Post on 07-Jan-2016
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Presented by: Joannie Nilan
HIGHHIGHOPTIONOPTION
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How We Change for 2012How We Change for 2012Section 2. Page 10Section 2. Page 10
Weight Management Program Managed by CIGNA/CareAllies:
1-800-582-1314 - Prompt 6o No participation requirements
o $0 copay for in-network office visits to a registered Dietician/Nutritionist
o Health and Wellness Coaches to assist with individual needs and guidance
o Workbook and Tool Kit to keep you on track and motivated
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How We Change for 2012How We Change for 2012Section 2. Section 2. (continued…)(continued…)
Plavix has been added to the list for Pharmacogenomic Testing for prescription drug therapies for certain conditions.o Anti-platelet drug used to assist in blood clotting
Out-of-Network Routine Gynecological visits for pap testo One annually
o Standard out-of-network rate
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How We Change for 2011How We Change for 2011Section 2. Section 2. (continued…)(continued…)
Routine Sigmoidoscopy screenings starting at age 50 – no longer limited to every 5 years
Routine Colonoscopy screenings starting at age 50 – no longer limited to once every 10 years
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FactsFactsSection 1. Page 8Section 1. Page 8
FFS / Non-PPOo Fee For Serviceo Standard benefitso World wide coverageo Do not discount serviceso Do not agree to accept the Plan allowanceo Higher deductibles, coinsurance, and out-of-pocket
PPOo Preferred Provider Organizationo Vendor negotiated contractso Agree to accept discounted fee for serviceso Always accept the Plan allowance (contracted
allowance)o Lower deductibles, coinsurance, copayments, and out-
of-pocket
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FactsFactsSection 1. Page 9Section 1. Page 9
Vendors o CIGNA – Medical PPO Vendor and
Precertification Vendor• 6,100 hospitals• 815,000 providers • Precert
o ValueOptions - Mental Health and Substance Abuse Vendor
• 4,000 facilities • 62,000 providers • Precert
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FactsFactsSection 1. Section 1. (continued…)(continued…)
Medco – Prescription Drug Vendor
○ 66,000 pharmacies
○ RX
○ Personalized Medicine
○ Specialty Drugs
○ Precert some drugs
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How to Get CareHow to Get CareSection 3. Page 11Section 3. Page 11
ID Cards/Health Benefits Election Form / Electronic Confirmation Letter
Precertificationo Inpatient Stayso Surgeries
• Cosmetic, Transplants, Morbid Obesity, Organic Impotence
o Rehabilitative Therapy (PT/OT/ST)
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How to Get CareHow to Get CareSection 3. Section 3. (continued…)(continued…)
o Infusion and Growth Hormone Therapy
o Nursing Visits
o DME
o High Tech Radiology/Imaging
o Mental Health and Substance Abuse
o Some Drugs
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Your CostYour CostSection 4. Page 18Section 4. Page 18
Cost Benefit PPO Non-PPO
Copayments(co-pays)
Office VisitRoutineHospital Admit
$18.00 $18.00$0/coinsurance
Coinsurance
$300 fee + coinsurance
Deductible Must meet Individual or Family deductible; whichever comes first
$275 Individual$550 Family
$500 Individual$1,000 Family
Coinsurance(Coins)
Benefits with Coins 10% Member90% Plan
30%* Member70% Plan
Out-of- Pocket
Co-pays and Coins only(Deductibles and non covered charges are not included)
$4,000 $10,000
*Of plan allowance and any difference between our allowance and billed amount
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BenefitsBenefits Section 5. Pages 28Section 5. Pages 28
5 (a). Medical Services and Supplies
Diagnostic and Treatment o Physician visits in office and other locations
o Lab, X-ray and other diagnostic tests such as…
• Blood test, urinalysis, pathology, EEG and EKG
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BenefitsBenefits Section 5. Section 5. (continued…)(continued…)
CT and Pet scans, MRIs, MRAs, Nuclear Medicine○ Require pre-certification; failure to do so may
result in a minimum $100 penalty
Genetic Testing for Drug Therapies○ Tamoxifen (for Breast Cancer)
○ Warfarin (anticoagulant)
○ Plavix (antiplatelet)
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BenefitsBenefits Section 5. Page 29Section 5. Page 29
Adult - Preventive Careo After age 12 one routine exam per person
every two calendar years
• Office visit
• Lab tests: comprehensive metabolic panel, lipid panel and urinalysis
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BenefitsBenefits Section 5. Section 5. (continued…)(continued…)
o Women age 18 or older, one routine GYN visit for Pap smear – PPO and in 2012 Non-PPO
o Member pays $18 co-payment if rendered by a PPO provider
o Non-PPO provider the member pays 30% of the Plan allowance and the difference between the allowance and the billed charge – deductible applies.
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BenefitsBenefits Section 5. Page 29Section 5. Page 29
Adult Routine Screenings One annual total blood cholesterol testFasting Lipoprotein once every 5 yearsOsteoporosis screeningsChlamydia infection testsColorectal cancer screenings
o Sigmoidoscopy and Colonoscopy screenings starting at age 50
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BenefitsBenefits Section 5. Section 5. (continued…)(continued…)
Prostate cancer screenings
Routine Pap smear
Abdominal aortic aneurysm screening
Routine mammograms with age restrictions
Adult immunizations recommended by the CDC
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BenefitsBenefits Section 5. Page 30Section 5. Page 30
Children - Preventive Careo Childhood immunizations recommended
by the American Academy of Pediatrics
o Well child physical exams and lab tests through age 12
o One screening for Amblyopia and Strabismus ages 2 – 6
o One screening of premature infants for Retinopathy
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BenefitsBenefits Section 5. Page 31Section 5. Page 31
Maternity Care o Delivery and Pre and Postnatalo No pre-cert required for inpatient hospital
benefits if mom and baby leave within 48 hours for a normal delivery and within 96 hours for a C-section
Infertility Serviceso Coverage for specific services see Plan
Brochureo Maximum Plan payout of $2500 annually
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BenefitsBenefits Section 5. Section 5. (continued…)(continued…)
Family Planningo Voluntary sterilizationo Surgically Implanted Contraceptiveso Injectable Contraceptives o IUDo Diaphragms
Oral contraceptives payable under Prescription Drug benefit
Non-covered: Reversal of voluntary sterilization and genetic counseling
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Allergy Careo Testing and treatment including materialso Allergy Shots
Treatment Therapieso Chemotherapy, Radiationo Dialysiso Respiratory and Inhalationo IV and Growth Hormone (Require Approval)• Drugs used are covered under the
Prescription Drug benefit
BenefitsBenefits Section 5. Page 32Section 5. Page 32
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Physical, Occupational and Speech Therapy
o Limited to 60 Combined Visits per Calendar Year
o Pre-authorization is Required
o Non-Covered: Maintenance Therapy, Exercise Programs, etc.
BenefitsBenefits Section 5. Page 33Section 5. Page 33
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Hearing Serviceso One exam and testing for hearing aids every
2 yearsVision Care
o Internal ocular lenses / first contact lenses to correct impairment
o Non-covered• Eyeglasses and contact lenses• Eye exercises• Refractive surgery
BenefitsBenefits Section 5. Page 33Section 5. Page 33
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Routine Foot Careo Only covered for a metabolic or peripheral vascular disease, such
as diabetes
Orthopedic and Prosthetic Deviceso Leg, arm, neck and back braces o Artificial limbs, eyeso External breast prostheses, surgical bras following a
mastectomyo Internal devices, joints, pacemakers and surgically
implanted breast implant following a mastectomyo Pre-authorization is recommendedo Non covered items:
• orthopedic/corrective shoes, arch and lumbosacral supports, foot orthotics, corsets, stockings, support hose
BenefitsBenefits Section 5. Page 34Section 5. Page 34
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Hearing Aidso No Deductibleo $1500 Benefit every 3 years
Durable Medical Equipment (DME) o Pre-certification Requiredo Covered:• Oxygen and Dialysis equipment• Hospital beds and wheelchairs• Ostomy supplies• Crutches and walkers
BenefitsBenefits Section 5. Page 35Section 5. Page 35
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o Non-Covered:• Whirlpool equipment• Sun and heat lamps• Light boxes• Exercise devices• Stair glides• Elevators• Air purifiers• Computer Story boards, light talkers or
other communication aids for the communication-impaired individual
BenefitsBenefits Section 5. Section 5. (continued…)(continued…)
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Home Health Services
o Preauthorization is Required
o Performed by a RN, LPN or LVN
o 25 Visit Limit per Calendar Year
o Maximum Plan Benefit of $90 per Day
BenefitsBenefits Section 5. Page 36Section 5. Page 36
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Chiropractic Serviceso 12 Visit Limit per Calendar Year
Acupuncture by a MD or DO
BenefitsBenefits Section 5. Section 5. (continued…)(continued…)
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Educational Programso Limited to the CIGNA Tobacco Cessation
Programo Program is 100% Voluntaryo Enhanced PPO Benefito Managed by CIGNA/CareAllieso Easy Enrollment• Telephonically or online
o Compliance Requirement• 4 Counseling sessions of 30 minutes each
BenefitsBenefits Section 5. Page 37Section 5. Page 37
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Tobacco Cessation Benefits
o Enhanced benefit immediately upon enrollment
o Coverage for 2 quit attempts per year
o Prescription and over-the-counter medications for Nicotine Replacement Therapy
o No Lifetime Limit
BenefitsBenefits Section 5. Section 5. (continued…)(continued…)
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5 (b). Surgical and Anesthesia ServicesSurgery
o A comprehensive range of services for operative procedures including pre and post operative care
Pre-certification required foro organ transplanto cosmetic surgeryo surgery for morbid obesity ando organic impotence
Anesthesia
BenefitsBenefits Section 5. Page 38Section 5. Page 38
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5 (c). Hospital or Other Facility and Ambulance
Inpatient Hospitalo Pre-certification required: • 48 hours before a scheduled admission and 48
hours after an emergency admission.• Failure to pre-cert results in a minimum $500
penalty• Member should always make sure the
hospital/doctor pre-certifies the stayo Non PPO hospital confinements have a $300
per admission feeo Calendar year deductible does not apply
BenefitsBenefits Section 5. Page 45Section 5. Page 45
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o Room and Board• Private rooms covered for isolation to prevent
contagiono Ancillary Services• General nursing care• Meals • Operating, recovery, maternity and other
treatment rooms• Prescribed drugs• Diagnostic lab tests and X-rays• Blood, supplies, equipment• Anesthetics
BenefitsBenefits Section 5. Section 5. (continued…)(continued…)
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o Non-covered Items:
• Any part of admission not medically necessary
• Custodial Care
• Personal Convenience Items
• Private Duty Nurses
BenefitsBenefits Section 5. Section 5. (continued…)(continued…)
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o Non-covered Facilities:
• Nursing Homes
• Skilled Nursing
• Residential Treatment
• Day and Evening Care
• Schools
BenefitsBenefits Section 5. Section 5. (continued…)(continued…)
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Cancer Centers of Excellence
o Higher level of benefits
o Member responsibility is only 5% of the Plans allowance when using a designated facility
o Managed by CIGNA/CareAllies: 1-800-582-1314
BenefitsBenefits Section 5. Page 46Section 5. Page 46
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Outpatient Hospital or Ambulatory Surgery Centero Operating, recovery and other treatment
roomso Prescribed Drugso Diagnostic Lab Test and X-rayso Blood and Administrationo Pre-surgical Testingo Supplies o Anesthetics
BenefitsBenefits Section 5. Page 47Section 5. Page 47
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Hospice Care o Annual Benefito $3,000 outpatiento $2,000 inpatiento $200 bereavement per family unit
Ambulanceo Local professional ambulance service when
medically necessaryo Ambulance service for routine transport is
not covered
BenefitsBenefits Section 5. Page 47Section 5. Page 47
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5 (d). Emergency Services and Accidents
Accidental Injuryo Bodily injury sustained solely thru violent,
external and accidental means o Broken Boneso Animal Biteso Poisonings
Medical Emergencyo Sudden and unexpected onset of a conditiono Heart Attacko Strokeo Sudden inability to breathe
BenefitsBenefits Section 5. Page 48Section 5. Page 48
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Accidental Injury: Within 24 hours our member pays
o nothing if rendered by a PPO providero only the difference between our Allowance and
the billed charge by a Non-PPO provider After 24 hours our member pays
o $18 co-pay if rendered by a PPO providero After Non-PPO deductible is satisfied, 30% of
Plan Allowance and any difference between our Allowance and billed charge
Inpatient benefits apply if admitted
BenefitsBenefits Section 5. Page 49Section 5. Page 49
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Medical Emergency: Outpatient Facility Charges in an Urgent Care
Center our member payso PPO facility - $40 Co-paymento Non-PPO facility – After Non-PPO calendar year deductible is
satisfied, 30% of Plan Allowance and any difference between our Allowance and billed charge
Outpatient Medical or Surgical Services and Supplies, Other Than Urgent Care Center our member payso PPO facility - After PPO calendar year deductible is satisfied,
member is responsible for 10% of Plan Allowanceo Non-PPO facility - After Non-PPO calendar year deductible is
satisfied, member is responsible for 30% of Plan Allowance and any difference between our Allowance and billed charge.
Ambulance
BenefitsBenefits Section 5. Section 5. (continued…)(continued…)
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5 (e). Mental Health and Substance Abuse
All services pre-certified through ValueOptions
The separate deductible for this benefit was eliminated in 2011
In and Out-of-Network mirror the medical benefits
BenefitsBenefits Section 5. Page 50Section 5. Page 50
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5 (f). Prescription Drug BenefitMedco Health Administers Our Drug PlanGeneric
o Generic is chemically equivalent to Brando Normally dispensed
Brando Prior authorization is recommendedo Higher member responsibility
BenefitsBenefits Section 5. Page 52Section 5. Page 52
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Non-Network Retailo 30 day supplyo 50% of the cost of the drugo $8.00 minimum
Network Retailo 30 day supplyo Generic = $8.00 co-payo Brand = 25% coinsurance with minimum of $8.00 and
$200 maximum out-of-pocketo Refill Restrictions• Only 2 fills of the same prescription• All other fills are at the non-network rate
BenefitsBenefits Section 5. Page 55Section 5. Page 55
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Mail Ordero 90 day supplyo Generic = $15.00 co-payo Brand = 25% coinsurance with $12.00
minimum and $600 maximum out-of-pocket
Drugs Requiring Preauthorizationo Organic Impotence o Cosmetic Purposeso Recommended for Brand Name
BenefitsBenefits Section 5. Section 5. (continued…)(continued…)
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Personalized Medicineo Voluntary Program
o Pharmacogenomic test for drug therapies
• Tamoxifen (for breast cancer)
• Warfarin (anticoagulant)
• Plavix (antiplatelet)
BenefitsBenefits Section 5. Section 5. (continued…)(continued…)
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5 (g). DentalAccidental Injury to Teeth
o Repair not replace sound natural teetho Result of an accident and be preformed within
2 years of accidento Different benefit level with in 24 hours and
after 24 hours
Routine Dentalo Two office visits per calendar year – Includes:
Exam, Cleaning, X-rays of all types, Fluoride Treatment, Fillings and Simple Extractions
BenefitsBenefits Section 5. Page 57Section 5. Page 57
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5(h). Special Features
Flexible Benefits Option
24-hour Nurse Line
TDD line for hearing impaired
Wellness
Review and Reward Program
BenefitsBenefits Section 5. Page 58Section 5. Page 58
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Disease Management – SmartStepsVoluntary ProgramVariety of Services to Manage Chronic
Conditionso Cardiac
o Diabetes
Managed by CIGNA/CareAllies: 1-800-582-1314
BenefitsBenefits Section 5. Section 5. (continued…)(continued…)
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Diabetes Management ProgramManaged by CareAllies: 1-800-582-
1314Compliance Requirements:
Members must have one annual:o Diabetic nephropathy and retinopathy screeningo Annual labs that include
• LDL and HDL cholesterol test• Triglycerides test• Serum Creatinine test
Must have: o AIC blood test every 6 monthso Services by a PPO provider every 6 months for diabeteso Coach contact once a quartero Take prescription regularly
BenefitsBenefits Section 5. Page 59Section 5. Page 59
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o As long as the member stays compliant with the program they will be rewarded with• $0 co-pay for PPO office visits for treatment of diabetes
(not including Podiatrist/Ophthalmologist)• $0 coinsurance for PPO lab tests related to treatment of
diabetes• $0 co-pay for Medco by Mail Generic drugs specific to
lowering blood sugar• $0 co-pay for Insulin from Medco by Mail• $0 co-pay for test strips, lancets, syringes, pen needles
and Insulin Pump supplies from Medco by Mail• $0 coinsurance for Insulin Pumps purchase in-network
(preauthorization required)
Members who have Medicare as their primary insurance do not have to participate in the program, but will automatically be eligible for $0 co-pay for Medco by Mail generic drugs, Insulin, test strips, and other supplies as noted.
BenefitsBenefits Section 5. Section 5. (continued…)(continued…)
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Hypertension Management ProgramManaged by CIGNA/CareAllies:
1-800-582-1314Compliance Requirements:
o Coach contact once every 3 monthso Members must know their numberso Members must see their doctor once per year for
Hypertension o Must take their prescriptions regularlyo Must schedule the next coach call
BenefitsBenefits Section 5. Section 5. (continued…)(continued…)
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o As long as the member stays compliant with the program they will be rewarded with:• $0 co-pay for PPO office visits for treatment of
Hypertension• $0 deductible/coinsurance for PPO Serum Creatinine
lab test related to treatment of Hypertension• $0 co-pay for Medco by Mail Generic drugs for
treatment of Hypertension
Members who have Medicare as their primary insurance do not have to participate in the program, but will automatically be eligible for $0 co-pay for Medco by Mail Generic drugs.
BenefitsBenefits Section 5. Section 5. (continued…)(continued…)
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Weight Management ProgramManaged by CIGNA/CareAllies:
1-800-582-1314o $0 co-pay for in-network office visits to a
registered Dietician/Nutritionist
o Access to Health and Wellness coaches
o Receive a Workbook and Tool Kit
BenefitsBenefits Section 5. Page 60Section 5. Page 60
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Medco Health Store - www.medco.comMedco’s consumer health products
websiteo 24/7 online access to consumer health products
o Purchase and shipment by mail of consumer health products
o Wide range of products at competitive prices
o Drug safety checking
BenefitsBenefits Section 5. Section 5. (continued…)(continued…)
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CIGNA / CareAllies Special Programs: 1-800-582-1314 Lifestyle programs
o Personalized Plans Healthy Rewards and MyCareAllies
o Discounts on Smoke Cessation Programso Discounts on Weight Reduction Programso Savings on Gym Membershipso Vision and Hearing Exam Discountso Discounts on Herbal Supplements and
Vitaminso Discounts on alternative medicine and
anti-cavity products
BenefitsBenefits Section 5. Section 5. (continued…)(continued…)
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General ExclusionsGeneral ExclusionsSection 6. Page 99Section 6. Page 99
Services or supplies deemed not medically necessary, administered by a non-covered provider, not specifically listed as covered
Experimental or investigationalCommunication aids Educational or self help trainingCharges in excess of the plan allowance“Never Events”
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Filing a ClaimFiling a ClaimSection 7. Page 100Section 7. Page 100
Complete claim form, i.e. HCFA, UB04, or Dental
Medicare or Other Insurance payment statement must be submitted if applicable
Timely Filing Limito December 31st of the year following the year
of service
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Coordinating BenefitsCoordinating BenefitsSection 9. Page 104Section 9. Page 104
Medicareo A = Hospitalo B = Medicalo C = Advantage/HMOo D = Prescription Drugs
Other Insurance Coverage (OIC)
Tricare/Champus/ ChampVA
Medicaid
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20122012 RATERATESS
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www.apwuhp.comwww.apwuhp.com
Online Tools and Resources
eHealthRecord
Microsoft Health Vault
o Personal Health Record
Health Assessment
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www.apwuhp.comwww.apwuhp.com
Consumer Choice Information
Online PPO Directory
Hospital Quality Ratings Guide
Treatment Cost Estimator
Prescription Drug Information
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High Option Benefit PlanHigh Option Benefit Plan
Also available on our website:
HPR Tab
Visitor Tab
Brochure
Newsletters
AARP Health Tools
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Thank You!Thank You!Please fill out your class evaluation form and place it in the drop box in the classroom.
Please note any questions for the HPR Roundtable discussion on the card provided and place in the drop box at the Registration Desk. The Roundtable discussion will be during Closing Session on:
Saturday, October 15, 2011 63