PPO Dual Options
Your Top Questions What is CareLink? Are my doctors in the plan? Are my medications covered by the plan? If I get sick what do I do? How much will I pay out of my pocket? What resources are available to me? 2
What is CareLink PPO? CareLink PPO is a national provider network plan offered by Tufts Health Plan and Cigna Health Care including doctors and hospitals that are selected for the quality and breadth of services they deliver You are not required to have a Primary Care Provider (PCP) or obtain referrals. However, we do recommend that you choose a PCP, because it is a great way to have a professional relationship with someone who can help you get the best care you need You may choose to receive covered services with providers innetwork or outside the network. Out-of-network services will cost you more than providers within the CareLink network. 3
What is CareLink PPO? You may have member cost-share to meet before some services are covered Emergency care services, both in and out-of-network are covered at the in-network level of benefits There is no out-of-pocket cost for preventive care when it is received in the CareLink network 4
Services Covered in Full (In-Network Level of Benefits) Services that are considered preventive are covered in full in-network. You pay no or copayment for these services when you receive them in the network. Listed below are examples of preventive services: Routine physical and OB/GYN exams Preventive mammograms and Pap smears Preventive immunizations Flu shots Preventive blood sugar and cholesterol screenings Outpatient routine prenatal and postpartum office visits Colonoscopy in the absence of a diagnosis or symptoms, with or without surgical intervention 5
Services That Require Deductible Then Coinsurance A service that applies toward your is something that is performed in order to treat, maintain, or diagnose a condition or illness. These examples are services that are subject to your in-network : High Tech Imaging such as MRIs, CT/CAT scans, PET scans Outpatient and inpatient hospital care and surgery Treatments and procedures, including setting of bones/casts, chemotherapy, injections, infertility/impotence services, and sleep studies 6
CareLink PPO 90/70
CareLink PPO 90/70 Plan Member Cost Share In-Network Out-of Network Individual Deductible $250 $750 Family Deductible $500 $1,500 Coinsurance 10% 30% Out-of-Pocket Max - Individual $1,000 $2,500 Out-of-Pocket Max- Family $2,000 $5,000 8
CareLink PPO 90/70 Plan Service Routine Physical Exams (including most preventive screenings) Non-routine Primary Care Physician Office Visits Specialist Office Visits Inpatient and Outpatient Hospital Care, Surgery Diagnostic Tests (x-rays, blood work) High-Tech Imaging (Cat Scan, MRI/MRA and PET Scan) In-Network Cost Share Covered in full $20 copay $20 copay 10% coinsurance after Covered in full 10% coinsurance after Out-of-Network Cost Share 30% coinsurance after 30% coinsurance after 9 9
CareLink PPO 90/70 Plan Service Spinal Manipulation (Chiropractic) 24 visits per year Short term physical and occupational therapy (20 visits for each type of service per year) Speech therapy In-Network Cost Share $20 copay $20 copay $20 copay Out-of-Network Cost Share Emergency $100 copay Durable Medical Equipment (DME) Routine Eye Exam (EyeMed 1 visit every 12 months) 10% coinsurance after $20 copay 30% coinsurance after 10 10
CareLink PPO 90/70 Plan Prescription Drug Coverage $ $ $ Tier 1 Lowest Cost Tier 2 Middle Cost Tier 3 Higher Cost $ Tier 4 Specialty Drugs Retail: $5 $15 $20 $30 Mail: $15 $38 $50 Not applicable Retail copayments reflect a 30-day supply. For mail, the copayment reflects a 90-day supply. Use CVS Caremark Mail Service Pharmacy for maintenance medications (those you use regularly). Specialty drugs would be obtained from the designated specialty pharmacy network. All specialty drugs would take a Tier 4 copayment RX copays track toward the in-network out-of-pocket maximum 11
CareLink PPO 80/60
CareLink PPO 80/60 Plan Member Cost Share In-Network Out-of-Network Individual Deductible $500 $1,500 Family Deductible $1,000 $3,000 Coinsurance 20% 40% Out-of-Pocket Max - Individual $2,000 $4,000 Out-of-Pocket Max - Family $4,000 $8,000 13
CareLink PPO 80/60 Plan Service Routine Physical Exams (including most preventive screenings) Non-routine Primary Care Physician Office Visits Specialist Office Visits Inpatient and Outpatient Hospital Care, Surgery Diagnostic Tests (x-rays, blood work) High-Tech Imaging (Cat Scan, MRI/MRA and PET Scan) In-Network Cost Share Covered in full $30 copay $30 copay Covered in full Out-of-Network Cost Share 40% coinsurance after 40% coinsurance after 14 14
CareLink PPO 80/60 Plan Service Spinal Manipulation (Chiropractic) 24 visits per year Short term physical and occupational therapy (20 visits for each type of service per plan year) Speech therapy In-Network Cost Share $30 copay $30 copay $30 copay Out-of-Network Cost Share Emergency $250 copay Durable Medical Equipment (DME) Routine Eye Exam (EyeMed 1 visit every 12 months) $30 copay 40% coinsurance after 15 15
CareLink PPO 80/60 Plan Prescription Drug Coverage $ $ $ Tier 1 Lowest Cost Tier 2 Middle Cost Tier 3 Higher Cost $ Tier 4 Specialty Drugs Retail: $5 $15 $25 $40 Mail: $15 $38 $63 Not applicable Retail copayments reflect a 30-day supply. For mail, the copayment reflects a 90-day supply. Use CVS Caremark Mail Service Pharmacy for maintenance medications (those you use regularly). Specialty drugs would be obtained from the designated specialty pharmacy network. All specialty drugs would take a Tier 4 copayment RX copays track toward the in-network out-of-pocket maximum 16
Additional Benefits
How to Find a Provider To see a list of participating providers 1. Select a plan 3. Find a provider 2. Select a provider type 18
What Tier is My Prescription Drug on? Tuftshealthplan.com/dentaquest > Drug Search Members covered by our pharmacy benefit may fill prescriptions at any of the more than 63,000 CVS Caremark-participating pharmacies, which include retail chain stores, independent pharmacies, and designated specialty pharmacies. 19
Once you find your drug on the list, check to see if it has one of the following program designations Pharmacy Program Prior Authorization Quantity Limitation Program Code (PA) (QL) What it means? Prior authorization is needed for your treatment. There may be a limit on how much of a drug we will cover for a given period of time. Step Therapy (ST PA ) You may be required to try a certain drug or drugs to treat a specific medical condition before Tufts Health Plan will approve the coverage of another drug to treat the same condition. Designated Specialty Pharmacy (SP) Prescriptions for certain type of specialty drugs must be filled by designated pharmacies. Non Covered (NC) Certain drugs that are experimental, are available over the counter, or have a generic equivalent may not be covered by Tufts Health Plan. New-to-Market Drug Evaluation (NTM) In an effort to make sure the new-to-market prescriptions we cover are safe, effective and affordable, we delay coverage of many new drug products until our P & T Committee and physician specialist have review them. These drugs require prior authorization. 20
Special 90-Day Grace Period for Prescription Drug Coverage From August 1 through October 31, 2015, Prior Authorization and Step Therapy will not apply to your retail prescriptions. There are certain prescription medications that are only covered by Tufts Health Plan when you have received special approval. For more information about pharmacy management programs, visit tuftshealthplan.com/dentaquest. 21
What If I Have a Mail Order Prescription? You can use the CVS Caremark Mail Order Pharmacy Service Requires a new script Call CVS Caremark Customer Service at 1-800-581-5300. If your medication doesn t need approval, you ll be transferred to the CVS Caremark Fast Start lane. Be sure to have the following ready! Your CareLink Plan ID Card Your medication name Your physician s name and phone number Your shipping address Your credit card Once your account is setup, you can easily order refills online or by phone. 22
Eye Care Benefits (EyeMed) Routine Eye Care Routine eye exams and other vision services are through the EyeMed Vision Care Network To receive full coverage for routine eye exams and other vision care services you must visit an optometrist or ophthalmologist in the EyeMed network You will also receive discounts on glasses and contacts from eye care providers in the EyeMed network To find an eye care provider in the EyeMed network or to find out if your eye doctor is in the network, go to tuftshealthplan.com and select EyeMed Vision Care, then select Start Search. Contact EyeMed Vision Care at 1-866-504-5908 23
What s on my CareLink ID Card? Use your QR code reader App on your smartphone to view a description of your benefits, copayments, etc. This is your pharmacy ID# information 24
Additional Member Resources for Sickness and Injury If you need immediate medical care and are unable to visit your provider, you have options: Cost Convenient Care Center Usage $ $$ Retail Care Clinic Diagnose and prescribe medications to treat conditions such as strep throat, pinkeye, and infections of the ears, nose and throat. Administer routine vaccinations for flu. Urgent Care Center Diagnose and treat conditions such as head colds, ear or throat infections and minor trauma (e.g. eye injuries, cuts and burns that do not respond to basic first aid). Back/muscle pain, strain or sprain. Please note you may need a referral. Call 911 or go to the nearest emergency room if you think you have a medical condition that could endanger your life or limb if not treated immediately. 25
Managing My Plan Online and On the Go A secure online site has been created just for your plan. Take time to sign up and you can: Check your specific plan benefits Search for a doctor in your network Find a specialist Request prescription refills Check on a claim and much more Check your status (if applicable) View your ID card 26
Your Support Member Services 866-352-9114 800-868-5850 TDD Hours: Monday-Thursday: 8 am 7 pm; Fri: 8 am 5 pm Visit tuftshealthplan.com and click Contact Us to send an email to Member Services Behavioral Health 800-232-1164 Hours: Monday-Friday: 8:30 am 5 pm 27
Dentaquest Dedicated Website Resources at your fingertips! Summary of Benefits and Coverage (SBCs) Provider search tool Transition of Coverage Questionnaire FAQ document for Dentaquest employees Member fitness rebate form www.tuftshealthplan.com/dentaquest Member enrollment form 28
Things to Remember Coverage for Dentaquest employees starts 8/1/15 This is a calendar year There is a 90-day grace period on Prior Authorization and Step Therapy for retail prescriptions Two plans offered You will be automatically enrolled in the similar product that you have today New hires or members making a change will require a member application You will receive credits for calendar year 2015 (1/1/15 through 7/31/15). Remember to fill your scripts with your current carrier (mail order will require a new script) Dedicated microsite is available www.tuftshealthplan.com/dentaquest Look for a new member ID card in the mail present this when you go to your doctor or go to the pharmacy For any questions prior to 8/1/15, you can call our Member Services team Call 1-866-352-9114 29
Questions
Appendix
Preventive Services are Not Subject to a Deductible Getting preventive care is one of the best ways to keep you and your family happy and healthy. Examples include: Yearly checkups Health screenings Immunizations In order to be covered in full, preventive care must be received from a doctor or provider in the CareLink network. Only certain services qualify as preventive. If you have any questions regarding whether a specific service is considered preventive, please check your benefit document or call Member Services at the number on your ID card. 32
Appendix Examples of Services That are Not Covered Cosmetic Surgery Dental care (adult) Long-term care/custodial care Methadone Maintenance Non-emergency care when traveling outside the U.S. Private-duty care Routine foot care Treatment that is experimental, for education or development purposes, or does not meet Tufts Health Plan Medical Necessity Guidelines This isn t a complete list so check your policy or plan document for a list of other excluded services. 33
Appendix Utilization Management How we use medical guidelines and standards to determine appropriateness of care To help members receive quality health care in an appropriate treatment setting, we provide utilization management (UM). UM includes evaluating requests for coverage by applying medically and necessary coverage guidelines (clinical criteria guidelines) for a determination of the medical necessity and appropriateness of the health care services under a member s benefit plan. Before (prospective): determine whether a treatment is medically necessary before it begins During (concurrent): reviews treatment during the course of care to determine medical necessity After (retrospective): review treatment for medically necessity after treatment is complete If you have any questions about what your specific plan covers, please read your Summary of Benefits or access your secure member account at mytuftshealthplan.com 34