Office of Group Benefits
Annual Enrollment 2012
FOR RETIREES WITH MEDICARE PART A & PART B1
Welcome
This presentation is a summary of
information and does not purport to present
complete details of all plan options offered
by the Office of Group Benefits. For
complete information on each plan option,
individuals should read plan documents
carefully and also consult other OGB and
plan administrators’ publications.
Welcome
This presentation will cover:
 Ways to Save
 Eligibility
 Overview of Health Plans
 Life Insurance
Office of Group Benefits
OGB serves state agencies, universities and school boards
Mental Health
Benefits
1%
Administrative
Costs
3.5%
Prescription Drug
Benefits
21.9%
Medical Benefits
71.4%
Life Insurance
2.2%
OGB’s administrative costs are only 3.5% of total costs
(June 30, 2011)
Annual Enrollment Timeline
Annual Enrollment
begins
October 3
2012 plan year
begins
November 4
Annual Enrollment
ends
January 1
Ways to Save
Your Health: Our Priority
6 Ways to Save
Choose the right health plan for you
1
 Out-of-state coverage differs by plan
 Out-of-state dependent? Job transfer? Travel?
 Are your providers in the plan’s network?
 All plans accessible through OGB website www.groupbenefits.org
Stay in your health plan’s provider network
 Avoid balance-billing
3
Request generic drugs
 Same active ingredients and big savings
2
Your Health: Our Priority
6 Ways to Save
4
Get preventive (wellness) exams
 Prevention
 Early diagnosis
After you fill your prescriptions for diabetes medication,
use your prescription drug benefit on the same day to
receive free diabetes testing supplies
6
5
Give providers complete, accurate information about
your health
 Get correct diagnosis and treatment
Ensure timely and correct payments
Prescription Cost Comparison
Brand-Name Drug
insomnia
$ 173.36
migraines
342.63
sumatriptan
66.85
231.48
gabapentin
21.54
prostate hyperplasia
143.47
tamsulosin
42.06
depression
198.93
venlafaxine XR
129.85
anti-viral
268.43
valacyclovir
149.43
pain
260.89
tramadol ER
138.33
258.79
bupriopion XL
61.16
seizures
404.79
lamotrigine
24.26
depression
320.23
fluoxetine
12.39
seizures
422.89
topiramate
31.06
147.35
simvastatin
9.59
147.95
pravastatin
12. 20
140.85
paroxetine
13.68
Ambien
Imitrex
seizures
Neurontin
Flomax
Effexor XR
Valtrex
Ultram ER
Wellbutrin XL
Lamictal
Prozac
Topamax
Zocor
depression
cholesterol
Pravachol
Paxil
Average Cost per Approved Generic Average Cost per
Prescription *
Alternative
Prescription *
cholesterol
depression
zolpidem
* Average costs as of 8-31-11 utilization; subject to change.
$
4.06
Source: Catalyst Rx
Premium Cost-Saving Strategies
Married Couples
If both are state or school retirees...
Both eligible?
May save if split coverage
Eligibility
Eligibility – Same for All Plans
Full-Time Employees and Dependents
 Legal spouse
Louisiana does not recognize same-sex marriages regardless of other
states’ laws
 Children up to age 26 – regardless of child’s student,
marital or tax status
No one can be enrolled simultaneously as both an employee and
a dependent in OGB health plans or life insurance
No dependent can be covered by more than one employee
Dependent verification required
Eligibility – Children
• Natural child of you or your legal spouse
• Legally adopted child
• Child placed in home for adoption
• Child in home under legal guardianship
or custody
• Grandchild dependent on you whose
parent is your covered dependent
Dependent Verification
Plan member must provide proof of the
legal relationship of each dependent
within 30 days of date of application for
coverage
Proof: Official documents
Marriage certificate
Birth certificate
Other court records or legal documents
Over-Age Dependents
Covered child under age 26 who is or
becomes incapable of self-sustaining
employment is eligible to continue
coverage as an overage dependent
 OGB must receive required medical records
before dependent reaches age 26
 Definition of incapacity broadened – now
includes both mental and physical incapacity
Pre-Existing Condition Limitation
for Late Applicants
Must complete enrollment form (GB-01) within
30 days for new dependent … otherwise,
pre-existing condition limitation (PEC) applies
 If diagnosed or treated within 6 months prior to enrollment
date, condition is pre-existing ... no benefits are payable
for that condition in first 12 months of coverage
 PEC limitation does not apply to anyone under age 19
 May be exempt from pre-existing condition limitation if
continuously covered without 63-day break in coverage
prior to enrollment date
What Happens If You Drop Coverage?
If you drop coverage, you lose it
FOREVER!
UNLESS …
 You joined a non-OGB Medicare Advantage
plan and it is no longer available or you
withdraw
 You joined TriCare for Life and it is
discontinued or had significant reduction in
benefits
 You lost other creditable continuous
coverage and you meet all requirements in
PPO Plan Document
Medicare Facts to Remember
Medicare Part A and Part B
 OGB health plans are secondary to Medicare
 Premium rates are reduced for retirees with Medicare
 Provider accepts Medicare assignment?
 Yes: Neither OGB nor patient is responsible for
charges above Medicare-allowable amount
 No: OGB will consider remaining eligible charges
Medicare and OGB Coverage
If you reached age 65 on or after July 1, 2005, AND are
retired AND are eligible for Medicare Part A premium-free,
then…
 You MUST enroll in Medicare Part B to receive OGB
health plan benefits for medical expenses covered by
Medicare Part B
 You must submit Social Security verification to OGB:
 If eligible – submit copy of Medicare card
 If not eligible – submit letter from Social Security
This also applies to your covered spouse
If you are not yet retired, this will apply when you retire
Overview of Health Plans
OGB Health Plans for All Retirees
PPO
HMO
(Statewide)
(Nationwide)
Administered by
OGB
Administered by
Blue Cross
Regional HMO
(Regions 6, 7, 8 & 9)
Fully insured by
Vantage Health Plan
Medical Home HMO
(Statewide – must choose
PCP in Region 9)
Fully insured by
Vantage Health Plan
Key Points
 Can change health plans during Annual
Enrollment
 Compare costs, benefits and restrictions
when choosing a plan
 Retirees who choose to keep the same plan
do not need to fill out an enrollment form
Key Points
Retirees who want to change plans must…
 Fill out an OGB enrollment form … or
 Write a letter to OGB that includes:




Your plan choice
Your name and address
Your date of birth
Your daytime phone number
Sign form or letter and mail it to ...
OGB Eligibility Division
P.O. Box 66678
Baton Rouge, LA 70896
... or visit any OGB Agency Services office
Providers? Restrictions?
 For PPO plan members with Medicare Parts
A and B:
 In-network and out-of-network benefits are
the same, except …
 The inpatient deductible is waived for inpatient stays at network hospitals
 To access HMO in-network benefits, plan
members must use network providers
A provider directory for each OGB health plan is
*
available on the website…www.groupbenefits.org
Plan Overview ...
Plan Member Out-of-Pocket Expenses
Administrator
PPO
HMO
All regions
OGB
Medical Home HMO **
Regional HMO
Nationwide
Statewide –
PCP must be in Region 9
Regions 6, 7, 8 & 9
Blue Cross
Vantage Health Plan
Vantage Health Plan
Lifetime
Maximum
per Person
Unlimited
Deductible
$300 retired
3-person maximum
None
None
None
Out-of-Pocket
Maximum
$2,000 per person
$1,000 per person
$3,000 per family
No maximum
$1,000 per person
$3,000 per family
Hospital
In-Network
20% of Medicare
co-insurance/
deductible *
0% of Medicare
co-insurance ***
0% of Medicare
co-insurance/deductible
0% of Medicare
co-insurance ***
Doctor Visits
20% of Medicare
co-insurance/
deductible *
0% of Medicare
co-insurance ***
0% of Medicare
co-insurance/deductible
Referrals waived for
in-network providers
0% of Medicare
co-insurance ***
Network
Providers
No restrictions
No restrictions
Restrictions apply
No restrictions
* Subject to plan year deductible and/or applicable co-insurance
** Must use in-network providers
*** May be subject to HMO co-payments/co-insurance based on amount paid by Medicare
Plan Overview ...
Plan Member Out-of-Pocket Expenses
Services
PPO
HMO
Medical Home
HMO **
Regional HMO
MRI/CAT
Scans
20% of Medicare
co-insurance/
deductible *
0% of Medicare
co-insurance ***
0% of Medicare
co-insurance
0% of Medicare
co-insurance ***
Sonograms
20% of Medicare
co-insurance/
deductible *
0% of Medicare
co-insurance ***
0% of Medicare
co-insurance
0% of Medicare
co-insurance ***
Chemotherapy
Radiation
Therapy
20% of Medicare
co-insurance/
deductible *
0% of Medicare
co-insurance ***
0% of Medicare
co-insurance
0% of Medicare
co-insurance ***
Routine PSAs
0% of Medicare
co-insurance
0% of Medicare
co-insurance
0% of Medicare
co-insurance
0% of Medicare
co-insurance ***
Cardiac
Rehabilitation
20% of Medicare
co-insurance/
deductible *
0% of Medicare
co-insurance ***
Complete within 6 months
Home Health
Care
Non-covered benefit
when Medicare is
primary
0% of Medicare
co-insurance
0% of Medicare
co-insurance ***
48 visits per plan year
Up to 18 visits per
6-week period
48 visits per plan year
Non-covered benefit
when Medicare is
primary
0% of Medicare
co-insurance/
deductible
Non-covered benefit
when Medicare is
primary
* Subject to plan year deductible and/or co-insurance
** Must use in-network providers
*** May be subject to HMO co-payments/co-insurance based on amount paid by Medicare
Plan Overview …
Plan Member Out-of-Pocket Expenses
Out-of-Network Providers
PPO
HMO
Louisiana
resident
Same as innetwork plus
$50 per day
deductible;
maximum $250
per admission
$1,000 deductible per
person; $3,000 family
maximum
Out-of-state
resident
Same as
in-network
Same as Louisiana
resident *
30% of reasonable
and customary
charge *
Medical Home HMO
Regional HMO
Emergencies
covered worldwide;
all other services
require prior plan
approval
30% of Vantage
allowable and
$1,000 deductible *
Same as Louisiana
resident
Same as Louisiana
resident *
* Plan member may owe deductible, co-payment, co-insurance and balance of billed charges
Mental Health & Substance Abuse
Treatment Benefit
Out-of-Network Providers
PPO
HMO
Medical Home HMO
Regional HMO
ValueOptions
ValueOptions
Vantage Health Plan
Vantage Health Plan
2
Member pays
20% of
contracted rate 1
$100 co-payment;
$300 maximum
per admission
Member pays 0%
of Medicare
co-insurance/
deductible
$100 co-payment;
$300 maximum per
admission
Outpatient
Member pays
20% of
contracted rate 1
$15 office visit
co-payment
Member pays 0%
of Medicare
co-insurance/
deductible 2
$15 office visit
co-payment 2
Inpatient
1
2
Subject to plan year deductible and/or co-insurance
Pre-authorization required
Prescription Drug Benefit
PPO and HMO (Administered by Medco and Catalyst Rx)
Prescription Drug Benefit In-Network
Plan
Member
Out-ofPocket
Expense
Generic and brand-name drugs:
 Plan member pays 50% of cost
 Maximum $50 per 31-day fill
 After $1,200 per person per plan year, plan member pays
co-pay of $15 for brand-name drug, $0 for generic drug
Plan member will be automatically enrolled in OGB
Medicare Part D prescription drug plan with wrap-around
coverage at no additional cost
Formulary Open *
Mail Order Same as above
Program
* OGB’s open formulary means all FDA-approved prescription drugs that
are currently covered will continue to be covered in 2012
Prescription Drug Benefit
Regional HMO (Administered by VHP’s Catalyst Rx)
Prescription Drug Benefit In-Network
Plan
Member
Out-ofPocket
Expense
Generic drug and brand-name drug with no generic available:
 Plan member pays 50% of cost
 Maximum $50 per 30-day fill
 After $1,200 per person per plan year, plan member pays
co-pay of $15 for brand-name drug, $0 for generic drug
Brand-name drug with FDA-approved generic available:
 Plan member pays cost difference between brand-name
drug and generic, plus 50% of brand-name drug cost
 Cost not applied to $1,200 out-of-pocket maximum
Formulary Closed with exceptions *
30-day supply – 1 co-pay
Mail Order
Program 60-day supply – 2 co-pays
90-day supply – 3 co-pays
* Prescription drugs not on Vantage’s formulary list may be available at higher out-of-pocket cost
Prescription Drug Benefit
Medical Home HMO (Administered by VHP’s Catalyst Rx)
Prescription Drug Benefit In-Network
Per 30-day fill
Plan Member  Generic drug – $5 co-pay
Out-of-Pocket  Preferred brand drug – $30 co-pay
Expense
 Non-preferred brand drug – $50 co-pay
 Specialty drug – 20% co-insurance
Formulary
Closed with exceptions *
Mail Order
Program
30-day supply – 1 co-pay
60-day supply – 2 co-pays
90-day supply – 3 co-pays
* Prescription drugs not on Vantage’s formulary list may be available at higher out-of-pocket cost
Prescription Drug Benefit
PPO and HMO Plan Members with Medicare Only
Effective January 1, 2012 …
OGB will transition to an Employer Group Waiver
Plan (EGWP) Medicare Part D prescription drug
plan – plus wrap-around coverage for medications
not included in the Medicare D plan
FDA-approved prescription drugs that are now
covered will continue to be covered in 2012
Applies to retirees (and covered spouses) who …
 Have Medicare Part A and/or Part B coverage; and
 Are enrolled in OGB’s standard PPO or HMO health plans
Prescription Drug Benefit
PPO and HMO Plan Members with Medicare Only
Effective January 1, 2012 …
OGB will enroll you in new Medicare Part D
prescription drug plan and wrap-around drug
coverage automatically – at no additional cost to you
 The current retiree drug subsidy (RDS) is being phased out
 The transition will enable OGB to receive new federal
EGWP subsidy for providing Medicare Part D prescription
drug coverage to retired OGB plan members with Medicare
 The EGWP subsidy will help OGB offset rising health care
costs … this helps OGB keep premiums as low as possible
Prescription Drug Benefit
PPO and HMO Plan Members with Medicare Only
Before December 1, 2011 …
 You will receive letters and information by mail
(from OGB, Medco and Catalyst Rx) about the
effects of the transition – if any – on your
OGB prescription drug benefits
 Be sure to read – and save – this information!
Prescription Drug Benefit
PPO and HMO Plan Members with Medicare Only
Effective January 1, 2012 …
 No change in plan member prescription co-payment
(50% of drug cost to $50 maximum) – for 31-day supply
 Same $1,200 plan member out-of-pocket maximum; after
maximum, co-pay still $15 brand-name drug, $0 generic
 No change in retail pharmacy network
 Drug formulary remains open
 Continued coverage for FDA-approved prescription drugs now
covered by Catalyst Rx
 Coverage for some drugs previously not covered
Prescription Drug Benefit
PPO and HMO Plan Members with Medicare Only
Effective January 1, 2012 …
 Fill limits increased to 31/62/93 days (now 30/60/90 days)
 Can buy 93-day fill at retail pharmacy – no 31-day wait
 Quantity limits may vary
 Prescriptions that now require prior authorization may
require re-authorization – no transfers (required by CMS)
 Can continue to get free testing supplies by mail or at
any network pharmacy when you fill diabetes
prescription (insulin or oral medication)
Prescription Drug Benefit
PPO and HMO Plan Members with Medicare Only
Effective January 1, 2012 …
 If your annual income is less than …
 $16,335 as an individual, or
 $22,065 for a family of 2
… you may qualify for a Medicare subsidy that
reduces your co-payment
 This means your out-of-pocket expenses for
prescription drugs may be lower
Prescription Drug Benefit
PPO and HMO Plan Members with Medicare Only
Effective January 1, 2012 …
You will have 2 separate ID cards …
 You will receive a new ID card from Medco for each plan member
with Medicare – for prescription benefits for that person only
 Medco (in partnership with Catalyst Rx) will administer your Medicare
Part D prescription drug coverage and wrap-around coverage
 You will continue to use your health plan ID card – for all other
medical benefits for all plan members with Medicare
 If you change health plans during Annual Enrollment, you will receive
a new OGB health plan ID card
 If you do not change health plans during Annual Enrollment, you will
continue to use your current OGB health plan ID card
IMPORTANT Reminder # 1
PPO and HMO Plan Members with Medicare Only
The information you receive by mail (from OGB, Medco and
Catalyst Rx) before December 1 will …
 Include more details about OGB’s EGWP Medicare Part
D prescription drug plan and wrap-around coverage
 Offer you a chance to “opt out” of OGB’s Medicare Part
D drug coverage – as required by CMS (the federal Centers
for Medicare and Medicaid Services) – but
OGB strongly recommends that you DO NOT OPT OUT!
If you opt out of OGB’s Medicare Part D coverage,
you also opt out of ALL of your OGB health
and prescription drug coverage -- FOREVER!
IMPORTANT Reminder # 2
PPO and HMO Plan Members with Medicare Only
After you are automatically enrolled in OGB’s
Medicare Part D prescription plan, DO NOT
purchase or enroll in …
 An individual Medicare Advantage plan
 A group Medicare Advantage plan not sponsored by OGB
 Another Medicare Part D plan for drug coverage only
because …
IMPORTANT Reminder # 2 (continued)
PPO and HMO Plan Members with Medicare Only
 Each person can be enrolled in only ONE
Medicare-type plan
 Signing up for ANY individual Medicare-type
plan cancels your current OGB coverage – and
could leave you without OGB health and
prescription coverage!
If a husband and wife currently have dual coverage,
each must now choose ONE plan based on his or her
own health situation
Retiree 100 – PPO Plan Members
Optional coverage available to retired plan
members who have Medicare Part A and Part B
as primary health coverage
 May provide higher reimbursements for eligible medical
expenses after deductibles are met
 Considers total charges billed by eligible provider, not
just balance due after Medicare has paid
 Additional premium – $39 per person per month
Sources of Information
OGB Website – www.groupbenefits.org
Plan Comparison & Premium Rates
Annual Enrollment Materials
Agency Human Resources Office
OGB Agency Services Offices
Your Health: Our Priority
The OGB website…
www.groupbenefits.org
….offers links to a current provider directory
for each health plan — accessible any time
 Go to the OGB home page
 Click on the Health Plans link to access a
searchable list of network providers (and other
information) for each OGB health plan
Life Insurance
Life Insurance
Prudential Insurance Co. of America
 Group term life insurance plan
 State pays half of premium for employees and retirees
 Employee pays full premium for dependent life insurance
 25% reduction in coverage and appropriate reduction in
premiums on July 1 after plan member reaches age 65
and age 70
Life Insurance
Basic Plan
Option I
Option II
Employee
$5,000
$5,000
Spouse
$1,000
$2,000
Each Child
$ 500
$1,000
Employee
Schedule in
Premiums
Helpful Information Book
Premiums for Dependent Life
Employee Pays
$0.88/mo
$1.76/mo
Life Insurance
Basic Plus Supplemental Plan
Option I
Option II
Employee
Schedule to maximum of $50,000
(amount based on employee’s
annual salary)
Same
Same
Spouse
$2,000
$4,000
Each Child
$1,000
$2,000
Employee Premiums
Schedule in Helpful Information Book
Premiums for Dependent Life
Employee Pays
$1.76/mo
$3.52/mo
Life Insurance
 Accidental Death and Dismemberment (AD&D)
benefits available to all active and retired
employee covered under Basic or Basic Plus plan
 Retirees over age 70 not eligible for AD&D
 ALL inquiries and changes in life insurance must
be made through your agency’s HR department
Sources of Information
 OGB website with links to all OGB health plans…..
www.groupbenefits.org
 OGB (PPO)…..1-800-272-8451
 Blue Cross and Blue Shield of LA (HMO)…..1-800-392-4089
 Vantage Health Plan (Medical Home & Regional HMO)…..1-888-823-1910
 Medco…..1-866-808-5271 (or 1-800-716-3231 TTY/TDD) * effective 12-1-11 *
 Catalyst Rx…..1-866-358-9530
 ValueOptions…..1-866-492-7143
Questions?