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  • For Plan Year 2010, there are a few changes to talk about. Medical Plans The Plan A Deductible and Coinsurance will each increase $100 for single and $200 for family. The Quest LabCard is being added to Plan A for 2010. This is currently only available on Plan B. There are no plan changes for Plans B and C. Prescription Drug Plan The Performance Drug List has been added to the pharmacy program. We will explain this in detail later in the program. Dental Plan The dental plan Deductible is increase $5 to $50 per person with a maximum of 3 applying to a family. The Deductible will now apply to all restorative services instead of only major restorative services. We are also expanding the value based plan design concept used on the medical and drug plans to the dental program by including an incentive to get regular exams and cleanings.
  • This chart summarizes the plan and vendor options available. All plans are available statewide and nationwide. Coverage outside the US is limited and you should contact the plan before planning a trip overseas. For 2010, the plan line up and offerings will be the same as it was in 2009.
  • The medical plans are standardized. All Plan A policies cover the same services. All Plan B are the same and all Plan C are the same. The SEHP provides a comprehensive health plan package but not all services are covered. You are encourage to review the plan documents that are available on the KHPA website and will be sent to you in January for the plan you have elected. If you have questions, please contact the plan customer service representatives at the phone numbers listed in the front of your open enrollment booklet. All our plans have identical coverage but they are not all the same. Each of our medical plans are preferred provider organizations. That means to get the best benefits you must use a network provider. Each of our medical vendors uses a unique provider network. You can review their networks on our website. Each plan has a rate that is based on the costs, discounts and claim experience of the plan so the rates vary between vendors. All of our medicals plans offer other services like websites with discounts, education tools and health promotions. Be sure to check out what they offer.
  • Review the open enrollment book for more information about plan design options. Once you pick a plan design, you need to review the provider networks of the vendors to determine which ones have the doctors and hospital that you use. Consider the other services provided by each of the plans, and finally review the premiums to decide which plan provides the coverage you need and the cost of that coverage.
  • On a PPO plan, claims are paid based on the network status of the provider. In exchange for directing patients to their care, Network providers agree to discounts and accept the health plans allowed charges as payment in full. Non Network providers do not agree to accept the plan allowance and may balance bill the member for any amount above what the plan allows. You may encounter a Non Network provider even when you go a Network facility. Some common examples are listed above. You may also hear these referred to as PEARL providers. In a medical emergency, if you use a network provider and encounter a PEARL, the all of the plans except BCBS will pay the provider as if they were a Network Provider. This reduces your responsibility for deductibles and coinsurance on these providers. You will still be responsible for any amounts above what the plan allows.
  • To illustrate the saving to you by using a Network provider, lets look at a sample claim for $1,500 that occurs on 1/2/2010. For the Network provider the plan allows $1,400 which is subject to the plan $150 Deductible and 20 percent Coinsurance. In this example the plan pays $1,000, you pay $400 and the provider writes off $100. For the Non Network provider, the plan allows the same $1,400 . The Non Network Deductible of $500 is applied and 50 percent Coinsurance. The plan pays $450 and You are responsible for the $500 Deductible + $450 Coinsurance + the $100 over the allow charge = $1,050. Using a Non Network provider has a big impact on your pocket book.
  • We encourage you to seek care from a Network Primary Care Provider. The following network providers are considered Primary Care Providers: General practice Family practice Internal medicine Pediatrics Geriatrics Physician extenders (physician assistants and advance registered nurse practitioners) You are not required to designate a PCP and a member may use more than one type of Primary Care Provider for care. We encourage each member to have a Primary Care Provider who helps direct their care. The plans are Preferred Provider Organization (PPO), therefore referrals are not required when seeking services. Office visits Copays for Primary Care Providers are lower, saving you money. Providers not on this list will be considered specialists and you will be responsible for a higher office visit copay.
  • All of the health plan designs encourage prevention and wellness. The goal is to maintain or improve your health and to identify any health issues early so that treatment can be provided. When you use your network provider, the health plan pays for your services in full. Immunizations are covered at 100 percent. Included in the coverage is shingles vaccine for members over the age of 60. Flu shots provided by network providers are also covered at 100%. If your provider asks that you pick up the medication at the pharmacy and bring it to their office for injection, you will need to use a Caremark network pharmacy. The vaccine will be covered under the pharmacy program at 100% under the Caremark plan. The plan provides 100 percent coverage for preventive care services listed above when services are provided by a Network provider.
  • Preventive Care Services are covered in full by the plan. Office visits with a Primary Care Provider will be subject to a $20 Copay. All other providers will be considered Specialists and will be subject to a $40 Copay. The deductible applies to services other preventive care or office visits. The deductible applies once per year and is $150 per person a maximum of $300 for the family After you have paid the deductible , you and the plan share in the cost of your care and this is called coinsurance. The plan pays 80 percent and you pay 20 percent of your covered health care expenses. You will pay your share of coinsurance until you reach the coinsurance maximum of $1,200 per person and a maximum of $2,400 applies to a family. After the coinsurance maximum is met, the plan pays covered services at 100 percent for the remainder of the calendar year. New to Plan is the addition of the Quest LabCard benefit.
  • Any provider may use the Quest lab service by calling Quest to pick up the sample. You and your provider will decide whether or not to do so. When you have covered outpatient lab work performed and billed by Quest, the plan pays 100 percent of the cost of the services. The plan can pay the additional amounts due to the negotiated discounts with Quest. Outside of the covered preventive care services, lab work not performed and billed by Quest is covered but subject to the plan deductible and coinsurance.
  • There are not changes to Plan B benefits Preventive care is covered at 100%. Office visits for adults are covered at $20 for primary care and $40 for specialist. For dependent children age 18 under, the office visit Copay has been reduced to $10 for Primary Care providers and $25 for Specialists. Plan B does not have a deductible. Services other than preventive care and office visits are subject to coinsurance. The plan pays 70 percent and you pay 30 percent of eligible services until your share reaches the coinsurance maximum of $2,200 per person or $4,400 for a family. After the coinsurance maximum is met, the plan pays at 100 percent for the remainder of the calendar year. Plan B also includes the Quest LabCard benefit.
  • Using the Quest Lab Card benefit saves you money. In this example a member goes and gets some common lab procedures done. Under Plan A, the plan allows $155.86 of the $194.83 billed. The plan pays 80 percent or $124.69 and you pay $ 31.17. If Quest is used for these same services, the plan is billed $35.33 for these same services and pays this amount in full and you have no out of pocket cost for the service.
  • If you choose to use a Non Network provider, you will be responsible for the first $500 of covered services as a deductible. A maximum of three deductibles will apply for a family. After the Deductible has been satisfied, you will be responsible for 50% Coinsurance until you reach the Coinsurance Maximums of $3,650 for single for $7,300 for a family. You are also responsible for any excess charges since the provider has not agreed to accept the health plan’s allowed charge. Preventive care is not covered with Non Network providers.
  • Generic drugs are your “Best Buys.” In addition to a lower coinsurance than brand name products, they also cost less. Generic drugs are safe, effective and FDA-approved. The FDA requires generic drugs to have the same quality, strength, purity and stability as brand-name drugs. Preferred Brand name drugs are listed on the Preferred drug list and have a 35% coinsurance. You can review the PDL on the KHPA website. or on Caremark.com Special case medications are high cost medications where the cost of 30 day supply exceeds $500. Your responsibility for a 30 day supply is capped at $75 per 30 day supply. Non Preferred brand name drugs are those products not listed on Preferred Drug List. You coinsurance for these products is 60%. Selecting a Non Preferred product will cost you more out of your pocket. The Discount tier (formerly Lifestyle) includes prescription items which are not covered by the plan but for which you can receive a discount on the purchase by using your Caremark card. These include impotence, infertility and allergy meds . A complete list is available on our website.
  • It is important that you take a copy of the Preferred Drug List (PDL) with you when you go to the doctor. For most conditions, there is more than one drug available that can effectively treat your condition. By having the PDL with you, you can discuss with your doctor what is the best and most cost effective drug for you. The PDL is available on the KHPA and Caremark websites. Selecting a generic drug is a best buy for your pocketbook! Also available on the website is a complete list of the Specialty drugs, Special Case medications and self inject able drugs covered under the drug plan.
  •   Performance drug list balances plan savings while limiting member disruption. With the performance drug list, You will continue to have access to preferred brand name medications and generics. The performance drug list mirrors the current preferred drug list. The change is in how Non Preferred brand name drugs in three specific classes of prescription drugs are processed. Those three (3) classes of prescription drugs include: cholesterol lowering medications (HMGs), proton pump inhibitors (PPIs, which reduce the production of acid in the stomach), and high blood pressure medications (ACE/ARBs).  These three classes of drugs include a large selection of lower costing generic drug options.  
  • If you are using an HMG’s, PPI’s or ARB’s , You will continue to have access to a robust list of both generic and preferred brand name drugs. The policy change will only affect You if You purchase a non preferred brand name drug and your claims history shows You have not previously tried a generic in the drug class first. The pharmacy will receive a message that the claim cannot be processed since the member has not tried the generic first.  If a member has tried a generic they will be able to purchase the non preferred product and will be responsible for paying  the non preferred drug coinsurance. Caremark will implement a comprehensive communication strategy with members to minimize disruption. Affected members will be contacted with information about the change so they can talk with their doctor about their options.
  • HMG’s are the cholesterol lowering products. The performance drug list will only affect a You if You try to purchase a non preferred brand name drug. Before you can fill a prescription for one of the Non Preferred products in red, the member would have to have tried one of the generic products in the green column. The Caremark claims system will review your claims history to see if you have previously purchased a generic in the drug class first. If this is no record of a generic in your history during the preceding 24 months, the pharmacy will receive a message that the claim cannot be processed since the member has not tried the generic first.  If your history shows that you have tried a generic previously, the claim will process without delay .You still be responsible for paying  the non preferred drug coinsurance of 60%.
  • For PPI’s which are long lasting stomach acid reducers, the Non Preferred brand name drugs are highlighted on the right in red. The preferred and generic are on the left in green. There are also a number of quality over the counter products available that may be less expensive then the prescription products and provide the same results. Talk to your doctor about will work for you.
  • Convenient home delivery of your medication directly from Caremark is available. New orders take 10-14 days to process. Reorders process in 5-7 days. The coinsurance and day supply is the same as at your local pharmacy but with the convenience of re-ordering online or by phone.
  • As we have seen in the last few years, the patents for a number of popular brand name drugs are set to expire this year and next. Here is a preview of the medications we expect to have generic launches. If you are currently using one of these items, talk to your doctor or pharmacist about moving to the generic as soon as it is available. A complete list of projected generic launches is available on our website.
  • Specialty and Biotech drugs are a special group of drugs designed to treat conditions that are not responsive to traditional therapies. These are drugs that are intended for home use. Many of these drugs are self injectable medications. A complete list of the specialty and biotech drugs is available on our website. If you are prescribed a specialty or biotech drug, call Caremark Connect and they will work with you and your doctor to coordinate the dispensing of the medication from Caremark’s specialty pharmacy. You will be assigned a care specialist who will work with you each month and coordinate the dispensing and shipping of your medication to the address of your choice.
  • This plan has two components. The Qualified High Deductible Health Plan is the insurance piece and the Health Saving Account is the bank account. You will have both. The IRS has set out guidelines on who can have a Health Savings Account. You may not enroll in this plan if you or anyone you cover is enrolled in Medicare. You may not enroll in this plan and be covered by another health plan that is not a Qualified High Deductible Health Plan. You may not have a traditional health care Flexible Spending Account. This includes a spouse’s health care FSA account. You may not have received within the last 3 months, or be eligible to receive, VA medical services.
  • If you select single coverage you will be responsible for paying the first $1,500 of covered expenses and the first $3,000 if family coverage is selected. Then claims are paid by the plan at 80%, and you pay 20% until your total out-of-pocket limit of $3,000 if you have single coverage or $6,000 if you have family coverage. After that, eligible claims are paid at 100% for the remainder of the calendar year when you use network providers. Preventive care services are not subject to the Deductible and are paid at 100% when received from a Network Provider. If you use the services of a Non Network provider, you will have a Deductible of $2,000 for single and $4,000 for family. Once the Deductible has been satisfied you will share in the cost of services by paying 50% Coinsurance until your Coinsurance and Deductible reach the out-of-pocket maximum of $3,650 single and $7,300 for a family. After that, eligible claims are paid at 100% of the allowed charge for the remainder of the calendar year.
  • Plan C has its own drug plan. Drugs are subject to the overall plan Deductible and then paid at the copayment levels listed above. This plan includes a generic incentive provision. That means if a drug is available as a generic and you elect to take the brand name drug instead, you will be responsible for the Copay and the difference in cost between the generic and the brand name drug. The Preferred Drug List is the same as the one used for Plans A and B. It is available on the KHPA website. For our more mature members, we want you to be aware that Medicare does not consider this drug benefit to be creditable coverage. For members who will be reaching Medicare age, this means that this is not considered a qualified plan under Medicare Part D. Since you are not allowed to carry this plan once you are eligible for Medicare, this may or may not present an issue for you.
  • The Health Savings Account is a bank account owned by you to fund your out-of-pocket and non covered health care costs. If you enroll in the Qualified High Deductible Health Plan, the State will contribute $37.50 per pay period for single coverage and $56.25 for family coverage into your HSA account. You will be required to contribute $25 per pay period to your HSA account. You may elect to contribute more if you wish on either a pre-tax or post-tax basis. Each one of the three vendors offering the Qualified High Deductible Health Plan has a banking partner for the Health Savings Account. The investment opportunities and fees will vary by the bank. Additional information regarding the Health Savings Account is available on our website. If you enroll in the Qualified High Deductible Health Plan, you will be responsible for opening the HSA account. This can be done online or by printing out the form and submitting it to the bank. You are responsible for documenting the use of the funds.
  • You have access to two dental PPO provider networks: Delta Dental PPO is the smaller network of dentists who offer the larger discounts and Delta Dental Premier is the larger network. The dental Deductible will apply to both basic and major restorative services in 2010 and has increase $5 to $50 per person and a maximum of $150 will apply to a family membership Orthodontic coverage is available and is limited to $1,000 per person per lifetime. The annual maximum benefit paid per person per year is $1,700.
  • Preventive care is covered in full by the plan. Members are covered for 2 exams and cleanings per calendar year. Maintaining your oral health is important to maintaining your overall health. You are encouraged to get your exams and cleanings and the new benefit design will reward those who do get at least 1 routine cleaning or exam per year.
  • Basic restorative services include coverage for fillings, oral surgery, root canals and treatment of gum disease. Major restorative services include crowns, bridges and dentures. Coverage for major restorative services is limited and we recommend that you have your dentist send in a predetermination before treatment begins to verify the coverage available before services are provided. A predetermination will provide you with the amount that the plan will pay and what your estimated responsibility will be for services.
  • For Plan Year 2010 we are incorporating the value based plan design concept into the dental program. The plan will continue to cover preventive care at 100%. We want to encourage members to use their preventive care. If issues are found early, they can be addressed sooner, and with less pain for you in your mouth and in your wallet. If a member has not had a preventive service in the prior 12 months, and they require a basic restorative service, the plan will pay that care at 50%. If you have not had a preventative exam or cleaning in the preceding 12 months and schedule an exam or cleaning, you will become eligible for the enhanced benefit level 90 days after the date of your exam. Emergency care does not qualify as a cleaning or exam.
  • For members who have had at least one exam or cleaning during the prior 12 months, the enhanced benefit reduces the member responsibility for basic restorative services to 20% if a Delta PPO provider is used and 40% if a Delta Premier dentist is used. The benefit for major restorative is not effected and remains 50%.
  • Vision is an optional program. You may enroll in vision even if you don’t elect medical coverage. There is no change to the Basic Vision Plan. This vision plan is designed to pay for basic eyeglasses and contact lenses. Remember that eye exams are paid at 100% under the medical plan when you use a network provider. Use your medical benefit for your eye exam and your vision insurance for hardware, lenses/frames or contact lenses If you are interested in mail order contact lenses, Superior offers a mail service: SVcontacts.com.
  • The enhanced plan includes all of the benefits of the basic plan, plus coverage for progressive, high index or poly-carbonate lenses and scratch and UV coating. There is a limited benefit for contact lens fitting exam fees. This is paid to network providers after a $35 copayment. The plan coverage depends on the type of lenses and whether you’re a new contact lens wearer or not. Standard Contact Lens Fitting Exam - This fitting is for a current wearer of disposable, daily wear or extended wear contact lenses. It includes two follow-up visits within three months. You pay the $35 copayment and the plan pays the balance. Specialty Contact Lens Fitting Exam This fitting is for a member who has never worn contact lenses or those requiring a more complex fit for toric, gas permeable or multi-focal contact lenses. It includes two follow-up visits within three months. You pay the $35 copayment and the plan pays the balance up to a maximum benefit of $50 . Enhanced Plan benefits are available only from Network Providers
  • The State is again offering a discount to members who reported that they did not use tobacco products or for those who use tobacco products but agree to enroll and complete a tobacco control course. You must go online during this open enrollment and elect your tobacco status for the upcoming year. For those who qualify a discount of $20 for 24 pay periods off their health insurance premiums will be provided. Tobacco users who enroll and complete the HealthQuest tobacco control program with the required time lines will also be eligible for the $20 discount for 24 pay periods. You are not required to quit using tobacco but you are required to complete the tobacco control program. How the program works? If it is determined that you have misrepresented your tobacco use to obtain the discount, you will lose the employer contribution toward the cost of your health insurance for the remainder of the plan year.
  • The following are the steps a member who enrolls in the tobacco control program would be required to complete the program. The program will start in January and you will need to contact the vendor to begin by 1/31/09. To obtain the discount you must complete the program within the time frames above. You are not required to quit using tobacco products although we hope you will to receive the discount for the entire year, you are required to complete all the steps of the program within the time frames outline above.
  • For Plan Year 2010, employees who elect to not disclose their tobacco status, those who do not wish to complete the HealthQuest Tobacco control program and anyone who fails to go online and elect their tobacco status will be paying the base rates. Members who elect to enroll in the tobacco control program but who do not complete the required steps within the time period requirements will be notified and their discount revoked for the remainder of the calendar year. You will be eligible to participate in the tobacco control program and get the discount during the next plan year by reenrolling during open enrollment.
  • You should take some time to review your options and determine what is best for you and your family. You have a number of resources available to assist you. The enrollment booklet provides an overview of your options, including a comparisons chart and the cost for coverage as well as information about enrolling. The phone numbers for each of the health plans is listed in the front of your open enrollment book. You may call customer service with any questions you have about the benefits, network and services provided to members. Additional information is available on the KHPA website. This site is available year round and provides you with update information about your plan. You may send questions to KHPA at [email_address] . This email address is available year round for you to send any questions you have about the SEHP.
  • Other resources available to you for your health and wellness are provided by HealthQuest. Again this year HealthQuest will be offering statewide screenings and Health assessments. More information on the HealthQuest and Lifeline programs is available on the website and in your open enrollment book.
  • Now that we’ve discussed your options and who can enroll, let’s talk about what you need to do. Open enrollment takes place from October 1 through October 31, 2009. You must go online to: declare your tobacco status review and enroll in your health plan elections Make changes in who is covered by your plan Enroll in a flexible spending account Enroll in HealthyKIDS if eligible Employees hired after September 10, 2009 will need to get with their Human Resources Office to obtain a paper enrollment form. Remember, after October 31, unless you experience a qualifying event, you cannot change your coverage level until the next open enrollment period. The choices you make now will be effective starting January 1, 2010.
  • If you are adding dependents during open enrollment to your health plan documentation of their eligibility is required. Please provide your HR office the above information for your spouse or children you are adding. Information is due to SEHP by November 1, 2009. The next opportunity to add the dependents will be open enrollment 2011 unless a qualifying event occurs.
  • You need to notified your agency of address changes. The State send the health plans your address information based on what is in the SHaRP payroll system on the date the file is created. To prevent delayed or lost cards, make sure your address is up to date. All Plan A members will be getting new medical and labcard id cards. Everyone gets a new Delta dental card Plan B and C vendors, Superior and Caremark are only issuing new cards to members with changes, If you lose your id card contact the vendors directly at the numbers on the inside cover of the open enrollment book to request a new card.
  • We’ve presented a lot of important information today, and I’m sure many of you have questions. I’ll be happy to answer any questions you may have now.

Open Enrollment PowerPoint Open Enrollment PowerPoint Presentation Transcript

  • State Employee Health Plan Non State Group Open Enrollment 2010
  • Changes for 2010
    • Medical Plans
      • Plan changes for Plan A
        • Deductible increased to $150/$300
        • Coinsurance maximum increased to $1,200/$2,400
        • Quest LabCard added
      • No plan changes for Plan B and Plan C
    • Prescription Drug Plan
      • Adding Performance Drug List
    • Dental Plan
      • Deductible increased to $50/$150
      • New value-based plan design
  • Medical Plan Options Plan A Plan B Plan C Blue Cross and Blue Shield of Kansas √ √ Coventry Health Care √ √ √ Preferred Health Systems √ √ √ UMR a UnitedHealthcare Co. √ √ √
  • Medical Plan
    • Standardized Plan designs :
      • All plans include preventive care
      • Not all services are covered
        • Review the benefit description
        • Questions - contact plan’s customer service
    • Differences:
      • Provider networks
        • All plans are Preferred Provider Organizations (PPO)
      • Rates
      • Additional services/discounts offered on Medical Plan’s websites
  • Selecting a Medical Plan
    • Pick a plan design (Plan A, B or C)
    • Review the Provider Networks
    • ● Each of the medical plans uses a different provider network
    • Review the other services each medical plan offers
    • 4. Review the premiums
  • PPO Providers
    • Claims paid based on the network status
    • Network providers accept the plan allowance
    • Non Network Providers can balance bill
      • Non Network Providers may work at Network Facilities - examples :
        • P athologists
        • E mergency Room Providers
        • A nesthesiologists
        • R adiologists
        • L aboratory Technicians
  • Plan A - Network Provider   Service on 1/2/2010 Plan Pays Member Pays Provider Write Off Billed Charge $1,500       Allowed Charge $1,400     $100 $150 Deductible ($150)   $150   20% Coinsurance $1,250 $1000 $250   Total   $1,000 $400 $100 Plan A - Non Network Provider   Service on 1/2/2010 Plan Pays Member Pays Provider Write Off Billed Charge $1,500       Allowed Charge $1,400   $100 $0 $500 Deductible ($500)   $500   50% Coinsurance $900 $ 450 $450   Total   $450 $1050 $0
  • Primary Care Providers
      • General practice
      • Family practice
      • Geriatrics
      • Internal medicine
      • Physician extenders
      • Pediatrics
    ● Primary Care Providers (PCPs) are defined as:
      • ● Use a network provider
      • ● Referrals not required by the medical plan
  • Preventive Care
    • Physical Exams
      • Well Woman
      • Well Man
      • Well Baby
      • Well Child
    • Immunizations
      • Over age 60 – shingles vaccine
      • Flu shots
    • Vision Exam
    • Hearing Exam
    • Bone Density Screening
    • Mammogram
    • Colonoscopy
  • Plan A – Network Providers
    • Preventive Care Covered at 100%
    • Office Visit Copays
      • $20 for Primary Care Office Visits
      • $40 for Specialist Office Visits
    • $150/$300 Deductible
    • 20% Coinsurance
    • Coinsurance Max $1,200/$2,400
    • Quest LabCard Benefit
  • Quest LabCard
    • Optional benefit
      • You will need to request tests are sent to Quest or..
      • Use a Quest collection site
      • The decision is up to you and your provider
    • 100% coverage of eligible outpatient lab tests
      • Saves you and the plan money
      • For non-emergency outpatient lab work only
      • Testing must be performed and billed by Quest
    • You will receive a Quest ID card
      • Quest logo will also be on your medical card
  • Plan B – Network Providers
    • Preventive Care Covered at 100%
    • Primary Care Office Visits
      • $20 Adult Copay
      • $10 Children age 18 and under Copay
    • Specialist Office Visits
      • $40 Adult Copay
      • $25 C hildren age 18 and under Copay
    • No Deductible
    • 30% Coinsurance
    • Coinsurance maximum $2,200/$4,400
    • Quest LabCard benefit
  • Quest Lab Card Savings
    • Current Lab Fees
    • Billed $194.83
    • Allowed: $155.86
    • Coinsurance 80%
    • Plan pays $124.69
    • Member pays $31.17
    • LabCard Fees
    • Total Charges $35.33
    • Coinsurance 100%
    • Plan Pays $35.33
    • Member Pays $0
    Charges on a typical lab claim for: CBC, Lipid Panel, TSH & Basic Metabolic Panel Plan saves $89.36 and Employee saves $31.17 Source: Quest Diagnostics, Inc.
  • Plans A & B - Non Network Providers
    • $500/$1,500 Deductible
    • 50% Coinsurance
    • Coinsurance Max $3,650/$7,300
    • Preventive care not covered
  • Drug Plan
    • Generic Drugs
      • 20% Coinsurance
    • Preferred Brand
      • 35% Coinsurance
    • Special Case Medications
      • $75 per 30-day supply
    • Non Preferred Brand
      • 60% Coinsurance
    • Discount Tier
      • 100% Member responsibility
  • Drug Plan
    • Print out the PDL and take it with you
      • Preferred Drug List (PDL) available on website
        • PDL is updated quarterly
    • Talk to your doctor about prescription drug options
    • Using Generics will save you money
    • Specialty, Special Case and injectables lists
    • on the website
      • www.khpa.ks.gov
      • www2.caremark.com/kse/
  • Performance Drug List
    • Three drug classes of Performance Drug List:
      • ACE/ARBs – Blood pressure lowering
      • HMGs – Cholesterol lowering
      • PPIs – Stomach acid reducers
    • Must try a Generic before using a Non Preferred Brand Name Drug
      • Claim system will review member’s history
    • Generic and Preferred Brands not effected
    • Those using a Non Preferred drug will be notified by Caremark
  • Performance Drug List
    • Preferred ACE/ARBs
    • Generic
      • benazepril & benazepril HCT
      • captopril & captopril HCT
      • enlapril & enlapril HCT
      • fosinopril & fosinopril HCT
      • lisinopril & lisinopril HCT
      • moexipril & moexipril HCT
      • quinapril & quinapril HCT
      • ramipril
      • trandolapril
    • Preferred Brands
      • Benicar & Benicar HCT
      • Micardis & Micardis HCT
    • Non Preferred ARBs
    • Diovan & Diovan HCT
    • Teveten & Teveten HCT
    • Tekturna & Tekturna HCT
    • Angiotensin Converting Enzyme Inhibitors (ACEs)
    • Angiotensin II Receptor Antagonists (ARBs) &
    • Direct Renin Inhibitors & Combinations
    Blood Pressure Lowering
  • Performance Drug List
    • Preferred HMGs
    • Generic
      • simvastatin
      • pravastatin
      • lovastatin
    • Preferred Brands
      • Lipitor
      • Crestor
    • Non Preferred HMGs
    • Vytorin
    • Lescol
    • Lescol XL
    • Altoprev
    • Pravachol
    • Zocor
    Cholesterol Lowering Agents HMG-CoA Reductase Inhibitors (HMGs or Statins)/Combinations
  • Performance Drug List
    • Preferred PPIs
    • Generic
      • omeprazole
      • pantoprazole
    • Preferred Brands
      • Prevacid
      • Nexium
    • Non Preferred PPIs
    • Aciphex
    • Prilosec
    Stomach Acid Reducers Proton Pump Inhibitors (PPIs)
  • Home Delivery Medical Plan
    • Convenient and easy
    • Timing of orders
      • New orders process within 10-14 days
      • Reorders process in 5-7 days
    • Up to a 60-day supply available
    • Same Coinsurance requirements
    • Convenient re-orders
      • Online @ Caremark.com
      • Phone: 1.800.294.6324
  • Projected Generic Launches
    • 4 th Qtr. 2009
    • Prevacid
    • Pulmicort Inhalation Suspension
    • Valtrex
    • 1 st & 2 nd Qtr. 2010
    • Arimidex
    • Flomax 24 hour ER
    • Hyzaar
    • Effexor XR
    http://www.khpa.ks.gov/sehp/2009_providers.html
    • 3 rd & 4 th Qtr. 2010
    • Aricept
    • Cozaar
    • Namenda
  • Specialty & Biotech Drugs Medical Plan
    • Designed for conditions that are difficult to treat with traditional therapy
      • Treatments for: cancer, MS, hemophilia, hepatitis C, rheumatoid arthritis and growth hormone
      • Self-administered drugs for home use
      • Overnight shipping
    • Available only at Caremark Specialty Pharmacy
      • Call Caremark Connect: 1.800.237.2767
        • Coordinates patient care with provider
      • List of Specialty & Biotech drugs available:
    http://www.khpa.ks.gov/sehp/2009_providers.html
  • Plan C – QHDHP w/ HSA
    • QHDHP is the medical & drug plan
    • HSA is the health savings account
    • You are not eligible to enroll for an HSA if:
      • Anyone covered by Medicare
      • Covered by another health plan that is not a QHDHP
      • Covered by a health care flexible spending account
      • Covered by TRICARE or TRICARE For Life
      • Eligible to receive VA medical services
  • Plan C - QHDHP
    • Network Provider Coverage
      • $1,500/$3,000 Deductible
      • 20% Coinsurance
      • $3,000/$6,000 Out-of-Pocket Maximum
      • Preventive Care Services paid at 100%
    • Non Network Provider Coverage
      • $2,000/$4,000 Deductible
      • 50% Coinsurance
      • $3,650/$7,300 Out-of-Pocket Maximum
      • Preventive Care is not covered
  • Plan C – QHDHP Drug Plan
    • Drugs are subject to the Deductible then:
      • Generic $10 Copayment
      • Preferred Brand $30 Copayment
      • Non Preferred Brand $55 Copayment
    • Copayment is per 31-day supply
    • Generic Incentive Provision
    • Uses Caremark Preferred Drug List, Performance Drug list and Specialty Pharmacy
    • Not “creditable” drug coverage for Medicare
  • Plan C – Health Savings Account (HSA)
    • Employer contribution to your HSA
      • $75.00 per pay month for single
      • $112.50 per pay month for family
    • Member contribution to HSA
      • Require contribution of $50 per month
    • HSA bank depends on medical plan vendor selected
      • http://www.khpa.ks.gov/SEHBP/benlink.htm
    • HSA funds can be used to pay:
      • Deductible, Coinsurance, Copayments
  • Dental Coverage
    • You have access to two PPO provider networks
      • Delta Dental PPO
      • Delta Dental Premier
    • Plan Deductible
      • Applies to Basic & Major Restorative Care
      • $50 per person, $150 per family
    • Orthodontic benefit
      • $1,000 per person per lifetime
    • Annual benefit maximum
      • $1,700 per person per year
  • Dental Preventive Care
    • Covered in full:
      • Prophylaxis/cleanings – twice per year.
      • Oral examinations – twice per year.
      • Bitewing x-rays –
        • adults – 1 x a year
        • children under 18 - 2 x a year
      • Full mouth x-rays – once each five (5) years.
      • Limited coverage for children only:
        • Sealants
        • Space maintainers
        • Topical fluoride
  • Dental Restorative Services
    • Basic Restorative
      • Regular restorative dentistry – fillings
      • Oral surgery
      • Endodontics – root canals
      • Periodontics – treatment of gum & bone disease
      • Additional Diagnostic X-Rays
    • Major Restorative
      • Special restorative dentistry – crowns
      • Prosthodontics – bridges, implants, dentures
      • TMJ Treatment – Requires prior authorization
    • Restorative care is subject to a $50 deductible
  • Value Based Plan Design Basic Benefit
    • If You have NOT had one preventive or office visit for cleaning or exam of the teeth in the preceding 12-month period:
    Benefit Level PPO Premier Non Network Preventive Care Covered in full Covered in full Allowed amount covered in full Basic Restorative Services 50% 50% 50% Major Restorative Services 50% 50% 50%
  • Enhanced Benefit
    • If You have had at least one preventive or office visit for cleaning or exam of the teeth in the preceding 12-month period :
    Benefit Level PPO Premier Non Network Preventive Services Covered in full Covered in full Allowed amount covered in full Basic Restorative Services 20% 40% 40% Major Restorative Services 50% 50% 50%
    • Exams subject to $50 Copay
    • $25 Materials Copay then:
      • 100% single-vision, standard bifocal, trifocal lenticular lenses
      • Up to $100 allowance for frames
    • Elective Contact lens allowance $150
      • Home delivery: SVcontacts.com
    Basic Vision Plan
  • Enhanced Vision Plan
    • Includes Basic Plan Coverage PLUS…
      • Progressive lenses up to $165
      • High index lenses or Poly-carbonate lenses up to $116
      • Scratch and UV coating
      • Contact Lens Fitting Fee
        • Subject to $35 Copay
        • Limited Coverage
    • Enhanced benefits not available from Non Network Providers
  • Non Tobacco Users Discount
    • You must complete enrollment form and declare tobacco status to get the discount!
    • $40 discount per month
    • Must be a non tobacco user
            • - or -
    • Tobacco users agreeing to enroll in the HealthQuest tobacco control program beginning 1/1/10
  • Tobacco Control Program
    • Enroll in the tobacco control program between 1/1/2010 and 1/31/2010 
    • Complete an assessment with a Quit Coach by 1/31/2010 
    • Complete a minimum of four remaining telephone discussions with a Quit Coach by 5/31/2010
    • Call the toll free number from 7 AM – 2 AM any time you need to speak with a Quit Coach.
    • Quit for Life will notify the SEHP once you have completed and you will receive a congratulatory letter from the SEHP. Additionally, employees will be requested to complete a survey to give their feedback on the program.
  • Paying the Base Rate in 2010
    • The following will NOT be receiving the discount:
      • Elects not to disclose Tobacco status
      • Tobacco users not enrolled in the tobacco control program
      • Failed to enroll and declare tobacco status
      • Members who enroll but fail to complete the tobacco control course within the required timeline will be notified of the loss of the non tobacco discount
    • Every 6.5 seconds someone around the world dies from tobacco use. In fact, it is the only legal consumer product that kills when used as intended. Tobacco use is the second leading cause of death around the globe; it causes more death globally than AIDS, illegal drugs, motor vehicle accidents, murder, and suicide combined .
    • Source: National Business Group on Health – Tobacco the Business of Quitting
  • Resources
    • Review the Open Enrollment (OE) booklet
    • Call the health plan customer service
      • Phone number in the front of the OE booklet
    • Visit the KHPA website: http://www.khpa.ks.gov/SEHP/Active.htm
      • Benefit descriptions available
      • Caremark PDL
      • Provider listings
      • Information on HSA accounts
    • Email ?’s to SEHP : benefits@khpa.ks.gov
  • HealthQuest
    • Health Screenings & Online Health Assessment
      • $50 gift card for completion
    • Health Coaching
    • Online Wellness Newsletter
    • HealthQuest Website and Blog
    • Wellness Presentations
    • LIFELINE Employee Assistance Program
      • 1-800-284-7575
      • 24/7 support
      • Confidential, personal counseling & referrals
    • http://www.khpa.ks.gov/healthquest/default.htm
  • Annual Open Enrollment
    • October 1 – October 31, 2009
    • Enroll: Using enrollment form
      • Declare tobacco status
      • Make changes
      • Add/drop dependents
    • Paper enrollment forms required:
      • New employees hired after September 10, 2009
    • Coverage effective January 1, 2010
  • Required Documentation
    • If you are adding a dependent, documentation of eligibility is required
      • Birth certificates
      • Marriage licenses
      • Affidavit of common law marriage
      • Social Security numbers for all covered members
    • Documentation must accompany enrollment form
    • If documentation is not received dependents will not be added to your plan for 2010
  • Identification Cards
      • Make sure your address is up-to-date
      • Plan A members will get new health plan id card
      • All Plan A members will get a LabCard id card
      • Delta Dental will be issuing everyone new id cards
      • New cards for new/changed memberships only
        • Superior Vision
        • Caremark
        • Plans B and C
      • If you lose your card, call the health plan
  • Open Enrollment Checklist
    • Enrollment: Use enrollment form
      • Must declare tobacco status
      • Review health plan selections
  • Questions?
  •