An Overview for Participants

PDRMA Health Program

2012 Plan Changes

What’s Changing in 2012?

The PDRMA Health Program will help you every step of the way

Administrative Changes

Eligibility Changes

Benefit Changes

Administrative Changes

PPO Network, ID Cards, Forms

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Change in Medical PPO NetworkA PPO network is a listing of doctors, hospitals, and other facilities contracted to provide health care at a discount.

Private Health Care Systems Aetna Signature Administrators

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Aetna Signature AdministratorsSearch for providers in your area at www.aetna.com/asa

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Provider Search Is Easy with ASATo see if your doctor is in the network, complete all fields, then select “More Options.”

If you just want to see a list of providers in your area, click “Start Search.”

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Provider Search Is Easy with ASATo see if your doctor is in the network, search by name.

You can also search by specialty, language, gender, and hospital affiliation!

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Provider Search Is Easy with ASATo see if your doctor is in the network, search by name.

If your search was too broad or narrow, you can adjust the distance in the search box on the left.

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Doctor Not in the Network?Double check before you give up!

Doctors use a variety of addresses and names when contracting with networks.

Call CoreSource at:

800-848-3012

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Use Caution When Asking Your DoctorASA PPO is different than other Aetna networks.

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Doctor Not in the Network?PDRMA Health Program can give you a nomination form, or your provider can request to join online.

It takes approximately 90 days to add a provider to the network.

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Doctor Not in the Network?If you are in the middle of treatment for an acute condition or are pregnant, you can apply for Transition of Care benefits.

If approved, the plan will pay your claims at the in-network level for up to 90 days.

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New PPO ID Cards – Vision Benefit LetterCheck your mailbox in late December for PPO ID cards and a separate Vision Benefit Letter.

Note: No vision benefit information on the 2012 medical PPO ID card.

Call PDRMA at 630-435-8998 to request a temporary PPO ID Card letter or replacement Vision Benefit Letter.

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New Forms for Open Enrollment, Nov. 7 – Dec. 2PDRMA Health has updated many forms for participants to use

during Open Enrollment and in the future.

• Eligibility Form.• Annual Certification Form.• Beneficiary Change Form • Coordination of Benefits Form. • HIPAA Authorization Form.

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New Forms for Open Enrollment, Nov. 7 – Dec. 2PDRMA Health has updated many forms for participants to

use during Open Enrollment and in the future.

• Eligibility Form.• Annual Certification Form.• Beneficiary Change Form.• Coordination of Benefits Form. • HIPAA Authorization Form.

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New Forms for Open Enrollment, Nov. 7 – Dec. 2PDRMA Health has updated many forms for participants to

use during Open Enrollment and in the future.

• Eligibility Form.• Annual Certification Form.• Beneficiary Change Form. • Coordination of Benefits Form. • HIPAA Authorization Form.

Eligibility Changes

Military Veteran and Civil Union Dependents

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Military Veteran Dependent ChildrenEligible starting Jan. 1, 2012.

• Ages 26 -30• Unmarried• Reside with employee• Financially dependent on employee

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Civil Union SpousesEligible effective June 1, 2011.

• Requires county-issued Civil Union Certificate.

• Couples can be same or opposite sex.• Children of Civil Union Spouses.

Benefit ChangesMedical PPO

Skilled Nursing Facility, Emergency Room, Pre-Certification

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Appropriate Level of CarePDRMA’s plan design is meant to encourage participants to

seek the most appropriate level of care.

• Removing barriers to lower levels of care

• Aligning cost share with cost of service.

• Having procedures that prevent unnecessary care.

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Skilled Nursing Facility (SNF)The requirement for a three-day inpatient hospital stay to be eligible for coverage in a SNF no longer applies for 2012.

• SNF stay will only require:

• Medical Necessity• Treatment Plan• Discharge Date

• This change makes it possible for participants to have care in a SNF after an outpatient surgery or short hospital stay.

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Emergency Room (ER) Copay$100 ER copay. No deductible and coinsurance.

• If you are admitted to the hospital from the ER, you do not pay the copay.

• This change makes it easier to know how much a visit to the ER will cost in comparison to Urgent Care or a Physician Office Visit.

• ER = $100• Urgent Care = $30• Specialist = $30• Primary Care = $20

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Pre-certification List UpdatePre-certification is beneficial to you and the plan.

• Health care delivery has changed and the pre-certification list should reflect current standards.

• New list is shorter and providers will be more likely to know what needs pre-certification.

• The changes to the list make it easier to get procedures that are almost always medically necessary.

• Precertification is not a guarantee the plan will cover procedure – check your Plan Document.

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Pre-certification List UpdateContinue to pre-certify the following items.

• Inpatient Hospitalization and complex care.• Speech/Occupational/Physical Therapy –

over 18 visits• Durable Medical Equipment - over $1000

Pre-Certification: 866-939-4659

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Pre-certification List UpdateA shorter list of outpatient procedures to pre-certify.

• Back and neck procedures.• Cranial banding.• External counterpulsation.• Hyperbaric therapy.• Uvulopalatopharyngoplasty (UPPP). • Unlisted laparoscopic procedure of abdomen.• Facet joint injection.• TMJ procedures.• Hysterectomy.

Pre-Certification: 866-939-4659

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Pre-certification List UpdateTake note of two new items that require pre-certification.

• Sleep Studies

• Injectable Medications

Medical Pre-Certification: 866-939-4659

Growth Hormone.Increlex.Mecasermin.Pegasys/PEG-Intron.Rebetron.Roferon. A Intron.A Infergen.Xolair. Darbepoetin Alpha.Epoetin Alpha, Epogen.Procrit and Micer Blood Clotting Factor IVIG. Synagasis.

CVS Specialty Pharmacy: 800-237-2767

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Pre-certification List UpdateYou should get pre-determinations for items that no longer require pre-certification in 2012.

No pre-certification required:

• Prosthetic and orthotic appliances and devices over $500.

• Outpatient intravenous drug infusion therapy - check the injectable drug list.

CoreSource Pre-Determination: 888-848-3012

Go to the ASA PPO website and check the network status of your preferred providers. www.aetna.com/asa.

Return the following to your Benefits Coordinator:

• Eligibility Form with any Open Enrollment changes, Nov 7 – Dec 2.

• Annual Certification Form.

• Coordination of Benefits Form (if you have covered dependents).

• HIPAA Authorization (if desired).

Next Steps

Look for…

New PPO ID Card and Vision Letter in late December.

New 2012 Plan Document early next year.

Questions

Call 630-435-8998 for the PDRMA Health Program Team