HIGH
OPTION
Presented by: Joannie Nilan
1
1
How We Change for 2012
Section 2. Page 10
Weight Management Program

Managed by CIGNA/CareAllies:
1-800-582-1314 - Prompt 6
o
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
2
2
How We Change for 2012
Section 2. (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 test
o
One annually
o
Standard out-of-network rate
3
3
How We Change for 2011
Section 2. (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
4
4
Facts
Section 1. Page 8

FFS / Non-PPO
o
o
o
o
o
o

Fee For Service
Standard benefits
World wide coverage
Do not discount services
Do not agree to accept the Plan allowance
Higher deductibles, coinsurance, and out-of-pocket
PPO
o
o
o
o
o
Preferred Provider Organization
Vendor negotiated contracts
Agree to accept discounted fee for services
Always accept the Plan allowance (contracted allowance)
Lower deductibles, coinsurance, copayments, and out-ofpocket
5
5
Facts
Section 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
6
6
Facts
Section 1. (continued…)

Medco – Prescription Drug Vendor
○ 66,000 pharmacies
○ RX
○ Personalized Medicine
○ Specialty Drugs
○ Precert some drugs
7
7
How to Get Care
Section 3. Page 11
 ID Cards/Health Benefits Election Form /
Electronic Confirmation Letter
 Precertification
o
o
Inpatient Stays
Surgeries
• Cosmetic, Transplants, Morbid Obesity, Organic
Impotence
o
Rehabilitative Therapy (PT/OT/ST)
8
8
How to Get Care
Section 3. (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
9
9
Your Cost
Section 4. Page 18
Cost
Benefit
PPO
Non-PPO
Copayments
(co-pays)
Office Visit
Routine
Hospital Admit
$18.00
$18.00
$0/coinsurance
Coinsurance
$300 fee +
coinsurance
Deductible
Must meet Individual or $275 Individual
Family deductible;
$550 Family
whichever comes first
$500 Individual
$1,000 Family
Coinsurance
(Coins)
Benefits with Coins
10% Member
90% Plan
30%* Member
70% Plan
Out-ofPocket
Co-pays and Coins only
$4,000
$10,000
(Deductibles and non
covered charges are not
included)
*Of plan allowance and any difference between our allowance and billed amount
10
10
Benefits
Section 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
11
11
Benefits
Section 5. (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)
12
12
Benefits
Section 5. Page 29

Adult - Preventive Care
o
After age 12 one routine exam per person
every two calendar years
• Office visit
• Lab tests: comprehensive metabolic panel,
lipid panel and urinalysis
13
13
Benefits
Section 5. (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.
14
14
Benefits
Section 5. Page 29
Adult Routine Screenings

One annual total blood cholesterol test

Fasting Lipoprotein once every 5 years

Osteoporosis screenings

Chlamydia infection tests

Colorectal cancer screenings
o Sigmoidoscopy and Colonoscopy screenings
starting at age 50
15
15
Benefits
Section 5. (continued…)

Prostate cancer screenings

Routine Pap smear

Abdominal aortic aneurysm screening

Routine mammograms with age
restrictions

Adult immunizations recommended by
the CDC
16
16
Benefits
Section 5. Page 30

Children - Preventive Care
o
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
17
17
Benefits
Section 5. Page 31

Maternity Care
o
o

Delivery and Pre and Postnatal
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 Services
o
o
Coverage for specific services see Plan Brochure
Maximum Plan payout of $2500 annually
18
18
Benefits
Section 5. (continued…)

Family Planning
o
o
o
o
o


Voluntary sterilization
Surgically Implanted Contraceptives
Injectable Contraceptives
IUD
Diaphragms
Oral contraceptives payable under
Prescription Drug benefit
Non-covered: Reversal of voluntary
sterilization and genetic counseling
19
19
Benefits
Section 5. Page 32

Allergy Care
o
o

Testing and treatment including materials
Allergy Shots
Treatment Therapies
o
o
o
o
Chemotherapy, Radiation
Dialysis
Respiratory and Inhalation
IV and Growth Hormone (Require Approval)
• Drugs used are covered under the Prescription
Drug benefit
20
20
Benefits
Section 5. Page 33

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.
21
21
Benefits
Section 5. Page 33

Hearing Services
o

One exam and testing for hearing aids every 2
years
Vision Care
o
o
Internal ocular lenses / first contact lenses to
correct impairment
Non-covered
• Eyeglasses and contact lenses
• Eye exercises
• Refractive surgery
22
22
Benefits
Section 5. Page 34

Routine Foot Care
o

Only covered for a metabolic or peripheral vascular disease, such as
diabetes
Orthopedic and Prosthetic Devices
o
Leg, arm, neck and back braces
o
Artificial limbs, eyes
o
External breast prostheses, surgical bras following a mastectomy
o
Internal devices, joints, pacemakers and surgically implanted
breast implant following a mastectomy
o
Pre-authorization is recommended
o
Non covered items:
• orthopedic/corrective shoes, arch and lumbosacral supports, foot
orthotics, corsets, stockings, support hose
23
23
Benefits
Section 5. Page 35

Hearing Aids
o
o

No Deductible
$1500 Benefit every 3 years
Durable Medical Equipment (DME)
o
o
Pre-certification Required
Covered:
• Oxygen and Dialysis equipment
• Hospital beds and wheelchairs
• Ostomy supplies
• Crutches and walkers
24
24
Benefits
Section 5. (continued…)
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 communicationimpaired individual
25
25
Benefits
Section 5. Page 36

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
26
26
Benefits
Section 5. (continued…)

Chiropractic Services
o

12 Visit Limit per Calendar Year
Acupuncture by a MD or DO
27
27
Benefits
Section 5. Page 37

Educational Programs
o
o
o
o
o
Limited to the CIGNA Tobacco Cessation Program
Program is 100% Voluntary
Enhanced PPO Benefit
Managed by CIGNA/CareAllies
Easy Enrollment
• Telephonically or online
o
Compliance Requirement
• 4 Counseling sessions of 30 minutes each
28
28
Benefits
Section 5. (continued…)

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
29
29
Benefits
Section 5. Page 38
5 (b). Surgical and Anesthesia Services
 Surgery
o

Pre-certification required for
o
o
o
o

A comprehensive range of services for operative
procedures including pre and post operative care
organ transplant
cosmetic surgery
surgery for morbid obesity and
organic impotence
Anesthesia
30
30
Benefits
Section 5. Page 45
5 (c). Hospital or Other Facility and
Ambulance
 Inpatient Hospital
o
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 stay
o
o
Non PPO hospital confinements have a $300 per
admission fee
Calendar year deductible does not apply
31
31
Benefits
Section 5. (continued…)
o
Room and Board
• Private rooms covered for isolation to prevent
contagion
o
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
32
32
Benefits
Section 5. (continued…)
o
Non-covered Items:
• Any part of admission not medically necessary
• Custodial Care
• Personal Convenience Items
• Private Duty Nurses
33
33
Benefits
Section 5. (continued…)
o
Non-covered Facilities:
• Nursing Homes
• Skilled Nursing
• Residential Treatment
• Day and Evening Care
• Schools
34
34
Benefits
Section 5. Page 46

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
35
35
Benefits
Section 5. Page 47

Outpatient Hospital or Ambulatory Surgery
Center
o
o
o
o
o
o
o
Operating, recovery and other treatment rooms
Prescribed Drugs
Diagnostic Lab Test and X-rays
Blood and Administration
Pre-surgical Testing
Supplies
Anesthetics
36
36
Benefits
Section 5. Page 47

Hospice Care
o
o
o
o

Annual Benefit
$3,000 outpatient
$2,000 inpatient
$200 bereavement per family unit
Ambulance
o
o
Local professional ambulance service when
medically necessary
Ambulance service for routine transport is not
covered
37
37
Benefits
Section 5. Page 48
5 (d). Emergency Services and Accidents
 Accidental Injury
Bodily injury sustained solely thru violent, external
and accidental means
o Broken Bones
o Animal Bites
o Poisonings
o

Medical Emergency
o
o
o
o
Sudden and unexpected onset of a condition
Heart Attack
Stroke
Sudden inability to breathe
38
38
Benefits
Section 5. Page 49
Accidental Injury:

Within 24 hours our member pays
o
o

After 24 hours our member pays
o
o

nothing if rendered by a PPO provider
only the difference between our Allowance and the
billed charge by a Non-PPO provider
$18 co-pay if rendered by a PPO provider
After Non-PPO deductible is satisfied, 30% of Plan
Allowance and any difference between our Allowance
and billed charge
Inpatient benefits apply if admitted
39
39
Benefits
Section 5. (continued…)
Medical Emergency:

Outpatient Facility Charges in an Urgent Care Center
our member pays
o
o

Outpatient Medical or Surgical Services and Supplies,
Other Than Urgent Care Center our member pays
o
o

PPO facility - $40 Co-payment
Non-PPO facility – After Non-PPO calendar year deductible is
satisfied, 30% of Plan Allowance and any difference between our
Allowance and billed charge
PPO facility - After PPO calendar year deductible is satisfied,
member is responsible for 10% of Plan Allowance
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
40
40
Benefits
Section 5. Page 50
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
41
41
Benefits
Section 5. Page 52
5 (f). Prescription Drug Benefit
Medco Health Administers Our Drug Plan
 Generic
o
o

Generic is chemically equivalent to Brand
Normally dispensed
Brand
o
o
Prior authorization is recommended
Higher member responsibility
42
42
Benefits
Section 5. Page 55

Non-Network Retail
30 day supply
o 50% of the cost of the drug
o $8.00 minimum
o

Network Retail
30 day supply
o Generic = $8.00 co-pay
o Brand = 25% coinsurance with minimum of $8.00 and $200
maximum out-of-pocket
o Refill Restrictions
• Only 2 fills of the same prescription
• All other fills are at the non-network rate
43
o
43
Benefits
Section 5. (continued…)

Mail Order
o
o
o

90 day supply
Generic = $15.00 co-pay
Brand = 25% coinsurance with $12.00 minimum
and $600 maximum out-of-pocket
Drugs Requiring Preauthorization
o
o
o
Organic Impotence
Cosmetic Purposes
Recommended for Brand Name
44
44
Benefits
Section 5. (continued…)

Personalized Medicine
o
Voluntary Program
o
Pharmacogenomic test for drug therapies
• Tamoxifen (for breast cancer)
• Warfarin (anticoagulant)
• Plavix (antiplatelet)
45
45
Benefits
Section 5. Page 57
5 (g). Dental

Accidental Injury to Teeth
o
o
o
Repair not replace sound natural teeth
Result of an accident and be preformed within 2
years of accident
Different benefit level with in 24 hours and after 24
hours
 Routine
o
Dental
Two office visits per calendar year – Includes: Exam,
Cleaning, X-rays of all types, Fluoride Treatment,
Fillings and Simple Extractions
46
46
Benefits
Section 5. Page 58
5(h). Special Features

Flexible Benefits Option

24-hour Nurse Line

TDD line for hearing impaired

Wellness

Review and Reward Program
47
47
Benefits
Section 5. (continued…)
Disease Management – SmartSteps

Voluntary Program

Variety of Services to Manage Chronic
Conditions

o
Cardiac
o
Diabetes
Managed by CIGNA/CareAllies:
1-800-582-1314
48
48
Benefits
Section 5. Page 59
Diabetes Management Program
 Managed by CareAllies: 1-800-582-1314
 Compliance Requirements:
Members must have one annual:
o
o
Diabetic nephropathy and retinopathy screening
Annual labs that include
• LDL and HDL cholesterol test
• Triglycerides test
• Serum Creatinine test
Must have:
o
o
o
o
AIC blood test every 6 months
Services by a PPO provider every 6 months for diabetes
Coach contact once a quarter
Take prescription regularly
49
49
Benefits
Section 5. (continued…)
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.
50
50
Benefits
Section 5. (continued…)
Hypertension Management Program

Managed by CIGNA/CareAllies:
1-800-582-1314

Compliance Requirements:
o
o
o
o
o
Coach contact once every 3 months
Members must know their numbers
Members must see their doctor once per year for
Hypertension
Must take their prescriptions regularly
Must schedule the next coach call
51
51
Benefits
Section 5. (continued…)
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.
52
52
Benefits
Section 5. Page 60
Weight Management Program
 Managed by CIGNA/CareAllies:
1-800-582-1314
o
$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
53
53
Benefits
Section 5. (continued…)
Medco Health Store - www.medco.com
 Medco’s consumer health products website
o
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
54
54
Benefits
Section 5. (continued…)
CIGNA / CareAllies Special Programs:

1-800-582-1314
Lifestyle programs
o

Personalized Plans
Healthy Rewards and MyCareAllies
o
o
o
o
o
o
Discounts on Smoke Cessation Programs
Discounts on Weight Reduction Programs
Savings on Gym Memberships
Vision and Hearing Exam Discounts
Discounts on Herbal Supplements and Vitamins
Discounts on alternative medicine and
anti-cavity products
55
55
General Exclusions
Section 6. Page 99






Services or supplies deemed not medically
necessary, administered by a non-covered
provider, not specifically listed as covered
Experimental or investigational
Communication aids
Educational or self help training
Charges in excess of the plan allowance
“Never Events”
56
56
Filing a Claim
Section 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 Limit
o
December 31st of the year following the year of
service
57
57
Coordinating Benefits
Section 9. Page 104

Medicare
o A = Hospital
o B = Medical
o C = Advantage/HMO
o D = Prescription Drugs

Other Insurance Coverage (OIC)

Tricare/Champus/ ChampVA

Medicaid
58
58
2012
RATES
59
59
www.apwuhp.com
Online Tools and Resources

eHealthRecord

Microsoft Health Vault
o

Personal Health Record
Health Assessment
60
60
www.apwuhp.com
Consumer Choice Information

Online PPO Directory

Hospital Quality Ratings Guide

Treatment Cost Estimator

Prescription Drug Information
61
61
High Option Benefit Plan
Also available on our website:

HPR Tab

Visitor Tab

Brochure

Newsletters

AARP Health Tools
62
62
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
63