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Page 1: Open Enrollment PowerPoint

State Employee Health State Employee Health PlanPlan

Non State GroupOpen Enrollment 2010

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Changes for 2010Changes for 2010Medical Plans

Plan changes for Plan ADeductible increased to $150/$300Coinsurance maximum increased to $1,200/$2,400Quest LabCard added

No plan changes for Plan B and Plan C

Prescription Drug PlanAdding Performance Drug List

Dental Plan Deductible increased to $50/$150 New value-based plan design

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Medical Plan Options Plan OptionsPlan A Plan B Plan C

Blue Cross and Blue Shield of Kansas √ √

CoventryHealth Care √ √ √

Preferred Health Systems √ √ √

UMRa UnitedHealthcare Co.

√ √ √

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Medical PlanMedical Plan

Standardized Plan designs:All plans include preventive care Not all services are covered

Review the benefit descriptionQuestions - contact plan’s customer service

Differences:Provider networks

All plans are Preferred Provider Organizations (PPO)

RatesAdditional services/discounts offered on Medical Plan’s websites

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Selecting a Medical PlanSelecting a Medical Plan1. Pick a plan design (Plan A, B or C)2. Review the Provider Networks

● Each of the medical plans uses a different provider network

3. Review the other services each medical plan offers

4. Review the premiums

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PPO ProvidersPPO Providers

Claims paid based on the network statusNetwork providers accept the plan allowanceNon Network Providers can balance bill

Non Network Providers may work at Network Facilities - examples:

PathologistsEmergency Room ProvidersAnesthesiologistsRadiologistsLaboratory Technicians

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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  $1,00

0 $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

$500Deductible ($500)   $500  

50% Coinsurance $900 $ 450 $450  

Total   $450 $1050 $0

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Primary Care ProvidersPrimary Care Providers

General practiceFamily practiceGeriatrics

Internal medicine

Physician extenders

Pediatrics

● Primary Care Providers (PCPs) are defined as:

● Use a network provider ● Referrals not required by the medical plan

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Preventive CarePreventive Care

Physical ExamsWell WomanWell ManWell BabyWell Child

Immunizations Over age 60 – shingles vaccineFlu shots

Vision ExamHearing ExamBone Density ScreeningMammogramColonoscopy

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Plan A – Network ProvidersPlan 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% CoinsuranceCoinsurance Max $1,200/$2,400Quest LabCard Benefit

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Quest LabCardQuest LabCardOptional benefit

You will need to request tests are sent to Quest or.. Use a Quest collection siteThe decision is up to you and your provider

100% coverage of eligible outpatient lab testsSaves you and the plan money For non-emergency outpatient lab work onlyTesting must be performed and billed by Quest

You will receive a Quest ID cardQuest logo will also be on your medical card

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Plan B – Network ProvidersPlan B – Network ProvidersPreventive 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 Children age 18 and under Copay

No Deductible30% CoinsuranceCoinsurance maximum $2,200/$4,400Quest LabCard benefit

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Quest Lab Card SavingsQuest Lab Card Savings

Current Lab Fees

Billed $194.83Allowed: $155.86Coinsurance 80%Plan pays $124.69Member 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.

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Plans A & B - Non Network Plans A & B - Non Network ProvidersProviders

$500/$1,500 Deductible50% CoinsuranceCoinsurance Max $3,650/$7,300Preventive care not covered

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Drug PlanDrug PlanGeneric Drugs

20% CoinsurancePreferred Brand

35% CoinsuranceSpecial Case Medications

$75 per 30-day supplyNon Preferred Brand

60% CoinsuranceDiscount Tier

100% Member responsibility

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Drug PlanDrug PlanPrint 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 optionsUsing Generics will save you moneySpecialty, Special Case and injectables lists

on the websitewww.khpa.ks.govwww2.caremark.com/kse/

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Performance Drug List Performance Drug List Three drug classes of Performance Drug List:

ACE/ARBs – Blood pressure loweringHMGs – 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 effectedThose using a Non Preferred drug will be notified by Caremark

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Performance Drug ListPerformance Drug ListPreferred ACE/ARBs

Genericbenazepril & benazepril HCTcaptopril & captopril HCTenlapril & enlapril HCTfosinopril & fosinopril HCTlisinopril & lisinopril HCTmoexipril & moexipril HCTquinapril & quinapril HCTramipriltrandolapril

Preferred BrandsBenicar & Benicar HCTMicardis & Micardis HCT

Non Preferred ARBs

Diovan & Diovan HCTTeveten & Teveten HCTTekturna & Tekturna HCT

Angiotensin Converting Enzyme Inhibitors (ACEs)

Angiotensin II Receptor Antagonists (ARBs) &

Direct Renin Inhibitors & Combinations

Blood Pressure Lowering

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Performance Drug ListPerformance Drug List

Preferred HMGs

Genericsimvastatinpravastatinlovastatin

Preferred BrandsLipitorCrestor

Non Preferred HMGsVytorinLescolLescol XLAltoprevPravacholZocor

Cholesterol Lowering Agents

HMG-CoA Reductase Inhibitors (HMGs or Statins)/Combinations

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Performance Drug ListPerformance Drug List

Preferred PPIs

Genericomeprazolepantoprazole

Preferred BrandsPrevacidNexium

Non Preferred PPIsAciphexPrilosec

Stomach Acid Reducers

Proton Pump Inhibitors (PPIs)

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Home DeliveryHome DeliveryConvenient and easyTiming of orders

New orders process within 10-14 daysReorders process in 5-7 days

Up to a 60-day supply availableSame Coinsurance requirementsConvenient re-orders

Online @ Caremark.comPhone: 1.800.294.6324

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Projected Generic Launches Projected Generic Launches 4th Qtr. 2009

Prevacid

Pulmicort Inhalation Suspension

Valtrex

1st & 2nd Qtr. 2010

ArimidexFlomax 24 hour ER

HyzaarEffexor XR

http://www.khpa.ks.gov/sehp/2009_providers.html

3rd & 4th Qtr. 2010

• Aricept

• Cozaar

• Namenda

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Specialty & Biotech DrugsSpecialty & Biotech DrugsDesigned for conditions that are difficult to treat with traditional therapy

Treatments for: cancer, MS, hemophilia, hepatitis C, rheumatoid arthritis and growth hormoneSelf-administered drugs for home useOvernight 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

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Plan C – QHDHP w/ HSAPlan C – QHDHP w/ HSA

QHDHP is the medical & drug planHSA is the health savings account You are not eligible to enroll for an HSA if:

Anyone covered by MedicareCovered by another health plan that is not a QHDHPCovered by a health care flexible spending account Covered by TRICARE or TRICARE For LifeEligible to receive VA medical services

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Plan C - QHDHP Plan C - QHDHP

Network Provider Coverage$1,500/$3,000 Deductible

20% Coinsurance$3,000/$6,000 Out-of-Pocket MaximumPreventive 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

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Plan C – QHDHP Drug PlanPlan C – QHDHP Drug Plan

Drugs are subject to the Deductible then:Generic $10 Copayment Preferred Brand $30 CopaymentNon Preferred Brand $55 Copayment

Copayment is per 31-day supplyGeneric Incentive ProvisionUses Caremark Preferred Drug List, Performance Drug list and Specialty PharmacyNot “creditable” drug coverage for Medicare

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Plan C – Health Savings Account Plan C – Health Savings Account (HSA)(HSA)

Employer contribution to your HSA

$75.00 per pay month for single$112.50 per pay month for family

Member contribution to HSARequire 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

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Dental CoverageDental CoverageYou have access to two PPO provider networks

Delta Dental PPODelta Dental Premier

Plan DeductibleApplies 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

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Dental Preventive Care 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:

SealantsSpace maintainersTopical fluoride

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Dental Restorative Dental Restorative ServicesServices

Basic RestorativeRegular restorative dentistry – fillingsOral surgeryEndodontics – root canals Periodontics – treatment of gum & bone disease Additional Diagnostic X-Rays

Major RestorativeSpecial restorative dentistry – crownsProsthodontics – bridges, implants, denturesTMJ Treatment – Requires prior authorization

Restorative care is subject to a $50 deductible

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Value Based Plan DesignValue Based Plan Design

Basic BenefitBasic BenefitIf 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 CareCovered in

full

Covered in full

Allowed amount

covered in full

Basic Restorative

Services50% 50% 50%

Major Restorative

Services50% 50% 50%

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Enhanced BenefitEnhanced 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

Services20% 40% 40%

Major Restorative

Services50% 50% 50%

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Exams subject to $50 Copay$25 Materials Copay then:

100% single-vision, standard bifocal, trifocal lenticular lensesUp to $100 allowance for frames

Elective Contact lens allowance $150Home delivery: SVcontacts.com

Basic Vision PlanBasic Vision Plan

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Enhanced Vision PlanEnhanced 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 coatingContact Lens Fitting Fee

Subject to $35 CopayLimited Coverage

Enhanced benefits not available from Non Network Providers

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Non Tobacco Users DiscountNon Tobacco Users DiscountYou must complete enrollment form and declare tobacco status to get the discount!$40 discount per monthMust be a non tobacco user

- or -

Tobacco users agreeing to enroll in the HealthQuest tobacco control program beginning 1/1/10

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Tobacco Control ProgramTobacco Control Program1. Enroll in the tobacco control program between

1/1/2010 and 1/31/2010  2. Complete an assessment with a Quit Coach by

1/31/2010  3. Complete a minimum of four remaining telephone

discussions with a Quit Coach by 5/31/20104. Call the toll free number from 7 AM – 2 AM any time

you need to speak with a Quit Coach.5. 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.

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Paying the Base Rate in Paying the Base Rate in 20102010

The following will NOT be receiving the discount:Elects not to disclose Tobacco statusTobacco users not enrolled in the tobacco control program Failed to enroll and declare tobacco statusMembers 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

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ResourcesResources

Review the Open Enrollment (OE) bookletCall 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 availableCaremark PDLProvider listingsInformation on HSA accounts

Email ?’s to SEHP: [email protected]

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HealthQuestHealthQuestHealth Screenings & Online Health Assessment

$50 gift card for completion

Health CoachingOnline Wellness NewsletterHealthQuest Website and BlogWellness PresentationsLIFELINE Employee Assistance Program

1-800-284-757524/7 supportConfidential, personal counseling & referrals

http://www.khpa.ks.gov/healthquest/default.htm

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Annual Open EnrollmentAnnual Open EnrollmentOctober 1 – October 31, 2009

Enroll: Using enrollment form

Declare tobacco statusMake changesAdd/drop dependents

Paper enrollment forms required:New employees hired after September 10, 2009

Coverage effective January 1, 2010

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Required DocumentationRequired DocumentationIf you are adding a dependent, documentation of eligibility is required

Birth certificates Marriage licensesAffidavit of common law marriageSocial Security numbers for all covered members

Documentation must accompany enrollment formIf documentation is not received dependents will not be added to your plan for 2010

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Identification CardsIdentification Cards

Make sure your address is up-to-date Plan A members will get new health plan id cardAll Plan A members will get a LabCard id cardDelta Dental will be issuing everyone new id cardsNew cards for new/changed memberships only

Superior VisionCaremarkPlans B and C

If you lose your card, call the health plan

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Open Enrollment ChecklistOpen Enrollment Checklist

Enrollment: Use enrollment formMust declare tobacco status Review health plan selections

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Questions?Questions?

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