Agenda. TRS-ActiveCare Program Highlights

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2 Agenda TRS-ActiveCare Program Highlights Enrollment Summary Facts and Figures Health Plan Options ActiveCare 1-HD, ActiveCare Select/ActiveCare Select Whole Health and ActiveCare 2 HMO Plans How to Enroll Who is Eligible to Enroll Cost of Coverage Enrollment Support 2

3 What is TRS-ActiveCare? Established and signed into law in 2001 (Chapter 1579, Texas Insurance Code) A statewide health care benefits program for employees of school districts, charter schools, regional educational service centers and other educational districts Law authorizes funding levels to help employees pay for coverage 1,127 districts/entities participate in TRS-ActiveCare (90% of eligible entities) 3

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5 What s new? What s New ActiveCare 1-HD ActiveCare Select or ActiveCare Select Whole Health Out-of-network deductible Out-of-network out-ofpocket maximum $5,000/$10,000 Not applicable no coverage for out-ofnetwork $13,100/$26,200 Not applicable no coverage for out-ofnetwork ActiveCare 2 $2,000/$6,000 $14,300/$28,600 What s Changing ActiveCare 1-HD ActiveCare Select or ActiveCare 2 ActiveCare Select Whole Health In-network out-ofpocket No change $7,150/$14,300 $7,150/$14,300 maximum Emergency Room copay No change $200 copay plus 20% after deductible $200 copay plus 20% after deductible Cost of coverage Increase for all coverage tiers Increase for all coverage tiers Increase for all coverage tiers If you live in Fort Bend, Harris, Montgomery, Galveston and Brazoria counties, you will have a new ActiveCare Select network available, effective Sept. 1,

6 ALEX Need help deciding which plan is right for you, ALEX, your online benefits advisor can: Help you understand and compare plans Explain health benefits terms - without all the jargon Show you how deductibles, coinsurance and out-of-pocket maximums work 6

7 ActiveCare 1-HD In-network out-of-pocket maximum (no changes) ActiveCare 1-HD meets IRS definition of a high deductible health 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. TRS does not administer an HSA. ActiveCare 1-HD has enhanced generic preventive drug coverage deductible and coinsurance will be waived for certain generic preventive drugs Out-of-Pocket Maximum (employee only/family) Plan Year Plan Year $6,550/$13,100* (includes deductibles of $2,500/$5,000, medical and prescription drug copays and coinsurance) *capped at $6,550 for each individual on a family plan $6,550/$13,100* (includes deductibles of $2,500/$5,000, medical and prescription drug copays and coinsurance) *capped at $6,550 for each individual on a family plan 7

8 NEW! ActiveCare 1-HD Out-of-network deductible and out-of-pocket maximum New out-of-network deductible and out-of-pocket maximum Out-of-network expenses will no longer count towards meeting the in-network deductible or accumulate towards reaching the in-network out-of-pocket maximum Out-of-Network Deductible (employee only/family) $5,000/$10, Plan Year Out-of-Pocket Maximum (individual/family) $13,100/$26,200* (includes deductibles of $5,000/$10,000, medical and prescription drug copays and coinsurance) *capped at $13,100 for each individual on a family plan 8

9 ActiveCare 2 in-network out-of-pocket maximum Plan Year Plan Year Out-of-Pocket Maximum (individual/family) $6,850/$13,700 (includes medical and prescription drug deductibles, copays and coinsurance) $7,150/$14,300 (includes medical and prescription drug deductibles, copays and coinsurance) 9

10 NEW! ActiveCare 2 Out-of-network deductible and out-of-pocket maximum New out-of-network deductible and out-of-pocket maximum Out-of-network expenses will no longer count towards meeting the in-network deductible or accumulate towards reaching the in-network out-of-pocket maximum Out-of-Network Deductible (individual/family) $2,000/$6, Plan Year Out-of-Pocket Maximum (individual/family) $14,300/$28,600 (includes deductibles of $2,000/$6,000, medical and prescription drug copays and coinsurance) 10

11 ActiveCare Select/ActiveCare Select Whole Health out-of-pocket maximum Out-of-Pocket Maximum (individual/family) Plan Year Plan Year $6,850/$13,700 (includes medical and prescription drug deductibles, copays and coinsurance) $7,150/$14,300 (includes medical and prescription drug deductibles, copays and coinsurance) 11

12 ActiveCare 1-HD Out of Pocket Maximum Illustration In this example, the family has met the in-network deductible as a group. The amounts in blue have been applied to their in-network individual and family in-network out-of-pocket maximum. Mom now has a claim with an allowed amount of $35,000. Since the plan deductible is met, her coinsurance amount (her 20%) is $7,000. Since she now has an individual limit, she will only be liable up to $6,550, and the the remaining $450 is paid at 100%. This combined with the other family members puts the combined family accumulations to $11,550. When this total is met by the remaining members, then all will be considered as met. $6,550 Individual Combined Family Deductible Out of Pocket Maximums $13,100 Family $6,550 Son $200 $4,700 Mom $0 Dad $4,700 $5,000 $200 $100 Daughter $100 Deductible Coinsurance Family $11,550 Mom Dad Son Daughter Family 12

13 ActiveCare 1-HD Out of Pocket Maximum Illustration In this example, the family has met the in-network deductible as a group. The amounts in blue have been applied to their individual and family in-network out-of-pocket maximum. Dad now has a claim with an allowed amount of $25,000. Since the plan deductible is met, his coinsurance amount (his 20%) is $5,000. Since he now has an individual limit, he will only be liable up to $6,550, and the remaining $3,150 is paid at 100%. This combined with the other family members puts the combined family accumulations to $6,850. When this total is met by the remaining members, then all will be considered as met. $6,550 Individual Combined Family Deductible Out of Pocket Maximums $13,100 Family Son $200 $1,850 $4,700 Mom $0 Dad $4,700 $5,000 $200 Daughter $100 $100 Deductible Coinsurance Family $6,850 Mom Dad Son Daughter Family 13

14 Family deductible illustration Amy covers a spouse and three dependents ActiveCare 1-HD with a $5,000 in-network family deductible The family deductible may be met by one or more people Plan pays benefits once entire $5,000 is met there is no individual deductible to meet Amy Ted Bob Sue Chris $5,000 ActiveCare Select with a $1,200 in-network individual deductible and a $3,600 in-network 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 $1,200 $800 $600 $400 $200 14

15 Choice POS II Network for ActiveCare 1-HD and ActiveCare 2 In-Network: Always verify provider network status Out-of-Network: Statewide 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 You pay more of the cost of out-of-network benefits Higher deductibles, coinsurance Higher out-of-pocket maximum You may need to file your own claim You could be balance billed for amounts over allowed amount 15

16 Choice POS II Plan overview (In-Network level of benefits) (In-Network level of benefits) ActiveCare 1-HD ActiveCare 2 Deductible $2,500 employee only $5,000 family $1,000 individual $3,000 family Out-of-Pocket Maximum (includes medical and prescription drug copays/deductibles/coinsurance) $6,550 employee only $13,100 family $7,150 individual 14,300 family Coinsurance (Plan pays/participant pays) 80% / 20% 80% / 20% Office Visit Copay 20% after deductible $30 for primary $50 for specialist Primary means care provided by family practitioners, internists, OB/GYNs and pediatricians. All other physicians are specialists. 16

17 Choice POS II Plan overview (In-Network level of benefits) Preventive Care Clarification ActiveCare 1-HD ActiveCare 2 Preventive Care Plan pays 100% (deductible waived) Plan pays 100% (deductible waived; no copay required) Routine eye exam (one per plan year) Hearing exam 20% after deductible $30 for primary $50 for specialist 100% coverage for certain age- and gender-specific preventive care services when network providers are used Must be billed by provider as preventive care 17

18 Choice POS II Plan overview (In-Network level of benefits) (In-Network level of benefits) Benefits (continued) Services ActiveCare 1-HD ActiveCare 2 High-tech Radiology (CT scan, MRI, nuclear medicine) 20% after deductible $100 copay per service, plus 20% after deductible Inpatient Hospital 20% after deductible $150 copay per day, plus 20% after deductible ($750 max copay per admission; $2,250 max/year) Emergency Room 20% after deductible $200 copay, plus 20% after deductible (copay waived if admitted) Outpatient Surgery 20% after deductible $150 copay per visit, plus 20% after deductible 18

19 Choice POS II Plan overview (In-Network level of benefits) Added Savings and Value with Quest Diagnostics Diagnostic Lab Services ActiveCare 1-HD ActiveCare 2 Quest Facility 20% after deductible Plan pays 100% (deductible waived) Other Facility 20% after deductible 20% after deductible 19

20 ActiveCare Select /ActiveCare Select Whole Health Plan In-Network Only Plan: No need to: Select a Primary Care Physician Obtain referrals for specialist care Always verify provider network status Out-of-Network: No coverage except in a true emergency Two Networks: Aetna Whole Health Aetna Select Receive highest level of benefits: Pay less for care No balance billing No claim forms: Provider files claim for you Is this plan for you? You may want to consider the this plan if you: Understand which ActiveCare Select network you will be placed in Do not expect to use out-of-network providers Do not cover dependents who live outside your plan s network area Want a lower deductible and a lower premium cost for coverage 20

21 ActiveCare Select/ ActiveCare Select Whole Health NEW network Kelsey Select (Network benefits ONLY plan*) You will be automatically enrolled in a network based on where you live If you live in one of these counties Ft. Bend Harris Montgomery Galveston Brazoria (certain zip code areas*) If you do not live in a county listed above ActiveCare Select Whole Health Network Memorial Hermann Accountable Care Network or Kelsey Select Kelsey Select Aetna Select Network *Brazoria Zip Code areas 77511, 77512, 77578, 77581, 77583, 77584, *Only pays for out-of-network care in a true medical emergency 21

22 ActiveCare Select/ ActiveCare Select Whole Health Plan overview (Network benefits ONLY plan*) You will be automatically enrolled in a network based on where you live If you live in one of these counties ActiveCare Select Whole Health Network Bexar Comal Collin Dallas Denton Ellis Ft. Bend Harris Montgomery Guadalupe Kendall Parker Rockwall Tarrant Baptist Health System and HealthTexas Medical Group Baylor Scott & White Quality Alliance Memorial Hermann Accountable Care Network Or Kelsey Select Galveston Brazoria (certain zip code areas) Kelsey Select Hays Travis Williamson Seton Health Alliance If you do not live in a county listed above ActiveCare Select Network *Only pays for out-of-network care in a true medical emergency 22

23 ActiveCare Select/ ActiveCare Select Whole Health Plan overview (Network benefits ONLY plan*) Preventive Care Clarification Preventive Care Plan pays 100% (no copay required) Routine eye exam (one per plan year) Hearing exam $30 for primary $60 for specialist 100% coverage for certain age- and gender-specific preventive care services when network providers are used Must be billed by provider as preventive care *Only pays for out-of-network care in a true medical emergency 23

24 ActiveCare Select/ ActiveCare Select Whole Health Plan overview (Network benefits ONLY plan*) Benefits (continued) Services High-tech Radiology (CT scan, MRI, nuclear medicine) Inpatient Hospital $100 copay per service, plus 20% after deductible $150 copay per day, plus 20% after deductible ($750 maximum copay per admission) Emergency Room Outpatient Surgery $200 copay, plus 20% after deductible (copay waived if admitted) $150 copay per visit, plus 20% after deductible *Only pays for out-of-network care in a true medical emergency 24

25 ActiveCare Select/ ActiveCare Select Whole Health Plan overview (Network benefits ONLY plan*) Added Savings and Value with Quest Diagnostics Diagnostic Lab Services Facility Quest Facility Plan pays 100% (deductible waived) Other Facility 20% after deductible *Only pays for out-of-network care in a true medical emergency 25

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27 Teladoc Teladoc may be a potential and more affordable alternative to emergency room and urgent care. Many common medical issues can be resolved through the convenience of just a phone call or NEW! this year - a video chat 24/7/365 Highlights include. Copays waived for and ActiveCare Select/ActiveCare Select Whole Health and ActiveCare 2 plans; only $40 consultation fee for ActiveCare 1-HD plan. Board certified providers specializing in family practice, internal medicine and pediatrics. Common diagnosis and treatment of common conditions such as sinusitis, upper respiratory infection, urinary tract infection, bronchitis, ear infections, influenza and the common cold. Consults available wherever the patient is at home, at work, or travelling within the United States. Guaranteed member call or video chat back within 60 minutes! The average call back time is minutes or schedule a call back at a specific time. Diagnosis, recommended treatment and prescriptions ordered when appropriate. A copy of the consult record will be sent to the member s PCP upon request. 27

28 Health and wellness resources For personal help with health conditions, challenges and goals Simple Steps To A Healthier Life Aetna Health Connections Beginning Right Maternity Program Aetna Care Advocate Team National Medical Excellence Program 24-Hour Nurse Information Line Live Healthy Challenge SM 28

29 Aetna Health Concierge A single source for help and information Answers to benefits questions Help to find care and services Information about helpful programs and resources A personal guide to Aetna Navigator 29

30 Aetna discount programs For savings on a wide variety of health needs Fitness memberships and equipment Hearing aids and exams Vision care Weight management programs Natural products and services 30

31 TRS-ActiveCare Aetna website 31

32 Your secure member website Aetna Navigator Check benefits and claims Search for doctors in the network See the cost and patient ratings of providers Order additional ID cards, or print a temporary ID card Cost of Care tools Know the cost before you go Take a confidential health assessment 32

33 Choose wisely save money Aetna Member Payment Estimator Helps you make smarter care choices Compares costs for common procedures and treatments Know the cost of the care before you go 33

34 Mobile apps and tools Aetna Mobile Secure Site Log-in Required Find a network doctor Check your plan coverage Check on a claim Show you ID card Contact TRS-ActiveCare Customer Service Teladoc 24/7/365 access to doctors by phone Get treatment for colds, allergies, ear infections and much more MyQuest Schedule a lab appointment Find a lab near you Check you results 34

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36 Your Prescription Drug Plan Caremark administers your prescription drug plans on behalf of TRS ActiveCare 1-HD, ActiveCare Select and ActiveCare 2 plans Benefit includes both a retail and mail component ActiveCare 1-HD will have enhanced generic preventive drug coverage. Certain generic preventive drugs are available at no cost. Go to to view the list. Caremark 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 36

37 Prescription Drug benefits network level Features ActiveCare 1-HD ActiveCare Select /ActiveCare Select Whole Health Active Care 2 Drug Deductible (per person, per plan year) Subject to plan year deductible $0 generic; $200 brand $0 generic; $200 brand Short-Term Supply at a Retail Location (up to 31-day supply) Tier 1 (Generic) Tier 2 (Preferred Brand) Tier 3 (Non-Preferred Brand) Extended-Day Supply at Mail Order or Retail-Plus Pharmacy Location (up to 60- to 90-day supply)** Tier 1 (Generic) Tier 2 (Preferred Brand) Tier 3 (Non-Preferred Brand) 20% coinsurance after deductible (deductible and coinsurance waived for certain generic preventive drugs) $20 for a 1- to 31-day supply $40 for a 1- to 31-day supply* 50% coinsurance for a 1- to 31-day supply* $45 for a 60- to 90-day supply $105 for a 60- to 90-day supply* 50% coinsurance for a 60- to 90-day supply* $20 for a 1- to 31-day supply $40 for a 1- to 31-day supply* $65 for a 1- to 31-day supply* $45 for a 60- to 90-day supply $105 for a 60- to 90-day supply* $180 for a 60- to 90-day supply* Specialty Medications 20% coinsurance after deductible 20% coinsurance per fill $200 per fill (up to 31-day supply) $450 per fill (32- to 90-day supply) *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. Go to to view the list of generic preventive drugs) **You can fill 32-day to 90-day supply through mail order. 37

38 Short-Term Supplies of Maintenance Medications - network level Features ActiveCare 1-HD ActiveCare Select /ActiveCare Select Whole Health ActiveCare 2 Short-Term Supply of a Maintenance Medication at Retail Location (up to a 31-day supply) The second time a participant fills a short-term supply of a maintenance medication at a retail pharmacy, they will pay a convenience fee. They will be charged the coinsurance and copays in the row below the second time they fill a short-term supply of a maintenance medication. Participants can avoid paying the convenience fee by filling a larger day supply of a maintenance medication through mail order or at a Retail-Plus location. Tier 1 (Generic) Tier 2 (Preferred Brand) Tier 3 (Non-Preferred Brand) 20% coinsurance after deductible (deductible and coinsurance waived for certain generic preventive drugs) $35 for a 1- to 31-day supply $60 for a 1- to 31-day supply* 50% coinsurance for a 1- to 31-day supply* $35 for a 1- to 31-day supply $60 for a 1- to 31-day supply* $90 for a 1- to 31-day supply* *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. Go to to view the list of generic preventive drugs) 38

39 Diabetic Meter and Supplies network level Features ActiveCare 1-HD ActiveCare Select/ActiveCare Select Whole Health Active Care 2 Preferred brand glucose meter Free Free Free Short-term retail supplies 90-day supply at Retail-Plus or mail-order service Copays waived for needles and syringes only if purchased same day as insulin and insulin processed first. Copays waived for needles, syringes and alcohol swabs regardless of whether processed on same day as insulin and regardless of brand. To receive test strips and lancets at no cost, you must use the preferred brand. Copays waived for needles and syringes only if purchased same day as insulin and insulin processed first. Copays waived for needles, syringes and alcohol swabs regardless of whether processed on same day as insulin and regardless of brand. To receive test strips and lancets at no cost, you must use the preferred brand. Copays waived for needles and syringes only if purchased same day as insulin and insulin processed first. Dispense as written penalty does not apply to waived copays. Copays waived for needles, syringes and alcohol swabs regardless of whether processed on same day as insulin and regardless of brand. To receive test strips and lancets at no cost, you must use the preferred brand. Dispense as written penalty does not apply to waived copays. 39

40 Caremark s online tools and mobile apps help connect patients and their caregivers Prescription Alerts Alerts you to refills available at mail or retail, remaining refills, last refill, past due refills; add to cart right there Savings Opportunities Displays savings for each member of the family, with ability to request a medication change online Recent Orders Provides capability to track orders and alerts members of any changes to status Refill and Manage Family prescriptions can be managed in one place with a few clicks 40

41 Innovation that can help participants make better decisions for healthier outcomes Only PBM to offer native pre-log in functions for iphone and Android Scan to refill multiple Rx checkout Pill identifier Drug interaction checker After log in functions available Find drug costs Find a pharmacy in network View digital ID card See prescription orders and history Refill prescriptions 41

42 Specialist Pharmacists are an integral part of the health care continuum The Caremark Specialty Pharmacy provides not only your specialty medicines, but also personalized pharmacy care management services: Access to a team of clinical experts that are specially trained in your condition On-call pharmacist 24 hours a day, seven days a week Coordination of care with you and your doctor Convenient delivery to the address of your choice, including your doctor s office Medicine- and condition-specific education and counseling Insurance and financial coordination assistance Confidential and empathetic care Online support and resources through including condition-specific information and the specialty pharmacy drug list 42

43 Information resources TRS Website Pharmacy Benefit Highlights List of maintenance medications FAQs Download forms Caremark Participant Website 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 Caremark widget Customer Service Benefits Booklet 43

44 What if I have questions? Personalized Service Call TRS-ActiveCare customer service for: Claim questions/status Network provider information Medical and Rx coverage questions Inquiries (telephone and ) ID card requests Transition of care information Help with online tools TRS-ActiveCare Customer Service

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46 Ways to Save Use the ER Wisely Visit the Emergency Room for life-threatening emergencies only Go to the right place for care Use urgent care or walk-in clinics for non-life-threatening emergencies Stay in Network Make use of Aetna s negotiated discounts with health care systems and professionals Use 90-day supply When it comes to medications that are taken regularly, ordering a large supply saves you time and money Informed Health Line Call the 24-Hour Nurse Line at to get guidance from a trained nurse Teladoc Take advantage of quick help, 24/7 at

47 Go to the Right Place for Care Knowing your options for medical care can help you save time and money. Follow this path to get the right level of care at the right place for the lowest cost. Login to your secure member website at to find your closest options. Avoid freestanding emergency rooms, if possible. These facilities have emergency in the name, but they are not physically attached to a hospital Aetna Inc

48 Fill 90-Day Supplies of Maintenance Medications to Save Money You may be paying higher out-of-pocket costs for maintenance medications When it comes to medications that are taken regularly, there are two easy ways to save time and money: Retail-Plus pharmacies that fill 90-day supplies of maintenance drugs. Use the Retail-Plus pharmacy locator online at 90-day refills by Caremark s mail-order services. There s no cost for shipping and Caremark will deliver anywhere you like. Caremark will contact the doctor for a new prescription and handle all the details. You can set up mail order by visiting Caremark.com/mailservice. You can fill a 90-day supply through mail order, and break up your coinsurance or copay into three monthly payments. For example, you can pay $15 per month to satisfy your $45 copay for a 90-day supply of a maintenance medication when using the mail-order service. 48

49 More Ways to Save Use generic drugs when available. - They are the most affordable drugs and offer you the lowest copay. Use mail order or Retail-Plus to save the most money. Use in-network freestanding medical service facilities for labs and imaging. Hospital-based labs and facilities can cost more. Don t confuse this with freestanding emergency rooms. Adopt healthy habits - Do your best to eat right, exercise and get regular health screenings. Join a Live Healthy America wellness program that is available with your TRS-ActiveCare plan. - Did you know? Using Quest Diagnostic Labs can save you money by offering additional savings. 49

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51 Company Overview FirstCare Health Plans joined the TRS-ActiveCare program in 2003 and currently covers 27,000+ school employees and their dependents. Hospital-based health plan owned by Covenant Health in Lubbock and Hendrick Health System in Abilene. Focuses exclusively on the Texas market, serving 108 counties with offices in Abilene, Amarillo and Lubbock; and, corporate headquarters in Austin. 51

52 Premium Overview Coverage Category Premiums Employee Only $ Employee and Spouse $1, Employee and Child(ren) $ Family $1, For detailed plan information, please refer to the evidence of coverage and schedule of benefits. 52

53 Benefit Highlights 100% preventive care coverage $0 PCP office visit copayments for dependents, age 19 and under Maximum out-of-pocket includes medical and Rx deductibles, copayments & coinsurance No Rx deductible for generic drugs $0 copayment for some generic drugs For detailed plan information, please refer to the evidence of coverage and schedule of benefits. 53

54 Benefit Highlights (cont.) Secure online access to membership and claim information at FirstCare.com/TRS No referral to network specialists Comprehensive network of quality physicians Coverage for dependents living outside service area* Expecting the Best maternity program Texas-based customer service *Care must be accessed through our affiliate provider networks For detailed plan information, please refer to the evidence of coverage and schedule of benefits. 54

55 Medical Benefits Overview for No PCP Copay for Dependents (Age 19 & under) Deductible $750 per individual/$2,250 per family Out-of-Pocket Maximum (includes medical/drug deductible, copayments & coinsurance) $6,000 per individual/$12,000 per family Office Visit Primary Care $20 Primary Care visits for dependents (age 19 and under) $0 Specialist $60 Inpatient/Outpatient 25% after deductible (member share) For detailed plan information, please refer to the evidence of coverage and schedule of benefits. 55

56 No Rx deductible for Tiers 1 & 2 and $0 copay for select generics (Tier 1) Deductible $100 per individual/$300 per family (Not applicable for Tiers 1 & 2) Rx Out-of-Pocket Maximum Now part of overall plan s Out-of-Pocket Maximum Office Visit Select Generic/ACA Tier 1 $0 Preferred Generic Tier 2 $15 Preferred Brand/ Non-Preferred Generic Non-Preferred Brand/ Non-Preferred Generic Tier 3 $40* Tier 4 $100* *after deductible For detailed plan information, please refer to the evidence of coverage and schedule of benefits. Specialty/Injectables Tier 5 20%* 56

57 FirstCare Service Area 108 counties across Texas To be eligible to enroll in a FirstCare plan, you must live or work in one of the shaded counties. 57

58 Abilene Region Provider Network FirstCare has a comprehensive network of local physicians, hospitals, and pharmacies that offer a full range of medical services. A complete list of network providers is available at FirstCare.com/TRS. Local FirstCare Contact: Whitney Hill whill@firstcare.com Abilene Hospital: Hendrick Medical Center Other Regional Hospitals: Anson General Hospital Ballinger Memorial Hospital Coleman County Medical Center Comanche County Medical Center Eastland Memorial Hospital Fisher County Hospital Hamlin Memorial Hospital Haskell Memorial Hospital Heart of Texas Memorial Hospital Knox County Hospital Mitchell County Hospital North Runnels Hospital Rolling Plains Memorial Hospital Stamford Memorial Hospital Stephens Memorial Hospital Stonewall Memorial Hospital Throckmorton County Memorial Hospital 58

59 Amarillo Region Provider Network FirstCare has a comprehensive network of local physicians, hospitals, and pharmacies that offer a full range of medical services. A complete list of network providers is available at FirstCare.com/TRS. Local FirstCare Contact: Dana Nicklaus dnicklaus@firstcare.com Amarillo Hospitals: Baptist St. Anthony s Hospital (BSA) Plum Creek Specialty Hospital Other Regional Hospitals: Childress Regional Medical Center Collingsworth General Hospital Coon Memorial Hospital Golden Plains Community Hospital Hansford County Hospital Hardeman County Memorial Hospital Hemphill County Hospital Hereford Regional Medical Center Moore County Hospital District Ochiltree Hospital District Pampa Regional Medical Center Parkview Hospital Parmer County Community Hospital Shamrock General Hospital Swisher Memorial Hospital 59

60 Lubbock Region Provider Network FirstCare has a comprehensive network of local physicians, hospitals, and pharmacies that offer a full range of medical services. A complete list of network providers is available at FirstCare.com/TRS. Local FirstCare Contact: Dana Johnston djohnston@firstcare.com Lubbock Hospitals: Covenant Health System University Medical Center Grace Medical Center Other Regional Hospitals: Brownfield Regional Medical Center Cochran Memorial Hospital Cogdell Memorial Hospital Covenant Health System (Plainview and Levelland) Crane Memorial Hospital Crosbyton Clinic Hospital HealthSouth Rehabilitation Hospital Iraan General Hospital District Lamb Healthcare Center Lynn County Martin County McCamey Hospital Medical Arts Hospital Medical Center Hospital Midland Memorial Hospital Muleshoe Area Medical Center Odessa Regional Medical Center Pecos County Memorial Permian Regional Medical Center Plains Memorial Hospital Rankin County Hospital Reeves County Hospital Seminole Memorial Hospital Winkler County Memorial Hospital W J Mangold Memorial Hospital Yoakum County Hospital 60

61 Waco/Bryan-College Station Region Provider Network FirstCare has a comprehensive network of local physicians, hospitals, and pharmacies that offer a full range of medical services. A complete list of network providers is available at FirstCare.com/TRS. Local Representative Contact: Claudia Rojas crojas@firstcare.com Waco Hospitals: Providence Health Center Bryan/College Station Hospitals: St. Joseph Regional Health Center College Station Medical Center Other Regional Hospitals: Burleson St. Joseph Health Center Central Texas Hospital Coryell County Memorial Hospital East Texas Medical Center Crockett & Fairfield Falls Community Hospital Goodall-Witcher Hospital Grimes St. Joseph Health Center Hamilton General Hospital Hill Regional Hospital Huntsville Memorial Hospital Lake Whitney Medical Center Little River Medical Center Llano Memorial Hospital Madison St. Joseph Health Center Metroplex Adventist Hospital Parkview Regional Hospital Rollins Brook Community Hospital Seton Highland Lakes Texas Health Harris Methodist Hospital Stephenville Trinity Medical Center 61

62 Why Choose FirstCare? No referral to network specialists Comprehensive network of quality physicians Coverage for dependents living outside service area* Texas-based customer service Worldwide emergency care Expecting the Best maternity program Has participated in the TRS-ActiveCare program since 2003 Serves 108 Texas counties *Care must be accessed through our affiliate provider networks For detailed plan information, please refer to the evidence of coverage and schedule of benefits. 62

63 Contact Us Please submit questions via to FirstCare: You can also write or call FirstCare Customer Service: FirstCare Health Plans 1901 West Loop 289 Suite 9 Lubbock, TX TRS website: 63

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65 Long-Term Partner SWHP has served TRS members in Central Texas since 2003 SWHP expanded to include North Texas in 2015 SWHP covers more than 22,000 TRS members Lifting your spirit 6565

66 SWHP Enhancements SWHP portal information optimized for smartphone (Health Plan app coming soon) Improved member website More than 1,300 pharmacies in North Texas $0 copay for first sick visit per member Wellness Assessment and Digital Health Coaching Lifting your spirit 6666

67 Online Tools Through the member portal at swhp.org, members can: - See required copays - Print an ID card or request a new one - Check the status of deductibles and out-of-pocket max - See claims and Explanations of Benefits (filtered by member/dependent) - Get information on specific providers - Review prescription usage Members can also send an to customer service advocates and receive responses through the portal s secure messaging feature. Lifting your spirit 6767

68 SWHP/TRS Plan Year Service Area Map Counties in orange include additional network providers available to deliver in-network care to members who live or work in our TRS/SWHP HMO network (counties in blue). Lifting your spirit 6868

69 Scott & White Health Plan Summary of Benefits for TRS Benefit Copay Medical Deductible $1,000 Individual / $3,000 Family Out-of-Pocket Maximum Primary Care Physician $6,550 individual / $13,100 family (includes combined Medical and RX copays, deductibles and coinsurance) $20/First copay waived for a sick visit (excludes wellness and preventive visits) Specialist Office Visit $50 Preventive Care $0 Outpatient Surgery Facility Inpatient Hospital $150 copay plus 20% after deductible $150 copay per day ($750 max) plus 20% after deductible Urgent Care $55 Emergency Room Manipulative Therapy $150 copay per visit, plus 20% after deductible ($150 copay waived if admitted within 24 hours) 20% without office visit $40 plus 20% with office visit (35 visits per calendar year max, 5 visit per month max) See trs.swhp.org for full list of benefits 6969

70 Unlimited Rx Benefit plus, only $5 for Preferred Generic Drugs! Prescription Drugs Retail (up to 30-day supply) Mail Order (up to 90-day supply) Rx Maximum Unlimited Rx Deductible Applies to Preferred Brand and Non-Preferred Drugs $150 per individual (Does not apply to preferred generics) $150 per individual (Does not apply to preferred generics) Preferred Generic $5 $10 Preferred Brand* 30% after Rx deductible 30% after Rx deductible Non-Preferred Brand or Non-Preferred Generic 50% after Rx deductible 50% after Rx deductible Non-Formulary Greater of $50 or 50% after Rx deductible N/A Rx copays and coinsurance apply to Out-of-Pocket Maximum. * If a brand name prescription is dispensed when a preferred generic is available, a copay of 50% applies after deductible. 7070

71 Prescription Coverage Is my prescription covered and what will I have to pay? Calling or ing our Scott & White Health Plan Pharmacy Team will help you with your questions: prescriptionservices@sw.org or Lifting your spirit 7171

72 Premium Rates Coverage Tier Premiums And remember, Employee you are Only not required to select $ a Primary Care Physician. You may see any network physician without a referral. Employee & Spouse $1, Employee & Child(ren) $ Employee & Family $1, Lifting your spirit 7272

73 Finding a provider has never been easier! Our provider search tool allows you to: Search by name, specialty, and/or ZIP code Add filters for gender, board certification, accepting new patients, and more See practice locations, contact information, and maps Get details, including network participation and hospital affiliations You can also: Customize your own profile Create custom directory results Try it out! Go to trs.swhp.org and click on the Find a Provider link located on the bottom of the TRS home page, and you will be on your way. A And remember, you are not required to select a Primary Care Physician. You may see any network physician without a referral. 7373

74 Thank you for your interest in Scott & White Health Plan. We look forward to being your health care provider. And, we wish you all the best in your school year! Lifting your spirit 7474

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76 Blue Essentials Access Plan Highlights Effective Sept. 1, 2017, Blue Cross and Blue Shield of Texas will offer Blue Essentials Access. HMO coverage was previously provide by Allegian Health Plan. Available for employees living, working or residing in Cameron, Hidalgo, Starr and Willacy Counties. The Blue Essentials Access plan was developed for members looking for cost saving alternatives, offering a choice of providers with no referral. Eligible members have access to a statewide Blue Essentials Network. 76

77 Blue Essentials Access Plan Highlights Medical Deductible $500 per individual $1,000 per family Out-of-Pocket Maximum $4,500 per individual $9,000 per family Office Visit Primary Care $25 Specialist $60 Inpatient / Outpatient Copayment 20% after deductible (member share) 77

78 Blue Essentials Access Plan Highlights Pharmacy Deductible $100 per individual Rx Yearly Maximum Unlimited Copayments Tier 1 $10 Tier 2 $40 Tier 3 $65 Tier 4 20% Formulary Closed Pharmacy Network excludes CVS 78

79 Blue Essentials Access Changes effective Sept. 1, 2017 Visit, day and dollar limits removed for home health, skilled nursing facilities, accidental dental care, prosthetics, orthotics, spinal manipulation and durable medical equipment ; Hearing aids are now covered - one per ear every 36 months; No maximum for specialty drugs, the 20% coinsurance will apply to the overall $4500 out-of-pocket maximum; Pharmacy network excludes CVS 79

80 Monthly Premium Rates for Premium rates effective Sept. 1, 2017 Coverage Category Employee Only $ Employee and Spouse $1, Employee and Child(ren) $ Family $1,

81 Blue Essentials Access Service Area Available to employees living, working or residing in the following counties: Cameron Hidalgo Starr Willacy Provider Network Statewide Access Provider Finder A complete list of network providers is available at: 81

82 Why Blue Essentials Access Works Employees can use a select network of providers statewide Employees traveling outside of Texas who need urgent care have access to the BlueCard program. Employees have access to health and wellness programs A dedicated Customer Service line for TRS-ActiveCare members 82

83 Blue Essentials Access - Contact us Personalized Service Call customer service for: Claim questions/status Network provider information Medical and Rx coverage questions ID card requests Transition of care information Help with online tools Customer Service

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85 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 Also an individual, who is not receiving health care coverage as an employee or retiree under (i) the Texas State College and University Employees Uniform Insurance Benefits Act (e.g., coverage offered by The University of Texas System or the Texas A & M University System), (ii) the Texas Employees Uniform Group Insurance Benefits Act (e.g., coverage offered by ERS); or (iii) TRS-Care. Health care coverage for public school employees and their families 85

86 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. 86

87 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), stepchild, 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 parent-child 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 87

88 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 can be covered as a dependent: If the child is a contributing TRS member, they are not eligible for split or pooled billing 88

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90 Three Steps to Enroll 1 Choose your health plan 2 Complete an Enrollment Application and Change Form Available online or from your Benefits Administrator 3 Sign, date and submit form to your Benefits Administrator 90

91 Annual enrollment Enrollment Period for Plan Year: July 1 Aug. 22 (Annual Enrollment) Use the Enrollment Guide and Provider Directories to pick a Plan and coverage that is right for you Your current plan election will carry forward to the new plan year (Sept. 1, 2017 to Aug. 31, 2018). You do not have to actively enroll for coverage this year. Premium adjusted to reflect any rate change, effective Sept. 1 91

92 Enrollment Application and Change Form Complete the enrollment process by using the Enrollment Application and Change Form. If you are a new enrollee: Enter all the requested information for you and any dependents you want to cover Choose coverage that is good for you Sign the Enrollment Application and Change Form Return the form to your Benefits Administrator If you are an existing employee: Select a different TRS-ActiveCare plan option Add or drop dependents Cancel and/or decline coverage (cancellations and declinations must be completed on two separate forms) Update name, address or any other demographic information Sign the Enrollment Application and Change Form Return the form to your Benefits Administrator 92

93 Enrolling for the first time Enrolling for the first time: Forms are due to the Benefits Administrator before: The end of the plan enrollment period, or 31 calendar days after your 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 93

94 Making changes/special enrollment events Enrollees may be able to enroll for coverage, change plan options or change the dependents covered 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. 94

95 Newborn coverage Covered first 31 days, if you have coverage Does not apply to newborn grandchildren You must add newborn within 31 days after the newborn s date of birth 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 (SSN) Submit application without SSN to enroll Re-submit another form after SSN is issued 95

96 Dependent disability process Dependent Child s Statement of Disability: A letter will be sent to the employee advising the loss of coverage for the dependent on their birthday unless they provide details of their disability Employee completes the Request for Continuation of Coverage for Disabled Child form and requests physician to complete the Attending Physicians Form Completed forms are to be faxed or mailed along with any supporting documentation the physician includes for review. Fax # /address for submission are noted on the forms. If notification from Aetna is not provided advising Approval of Disability, the dependent s enrollment will be terminated on the last day of the month in which the 26 th birthday occurs. 96

97 Split Premium Process Split Premium Form Online only: New the paper Application to Split Premium form will no longer be available. Instead each employee and Benefits Administrator must complete their portion of the online Application to Split Premium form. The Split Funded arrangement will remain in effect for the next year, unless your district/entity requires you to complete a new form yearly Must be employed by districts/entities participating in TRS-ActiveCare The cost for TRS-ActiveCare coverage will be split between the two employers One employee must decline coverage The Benefits Administrator must also sign and approve the form The employee who declined coverage is considered as being covered under a group health plan 97

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99 Three steps to enroll 1 Choose your health plan 2 Log in to WellSystems Enrollment Portal and make any additions, changes or plan elections. If your district/entity uses another third party administrator portal, see your Benefits Administrator for instructions 3 Submit transaction It will be reviewed and approved by your Benefits Administrator 99

100 Annual enrollment Enrollment Period for Plan Year: July 1 Aug. 22 (Annual Enrollment) Use the Enrollment Guide and Provider Directories to pick a Plan and coverage that is right for you Your current plan election will carry forward to the new plan year (Sept. 1, 2017 to Aug. 31, 2018). You do not have to actively enroll for coverage this year Premium adjusted to reflect any rate change, effective Sept

101 Enrolling in the Plan New enrollee New nroee Complete the enrollment process by registering on the WellSystems Enrollment Portal The WellSystems Enrollment Portal can be accessed directly by employees to enroll or change coverage/self-service sign-on. Go to: If you are a new enrollee You will need to establish a username and password Enter the required information (* Indicates that it is a mandatory field) Once all required fields are completed, enter your first and last name in the verification field Verify the date of the signature and click continue You will receive a notification that you have been successfully registered Now you are ready to enroll Log in to the WellSystems Enrollment Portal using your username and password you created during registration Complete the fields. Remember * indicates that it is a mandatory field Click save and continue to the dependent page if applicable If there are no dependents to enroll check I do not wish to or need to cover dependents 101

102 Enrolling for the first time The enrollment must be completed 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 102

103 Enrolling in the Plan Returning enrollee If you are a returning enrollee and you want to change your benefit plan coverage for , must actively enroll this year: Log in to the WellSystems Enrollment Portal using your username and password you created during registration Complete the fields remember (* indicates that it is a mandatory field) Click save and continue to the dependent page, if applicable If there are no dependents to enroll, check, I do not wish to or need to cover dependents Add or drop dependents Select a TRS-ActiveCare plan option Cancel and/or decline coverage Update name, address or any other demographic information 103

104 Making changes/special enrollment events Enrollees may be able to enroll for coverage, change plan options or change the dependents covered 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. 104

105 Newborn coverage Covered first 31 days, if you have coverage Does not apply to newborn grandchildren You must add newborn within 31 days after the newborn s date of birth 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 (SSN) Submit application without SSN to enroll Re-submit another form after SSN is issued 105

106 Dependent disability process Dependent Child s Statement of Disability: A letter will be sent to the employee advising the loss of coverage for the dependent on their birthday unless they provide details of their disability Employee completes the Request for Continuation of Coverage for Disabled Child form and requests physician to complete the Attending Physicians Form Completed forms are to be faxed or mailed along with any supporting documentation the physician includes for review. Fax # /address for submission are noted on the forms. If notification from Aetna is not provided advising Approval of Disability, the dependent s enrollment will be terminated on the last day of the month in which the 26 th birthday occurs. 106

107 Split Premium Process Split Premium Form Online Only: New the paper Application to Split Premium form will no longer be available. Instead each employee and Benefits Administrator must complete their portion of the online Application to Split Premium form. The Split Funded arrangement will remain in effect for the next year, unless your district/entity requires you to complete a new form yearly Must be employed by districts/entities participating in TRS-ActiveCare The cost for TRS-ActiveCare coverage will be split between the two employers One employee must decline coverage The Benefits Administrator must also sign and approve the form The employee who declined coverage is considered as being covered under a group health plan 107

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109 Cost of coverage Funding to Help Offset the Cost of TRS-ActiveCare Coverage District/Entity (minimum) $150 State of Texas $75 Total Per Month $225 Funding applies to active, contributing TRS members Cost charts illustrate the monthly gross premiums 109

110 Monthly cost for coverage See page 34 of Enrollment Guide $225 in district/entity and state funds to help pay for coverage 110