2010-2011 plan year effective september 1, 2010. 2 your trs-activecare id card will be mailed to...
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Your TRS-ActiveCare ID card will be mailed to your home
Enroll by May 19 to receive ID card by September 1
ActiveCare 1-HD, 1, 2 and 3 – All enrollees, including existing plan participants, will receive
new ID cards – New! Separate cards for medical and prescription drugs
• Blue Cross and Blue Shield of Texas
• Medco
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PPO Network for ActiveCare 1-HD, 1, 2 and 3
Network
There is no need to:– Select a Primary Care Physician– Obtain referrals for specialist care
Receive the highest level of benefits:
– Pay less for care– No balance billing
No claim forms– Provider files claim for you
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
Always verify provider network status
New for 2010-2011: The allowable amount for non-contracting providers
will be limited to 50% of billed charges
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PPO Plan Overview (Network Level of Benefits)
Plan Features ActiveCare 1-HD ActiveCare 1 ActiveCare 2 ActiveCare 3
Deductible (individual/family)
$2,400/$2,400 $1,200/$3,000 $500/$1,500 None
Out-of-Pocket Maximum
(does not include deductibles)
$3,000/$5,000 $2,000/$6,000 $2,000/$6,000 $1,000 per individual
Coinsurance
(Plan pays/participant pays)
80% / 20% 80% / 20% 80% / 20% 80% / 20%
New Deductiblesfor 2010-2011 (per IRS rules)
ActiveCare 1-HD and ActiveCare 1
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PPO Plan Overview (Network Level of Benefits)
Services ActiveCare 1-HD ActiveCare 1 ActiveCare 2 ActiveCare 3
Office Visit Copay 20% after deductible $30 for primary
$50 for specialist
$20 for primary
$30 for specialist
Preventive Care Routine physicals* Well-woman exams* Routine
mammograms* Eye exams* Well-baby exams Immunizations Hearing exams PSA screenings Colorectal
screenings Osteoporosis
screenings
* Services limited to one per person per plan year
$0 copay up to $500 per person, per plan year
Remaining charges subject to deductible and coinsurance
$30 for primary
$50 for specialist
Includes all preventive care services billed
with an office visit by a network
doctor
Coinsurance applies when no
office visit is billed or when services are performed
outside the office
(deductible waived)
$20 for primary
$30 for specialist
Includes all preventive care
services billed with an office visit by a
network doctor
Coinsurance applies when no
office visit is billed or when services
are performed outside
the office
(no deductible)
New Copaysfor 2010-2011ActiveCare 2
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ActiveCare 1-HD vs. ActiveCare 1Plan Features ActiveCare 1-HD ActiveCare 1
Meets IRS definition of High Deductible Health Plan
Yes, for all coverage categories
(employee only, employee and spouse, employee and
child(ren) and employee and family)
Yes, for employee-only coverage
No, for other coverage categories
Deductible$2,400 for employee only
$2,400 for family
$1,200 per individual
$3,000 per family
Maximum Coinsurance $3,000 for employee only
$5,000 for family
$2,000 per individual
$6,000 per family
Out-of-Pocket Maximum
(includes deductibles)
$5,400 for employee only
$7,400 for family
$3,200 per individual
$9,000 per family
Monthly Premium CostLower premium than
ActiveCare 1in all coverage categories
except employee and family
Higher premium than ActiveCare 1-HD in all
coverage categories except employee and family
New for 2010-2011: Deductible and out-of-pocket maximum amounts increased per IRS guidelinesNew for 2010-2011: Deductible and out-of-pocket maximum amounts increased per IRS guidelines
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Important:
Bariatric surgery procedures for weight loss, such as lap band and gastric bypass, must be performed at one of the Blue Distinction Centers for Bariatric Surgery or the procedure will not be covered by TRS-ActiveCare
Blue Distinction Centers for Bariatric Surgery
List of Blue Distinction Centers for Bariatric Surgery is subject to change
Refer to the Doctors and Hospitals section of the Web site, www.bcbstx.com/trs or call Customer Service for most current list
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Enrollment
Enrollment Periods for 2010-2011 Plan Year:– April 21,22,23 (HISD Spring Enrollment)– August date TBA (HISD Summer Enrollment)
Preexisting condition exclusion applies to those that previously declined coverage; may be reduced by prior creditable coverage
All employees must attend enrollment to:– Change TRS-ActiveCare plan option– Add or drop dependents– Cancel and/or decline coverage– Enroll for TRS-ActiveCare coverage with a different
participating district/entity – Change name or address or correct date of birth or Social Security number
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Eligible Dependents
Spouse (including a common law spouse)
Unmarried children under age 25– Natural child– Adopted child– Stepchild– Foster child
Other eligible dependents listed inEnrollment Guide– Grandchildren (unmarried)
– Disabled children (unmarried, of any age)
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Special Eligibility Situations
If employee and spouse both work for a participating district/entity:
– A spouse may be covered as an employee or as a dependent of an employee
– Only one parent can cover dependent children
A child (under age 25) employed by a district/entity and a contributing TRS member cannot be covered as a dependent
The child must be covered as an employee If the child is not a contributing TRS member, the child
may be covered as a dependent
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Preexisting Condition Waiting Period and Creditable Coverage
Pre-x does not apply to employees that initially enroll when the district/entity begins participating in TRS-ActiveCare or to new hires who enroll within 31 days after their actively-at-work date
A 12-month pre-x condition waiting period may apply due to:– A special enrollment event
– A future plan enrollment period (to be determined by TRS for each plan enrollment period)
– A transfer to another participating district/entity (or rehire) if the employee or any covered dependent has any remaining preexisting waiting period or a gap in coverage of 63 or more consecutive days
Pre-x waiting period may be reduced by creditable coverage
Exception: If a participant has been covered by TRS-ActiveCare at any time since 2002, pre-x may apply if employee is hired by another participating district/entity (or rehired by same district/entity)
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Monthly Costfor Coverage
See page 27 of Enrollment Guide
$225 in district/entityand state funds to help pay for coverage
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Cost of Coverage (Cont’d)
Employee and family coverage for ActiveCare 1-HD is more expensive than ActiveCare 1 because the deductible and out-of-pocket maximum amounts for family are less and the plan may begin paying 100% benefits sooner
PPO Plans ActiveCare 1-HD ActiveCare 1
Coverage Category Your Cost Your Cost
Employee Only $37 $72
Employee and Spouse $417 $452
Employee and Child(ren) $184 $249
Employee and Family $615 $521
Family Deductible $2,400 $3,000
Family Out-of-Pocket Maximum
$7,400 $9,000
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Cost of Coverage (Cont’d)
New Copays for 2010-2011 (Active Care 2) $30 for an office or preventive care visit for primary and $50 for specialist.
PPO Plans ActiveCare 2 ActiveCare 3
Coverage Category Your Cost Your Cost
Employee Only $171 $308
Employee and Spouse $676 $988
Employee and Children $405 $625
Employee and Family $766 $1,109
Family Deductible $1,500 None
Family Out-of-Pocket Maximum
$7,500 $1,000 per individual
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Application to Split Premium
Married couples working for different participating entities may “pool” funds
Optional
Requires an Application to Split Premium form to be completed by both employees and employers
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Can Changes in Coverage Be Made After Your Application Has Been Submitted?
Changes can be made up to the end of your enrollment period
Plan choices will remain in effect through August 31, 2011 unless there’s a special enrollment event such as:
– Marriage or divorce– Birth, adoption or placement for adoption of a child– A child marries or reaches age 25– A court order to provide health coverage for an eligible child – Loss of coverage
Changes must be made within 31 days after the event date (special rules apply to newborns)
New application must be submitted for any change
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Newborns
Covered first 31 days if employee has coverage
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
Not necessary to wait for newborn’s Social Security number
– Submit application without SSN to enroll– Re-submit another form after SSN is issued
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Online member management tool Check claim status, view claim
summaries and print EOBs (Explanations of Benefits)
Order additional ID cards, and print temporary ID
Monthly health articles Links to health information
and wellness tools and resources, including the Personal Health Manager
Send secure e-mail messages to BCBS Customer Advocates available Monday thru Friday, 7 a.m. to 10 p.m. (CT)
Blue Access® for Members
Available online
Enrollment Video Application Form Enrollment GuideBenefits Booklet
24/7 Nurseline, Lifestyle and
Condition Management and
Special Beginnings phone numbers
www.bcbstx.com/trs
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Blue Care Connection®
Whether you decide to skip fast food, quit smoking, or walk more, every day decisions can have a positive impact on your health; Blue Care Connection offers guidance at every level of health
Complex / CatastrophicWell Members Low- Risk Moderate- Risk High-Risk
< < < Wellness > > >
Total Care Approach to Health and Wellness
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Condition Management
• Support from Blue Care Advisors—clinical professionals who can help you manage chronic health conditions such as: asthma, diabetes, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disorder and other health conditions
• Understanding and following your physician’s orders
• Review medications, side effects, compliance, refills and current services
• Establish goals with you and caregivers, scheduling follow-ups as appropriate
If you have a chronic condition, we offer support.
1-800-462-32751-800-462-3275
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Self-Paced Approach
• Online program and resources available in the Personal Health Manager
• Secure e-mail outreach to keep members on track
Lifestyle Management Support
• Counseling and coaching with licensed Wellness Coaches
• 24/7 Nurseline
• Referrals when appropriate
Tobacco Cessation and Weight Management
1-800-462-32751-800-462-3275
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Special Beginnings®
Special Beginnings helps expectant mothers and their babies get off to a healthy start by providing prenatal and postnatal health education and guidance at no additional cost
Once enrolled in the program, plan participants receive:
• Pregnancy risk assessment and ongoing communication/monitoring
• Educational material covering pregnancy and infant care topics
• Frequent, personal contact with program staff from early pregnancy through six weeks after delivery
• Assistance in managing high-risk conditions such as gestational diabetes and preeclampsia
Program components are available in English and Spanish
1-888-421-77811-888-421-7781
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Advice anytime.Round-the-clock health and the wellness advice from licensed professionals
24/7 Nurseline
Advice isn’t just neededfrom 9 to 5.24/7 Nurseline is here to help. Nurses provide health advice and
information about high fevers, earaches, cuts and bruises and more
Audio health library on topics such as kicking the smoking habit and ways to get a good night’s rest
Available in English and Spanish
24/7 1-800-581-03681-800-581-0368
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Personal Health Manager (PHM)
Your online wellness experience begins with the Personal Health Manager
Features include: Lifestyle Management tools:
Weight Management Tobacco Cessation Fitness and Nutrition Plans Stress Reduction
Health Risk Assessment
“For Your Health” features Blue PointsSM Rewards “Ask-A” feature – health and
wellness questions via secure e-mail
Online health encyclopedia Interactive symptom checker
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Personal Health Manager – Home Page
Use the Interactive Symptom Checker
Read the latest health news, search for specific health topics or explore the prescription drug index
Ask a Question to a certified Nurse, Trainer, Dietitian or Life Coach
Access MemberCare Profile
Take a Health Risk Assessment
Read secure messages
Review member alerts
Explore topics in the Health Information and Care Center
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Ask the experts.Expert advice from licensed professionalsvia the Personal Health Manager
“Ask A” Online Advisor
Expert advice at your fingertips.Our “Ask A” feature is here to help.
Ask A Trainer, Dietitian orLife Coach:
Send questions about fitness, nutrition, or managing stress.
Ask A Nurse:
Interact online with a Blue Care Advisor on non-emergency, health-related questions using the secure “Ask A Nurse” feature.
Confidential and Secure – Receive an e-mail response within one business day
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Receive Personalized report and next steps:
• Report provides member with summary of health risks and areas where they could improve
• Recommended ‘next steps’ and suggestions to make positive changes to your lifestyle.
Health Risk Assessment – Easy To Use
Complete the assessment in as little as10 to 15 minutes
Choose your assessment topic:
• Health & well-being*
• Sleep
• Stress management
• Nutrition
• Fitness & physical activity
• Back & joint health
*We recommend completingthe Health & Well-beingassessment first.
1 2 3
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Health Risk Assessment (HRA)
A Health Risk Assessment helpsassess your health risks, interests and readiness to change Examines your overall health
and well-being
Provides a detailed report with overall health and well-being score and sub-scores for: Medical health, job satisfaction,
life load, risk and lifestyle, mood, nutrition, sleep, stress, pain and body weight
Recommends areas for improvement
Confidential and secure (results are not shared with employers)
Be informed about your overall health and well-being
Earn Blue PointsSM
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Stay motivated.Earn Blue Points in the Personal Health Manager
Blue PointsSM Incentives
TRS-ActiveCare PPO plan participants and their covered dependents accumulate Blue Points in the Personal Health Manager
Complete designated health and wellness activities
Report completed activities in the Personal Health Manager
Track your available balance
Redeem earned Blue Points for a variety of items!
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Your Medco Prescription Drug Plan
Medco administers your prescription drug plans on behalf of TRS– ActiveCare 1-HD, 1, 2, and 3 plans
Benefit includes both a retail and mail component
Medco has its own mail-order pharmacy – Medco By Mail – where specialist pharmacist focus on compliance and lower cost options for the patient, and the automated filling system ensures the prescription is filled accurately.*
• Medco’s mail-order pharmacies fill about 2 million prescriptions per week through a highly automated process that is 99.9997% accurate and is 23 times more accurate than a retail pharmacy
“Dispensing Error Rate in a Highly Automated Mail-Service Pharmacy Practice”; Nov. 2007, Pharmacology, a peer-reviewed journal of the American College of Clinical Pharmacy
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Prescription Drug Benefits - Network Level
Features ActiveCare 1-HD ActiveCare 1 ActiveCare 2 ActiveCare 3
Drug Deductible(per person, per plan year)
Subject to plan year deductible
Subject to plan year deductible
$50 $50
Retail Short-Term(up to 30-day supply)
Generic/Preferred Brand/Non-Preferred Brand
20% coinsurance
after deductible
$10
$25*
$45*
$10
$25*
$40*
Retail Maintenance(after second fill, up to 30-day supply)
Generic/Preferred Brand/Non-Preferred Brand
$15
$35*
$60*
$15
$35*
$55*
Medco by Mail(up to 90-day supply)
Generic/Preferred Brand/Non-Preferred Brand
$20
$62.50*
$112.50*
$20
$62.50*
$100*
* If you obtain a brand-name drug when a generic equivalent is available, you are responsible for the generic copayment plus the cost difference between the brand-name drug and the generic drug. Chart illustrates benefits when network pharmacies are used. Non-network benefits are also available; see Enrollment Guide for more information.
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Specific Rx Benefit Information
Retail pharmacies are ideal for acute (short-term) and new medication you may be trying for the first time
In compliance with SB 0704, 81 (R) Texas Legislature, TRS will make available through Medco a retail maintenance network effective September 1, 2010. Retail pharmacies who choose to participate in this network will be able to dispense up to a 90-day supply of medication. Please contact Medco customer service for more information on pharmacies that may choose to participate in the retail maintenance network. Medco is in the process of soliciting this network. We will not know which pharmacies will choose to participate until later this summer.
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Specific Rx Benefit Information
If you are taking a long-term medication, filling your prescriptions through Medco’s mail-order pharmacy provides several benefits:
– You can receive up to a 90-day supply of your medication at a lower copay
– Prescriptions are delivered directly to you and you can order refills online and check the status of your orders
– You have access to specialist pharmacists
• Specifically trained in specific conditions
• Review all of your incoming prescriptions for potential safety issues and will contact you and your doctor to discuss any issue
– Medco only buys medication from the most reputable suppliers
You have access to specialist pharmacists whether you fill your prescription at a retail pharmacy or at Medco By Mail.Your medication questions can be answered by calling 1-866-355-5999
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My Rx Choices® Your online savings tool
Lower your cost for prescriptions with My Rx Choices®
– Features include:• Personal assessment of cost-saving opportunities based on your
prescription plan and the medications you use
• Print a kit to help your doctor better understand the economic impact of different medication alternatives
• Alternative medications are based upon greatest cost savings to you presented in order, starting with the highest value
• Brand-to-generic and retail-to-mail comparisons are shown
• The average amount saved by My Rx Choices® users is $294!
Simply visit www.medco.com/save. You’ll need to take a moment to register before using this service. You can also call 1-866-355-5999
You have to shop your benefit. Prices can vary at different retail pharmacies
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My Rx Choices® Available through Customer Service or on www.medco.com
The My Rx Choices® home page allows the user to:
– Select a patient within a household (pre-populated with all under age 18 dependents and spouse information will be shown if authorization has been given)
– Select a drug to compare from a pre-populated list of prescriptions for the user.
Your potential savings are clearly presented
Members may print a kit to discuss with their doctor
Generic alternatives are provided
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Information Resources TRS Web site – www.trs.state.tx.us/trs-activecare
– Pharmacy Benefit Highlights– List of maintenance medications– FAQs– Download forms
Medco Member Web site – www.medco.com– Prior authorization list– Formulary information– Locate a participating pharmacy– Health and wellness information– My Rx Choices® / Price a Medication– Online ordering– Order Medco By Mail refills– Download forms– Medco widget
Customer Service 1-866-355-5999 Benefits Booklet
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Customer Service
1-866-355-5999
What if I Have Questions?
Call TRS-ActiveCare customer service for:– Claim questions/status– Network provider information– Membership and eligibility – Medical coverage questions– Inquiries (telephone and e-mail)– ID card requests– Transition of care information– Help with online tools!
Personalized Service