring Preauthorizationo Organic Impotence o Cosmetic Purposeso Recommended for Brand Name


4545

Personalized Medicineo Voluntary Program

o Pharmacogenomic test for drug therapies

• Tamoxifen (for breast cancer)

• Warfarin (anticoagulant)

• Plavix (antiplatelet)


4646

5 (g). DentalAccidental Injury to Teeth

o Repair not replace sound natural teetho Result of an accident and be preformed within

2 years of accidento Different benefit level with in 24 hours and

after 24 hours

Routine Dentalo Two office visits per calendar year – Includes:

Exam, Cleaning, X-rays of all types, Fluoride Treatment, Fillings and Simple Extractions


4747

5(h). Special Features

Flexible Benefits Option

24-hour Nurse Line

TDD line for hearing impaired

Wellness

Review and Reward Program


4848

Disease Management – SmartStepsVoluntary ProgramVariety of Services to Manage Chronic

Conditionso Cardiac

o Diabetes

Managed by CIGNA/CareAllies: 1-800-582-1314


4949

Diabetes Management ProgramManaged by CareAllies: 1-800-582-

1314Compliance Requirements:

Members must have one annual:o Diabetic nephropathy and retinopathy screeningo Annual labs that include

• LDL and HDL cholesterol test• Triglycerides test• Serum Creatinine test

Must have: o AIC blood test every 6 monthso Services by a PPO provider every 6 months for diabeteso Coach contact once a quartero Take prescription regularly


5050

o As long as the member stays compliant with the program they will be rewarded with• $0 co-pay for PPO office visits for treatment of diabetes

(not including Podiatrist/Ophthalmologist)• $0 coinsurance for PPO lab tests related to treatment of

diabetes• $0 co-pay for Medco by Mail Generic drugs specific to

lowering blood sugar• $0 co-pay for Insulin from Medco by Mail• $0 co-pay for test strips, lancets, syringes, pen needles

and Insulin Pump supplies from Medco by Mail• $0 coinsurance for Insulin Pumps purchase in-network

(preauthorization required)

Members who have Medicare as their primary insurance do not have to participate in the program, but will automatically be eligible for $0 co-pay for Medco by Mail generic drugs, Insulin, test strips, and other supplies as noted.


5151

Hypertension Management ProgramManaged by CIGNA/CareAllies:

1-800-582-1314Compliance Requirements:

o Coach contact once every 3 monthso Members must know their numberso Members must see their doctor once per year for

Hypertension o Must take their prescriptions regularlyo Must schedule the next coach call


5252

o As long as the member stays compliant with the program they will be rewarded with:• $0 co-pay for PPO office visits for treatment of

Hypertension• $0 deductible/coinsurance for PPO Serum Creatinine

lab test related to treatment of Hypertension• $0 co-pay for Medco by Mail Generic drugs for

treatment of Hypertension

Members who have Medicare as their primary insurance do not have to participate in the program, but will automatically be eligible for $0 co-pay for Medco by Mail Generic drugs.


5353

Weight Management ProgramManaged by CIGNA/CareAllies:

1-800-582-1314o $0 co-pay for in-network office visits to a

registered Dietician/Nutritionist

o Access to Health and Wellness coaches

o Receive a Workbook and Tool Kit


5454

Medco Health Store - www.medco.comMedco’s consumer health products

websiteo 24/7 online access to consumer health products

o Purchase and shipment by mail of consumer health products

o Wide range of products at competitive prices

o Drug safety checking


5555

CIGNA / CareAllies Special Programs: 1-800-582-1314 Lifestyle programs

o Personalized Plans Healthy Rewards and MyCareAllies

o Discounts on Smoke Cessation Programso Discounts on Weight Reduction Programso Savings on Gym Membershipso Vision and Hearing Exam Discountso Discounts on Herbal Supplements and

Vitaminso Discounts on alternative medicine and

anti-cavity products


5656

General ExclusionsGeneral ExclusionsSection 6. Page 99Section 6. Page 99

Services or supplies deemed not medically necessary, administered by a non-covered provider, not specifically listed as covered

Experimental or investigationalCommunication aids Educational or self help trainingCharges in excess of the plan allowance“Never Events”

5757

Filing a ClaimFiling a ClaimSection 7. Page 100Section 7. Page 100

Complete claim form, i.e. HCFA, UB04, or Dental

Medicare or Other Insurance payment statement must be submitted if applicable

Timely Filing Limito December 31st of the year following the year

of service

5858

Coordinating BenefitsCoordinating BenefitsSection 9. Page 104Section 9. Page 104

Medicareo A = Hospitalo B = Medicalo C = Advantage/HMOo D = Prescription Drugs

Other Insurance Coverage (OIC)

Tricare/Champus/ ChampVA

Medicaid

5959

20122012 RATERATESS

59

6060

www.apwuhp.comwww.apwuhp.com

Online Tools and Resources

eHealthRecord

Microsoft Health Vault

o Personal Health Record

Health Assessment

6161

www.apwuhp.comwww.apwuhp.com

Consumer Choice Information

Online PPO Directory

Hospital Quality Ratings Guide

Treatment Cost Estimator

Prescription Drug Information

6262

High Option Benefit PlanHigh Option Benefit Plan

Also available on our website:

HPR Tab

Visitor Tab

Brochure

Newsletters

AARP Health Tools

6363

Thank You!Thank You!Please fill out your class evaluation form and place it in the drop box in the classroom.

Please note any questions for the HPR Roundtable discussion on the card provided and place in the drop box at the Registration Desk. The Roundtable discussion will be during Closing Session on:

Saturday, October 15, 2011 63

presented by: joannie nilan

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