PPO Plan Overview. ActiveCare 1-HD, 2 and 3 Plans Plan Year

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1 PPO Plan Overview ActiveCare 1-HD, 2 and 3 Plans Plan Year

2 New Deductible and Out-of-Pocket Maximum for ActiveCare 1-HD 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 Deductible (employee only/family) Out-of-Pocket Maximum (employee only/family; does not include deductibles) Plan Year 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 2

3 New Deductible and Out-of-Pocket Maximum for ActiveCare 2 Deductible (individual/family) Out-of-Pocket Maximum (individual/family; does not include deductibles) Plan Year Plan Year ActiveCare 2 ActiveCare 2 $750/$2,250 $1,000/$3,000 $2,000/$6,000 $4,000/$8,000 3

4 Family Deductible Illustration Amy covers spouse and three dependents 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 Amy Ted Bob $4,800 Sue Chris 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 4

5 Out-of-Pocket (OOP) Maximum Illustration Amy covers spouse and three dependents 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 Amy Ted Bob $4,200 Sue Chris 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 5

6 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 6

7 PPO Plan Overview (Network Level of Benefits) ActiveCare 1-HD ActiveCare 2 ActiveCare 3 Deductible $2,400 employee only $4,800 family $1,000 individual $3,000 family $300 individual $900 family Out-of-Pocket Maximum (does not include copays or deductibles) $3,850 employee only $4,200 family $4,000 individual $8,000 family $1,000 per individual Coinsurance (Plan pays/ participant pays) 80% / 20% 80% / 20% 80% / 20% Office Visit Copay 20% after deductible $30 for primary $50 for specialist $20 for primary $30 for specialist Primary means care provided by family practitioners, internists, OB/GYNs and pediatricians. All other physicians are specialists. 7

8 PPO Plan Overview (Network Level of Benefits) Preventive Care Clarification Services ActiveCare 1-HD ActiveCare 2 ActiveCare 3 Preventive Care Plan pays 100% (deductible waived) Plan pays 100% (no copay required) Plan pays 100% (no copay required) Routine eye exam (one per plan year) Hearing exam 20% after deductible $30 for primary $50 for specialist $20 for primary $30 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 8

9 PPO Plan Overview (Network Level of Benefits) Benefits (continued) Services ActiveCare 1-HD ActiveCare 2 ActiveCare 3 High-tech Radiology (CT scan, MRI, nuclear medicine) 20% after deductible $100 copay per service, plus 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) $150 copay per day, plus 20% after deductible ($750 max copay per admission; $2,250 max/year) Emergency Room 20% after deductible $150 copay, plus 20% after deductible (copay waived if admitted) $150 copay, plus 20% after deductible (copay waived if admitted) Outpatient Surgery 20% after deductible $150 copay per visit, plus 20% after deductible $150 copay per visit, plus 20% after deductible 9

10 New!! Effective Sept. 1, 2013 Help get benefits information and find network providers for: MRIs CAT or CT Scans Endoscopy procedures Colonoscopy procedures Back or spinal surgery Knee surgery Shoulder surgery Hip or joint replacement surgery Bariatric surgery Benefits Value Advisor Real-time access to current cost and quality transparency Appointment scheduling Understanding benefits and how to best use them Referrals to condition management programs Clinical decision support tools Preauthorization coordination One-Call Solution: Customer Service 10

11 Prescription Drugs ActiveCare 1-HD, 2 & Plan Year

12 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 % 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 12

13 Prescription Drug Benefits Network Level Features ActiveCare 1-HD ActiveCare 2 ActiveCare 3 Drug Deductible (per person, per plan year) 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) 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) Subject to plan year deductible 20% coinsurance after deductible 20% coinsurance after deductible $0 generic; $200 brand $20 $40* $65* $25 $50* $80* $45 $105* $180* * 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. $75 $15 $35* $60* $20 $45* $75* $45 $105* $180* $200 per fill $200 per fill 13

14 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. 14

15 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 15

16 Specialist Pharmacists are an integral part of the healthcare continuum 97% of patients 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 single condition Advanced tools let pharmacists see the whole patient along with their drug regimen across prescribers and pharmacies Extremely Satisfied/Very Satisfied with overall counseling experience We strive to have our pharmacists deliver the level of patient care that any of us would want for our families. Glen Stettin, M.D., Express Scripts Chief Medical Officer 16

17 Express Scripts online tools and mobile apps help connect patients and their caregivers Benefit education and management: Benefit highlights Forms and cards Pricing and coverage details New! Accessibility features Online prescription management: Refills, renewals and order status Worry-free Fills Transfer to mail Claims, balances and history Locate a pharmacy Preferences Omission Not Using Controller Medication for Asthma Gap In Care Alerts Help participants identify and address potential safety issues with their prescriptions 17

18 Pharmacy Care Online Alerts Adherence Omission On track 18

19 Close-up: Sample Alert Message Information about the alert and why it s important Ability for patients to self-close gaps as appropriate Video clips relevant to each alert Links to additional resources Access to Express Scripts pharmacists Printable information to take to the doctor 19

20 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 You ll need to take a moment to register before using this service. You can also call You have to shop your benefit. Prices can vary at different retail pharmacies 20

21 Managing prescription with ease: Transfer to mail online conversion program 21

22 New! Accessibility Features 22

23 Innovation that can help participants make better decisions for healthier outcomes Boost compliance and adherence Save money Improve care Manage Refills and Renewals Update in real-time Enable informed decisions Auto populate with personalized information Unique functionality not available anywhere in healthcare today 23

24 Information Resources TRS Website Pharmacy Benefit Highlights List of maintenance medications FAQs Download forms Express Scripts 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 Express Scripts widget Customer Service Benefits Booklet 24

25 FirstCare Health Plans HMO Plan Option

26 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 26

27 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 Employee Only $ Employee and Spouse $ Employee and Child(ren) $ Family $

28 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 28

29 Medical Benefits for No Plan Changes! 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) 29

30 Rx Benefit Comparison for 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 30

31 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. 31

32 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 Local Representative 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 Hendrick Medical Center 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 32

33 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 Local Representative Contact Dana Nicklaus dnicklaus@firstcare.com Amarillo Hospitals: Northwest Texas Healthcare System Northwest Texas Surgery Center 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 33

34 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 Local Representative Contact Dana Johnston djohnston@firstcare.com Lubbock Hospitals: Covenant Health System University Medical Center Other Regional Hospitals: Brownfield Regional Medical Center Cochran Memorial Hospital Cogdell Memorial Hospital Covenant Health System 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 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 34

35 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 Local Representative Contact Dan Mayfield dmayfield@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 35

36 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 address for TRS-ActiveCare members and Benefit Administrators trsquestions@firstcare.com 36

37 Contact Us You may submit your questions or comments via to You can also write or call customer service at: FirstCare Health Plans 1901 West Loop 289 Suite #9 Lubbock, TX

38 How to Enroll How to Enroll Plan Year

39 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 39

40 Enrollment Enrollment Periods for 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 40

41 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. 41

42 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 42

43 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 43

44 Blue Access for Members Enrollment Info 44

45 Blue Access for Members SM 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 Locate a network doctor or hospital Order additional ID cards, or print a temporary ID Take a confidential health assessment Send secure messages to BCBSTX Customer Advocates Monday thru Friday 7 a.m. to 10 p.m. (CT) 45

46 Blue Access Mobile SM Blue Access for Members SM Secure Site Log-in Required 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 A claim has been paid. Please log in to Blue Access for Members for details. Public Site No log-in required 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) 46

47 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 ) ID card requests Transition of care information Help with online tools! Customer Service