Presentation on theme: "Health Care Coverage for You and Your Family!"— Presentation transcript:
1 Health Care Coverage for You and Your Family! Welcome to the enrollment meeting for TRS-ActiveCare—health care coverage for you and your family.Since 1937, the Teacher Retirement System of Texas (TRS) has served public education employees by delivering their retirement and related benefits and by managing the trust fund established to finance their benefits.Since its inception in September 1, 2002, participation in the TRS-ActiveCare program has grown to more than 200,000 employees plus their 133,000 dependents (over 330,000 total members) — over one quarter of a million covered lives. Of the 1,249 districts/entities eligible to participate in TRS-ActiveCare, over 85 percent, or 1,066, now do so.Welcome
2 Agenda Who is eligible to enroll Plan options and what’s new Cost of health coverageHow to enrollEnrollment supportQuestionsOur agenda today will cover the following:What’s new this yearWho is eligible to enrollPlan optionsCost of health coverageHow to enrollEnrollment supportQuestions
3 Who is Eligible to Enroll? To be eligible for TRS-ActiveCare coverage, you must:Be employed by a participating district/entity andBe an active, contributing TRS member orBe employed 10 or more regularly scheduled hours each weekWho can enroll in TRS-ActiveCare?To be eligible for TRS-ActiveCare, you must be employed by a participating entity. Then, ask yourself these questions:(1) Are you an active, contributing TRS member?(2) Are you employed for 10 or more regularly scheduled hours each week?If the answer is yes to either question, then you are eligible for TRS-ActiveCare coverage.Health care coverage for public school employees and their families
4 Employees NOT Eligible to Enroll State of Texas employees or retireesHigher education employees or retireesTRS retirees, receiving or who declined coverage under TRS-CareThese individuals are not eligible to enroll for TRS-ActiveCare coverage as employees, but they can be covered as a dependent of an eligible employee.Employees that are not eligible to enroll in TRS-ActiveCare include individuals:Receiving health care coverage as an employee or retiree under the Texas State College and University Employees Uniform Insurance Benefits Act, for example, a school employee that has UT SELECT coverage as an employee with The University of Texas System.Receiving health care coverage as an employee or retiree under the Texas Employee Uniform Group Insurance Benefits Act, for example, a school employee that has HealthSelect coverage as an employee with ERSA TRS retiree receiving, or who waived coverage, under TRS-Care, including a retiree who has returned to work. Note: If a retiree has returned to work and has never been eligible for TRS-Care, he or she would be eligible for TRS-ActiveCare coverage, as long as the retiree meets all the TRS-ActiveCare eligibility requirements.Basically, employee coverage is not available from two state sources.However, these individuals–retirees, higher education and state of Texas employees–while they are not eligible to enroll for TRS-ActiveCare coverage as employees, they can be covered as a dependent of an eligible employee.
5 Eligible Dependents Spouse (including a common law spouse) Unmarried children under age 25Natural childAdopted childStepchildFoster childOther eligible dependents listed in Enrollment GuideGrandchildren (unmarried)Disabled children (unmarried, of any age)You may also cover your eligible dependents at the same time you enroll for coverage.Eligible dependents of a covered employee include a spouse (including a common law spouse) and an unmarried child under the age of 25 described by any of the following: a natural or adopted child, a stepchild and a foster child.More examples of eligible dependent children under age 25 include the following:An unmarried child under the legal guardianship of the employeeAn unmarried child in a regular parent-child relationship with the employee. See Enrollment Guide for the eligibility criteria; all four eligibility criteria must be met.An unmarried grandchild whose primary residence is the household of the employee and who is a dependent of the employee for federal income tax purposes.A child of a covered employee, regardless of age, may be eligible for dependent coverage provided that the child is either mentally retarded or physically incapacitated to such an extent as to be dependent on the employee on a regular basis as determined by TRS and the child meets other requirements as determined by TRS.Any other individuals who are required to be covered under applicable law. (Example: A child for whom the employee (or the employee’s spouse) has received a court order requiring coverage.)Note: Siblings over age 25 or parents are not the children of an employee and do not meet the definition of an eligible dependent.When enrolling dependent children, you will be asked on the TRS-ActiveCare Enrollment Application and Change Form to indicate your child’s relationship to you, the employee. Check natural/adopted, stepchild, foster child, legal guardianship, grandchild or other child, as appropriate. You’ll also want to read the coverage conditions on the back of the Enrollment Application and Change Form that you understand the eligibility criteria for TRS-ActiveCare.
6 Newborns Covered the first 31 days if employee has coverage To continue coverage, employee must add newborn within 60 days after the date of birthHowever, an employee has up to one year after the newborn’s date of birth if:Employee has “employee and family” or “employee and child(ren)” coverage at the time of birth and at the time of enrollmentSpecial rules apply to newborn children.TRS-ActiveCare automatically provides coverage for a newborn child of a covered employee for the first 31 days after the date of birth. To add coverage for the newborn, the employee must sign, date and submit an Enrollment Application and Change Form to the Benefits Administrator within 60 days after the date of birth. However, an employee has up to one year after the newborn's date of birth to add the newborn to coverage if the employee has employee and family or employee and child(ren) coverage with TRS-ActiveCare at the time of the newborn’s birth and at the time of enrollment. If the application is submitted after the enrollment period for the newborn child, the request to add coverage will be denied—even if there would be no change in premium.
7 PPO Plan Options ActiveCare 1, 2 and 3 Let’s now discuss the health care benefits available through the PPO plans: ActiveCare 1, ActiveCare 2 and ActiveCare 3.PPO Plan OptionsActiveCare 1, 2 and 3
8 What’s New for 2008-2009? ActiveCare 1, 2 and 3 No premium increase No benefit changesEmphasis on health and wellnessNew plan features available April 1, 2008Blue Care Connection24/7 NurselinePersonal Health Manager (PHM) online health and wellness resourceLive Chat secure, online real-time access for customer service inquiriesWhat’s New in ?ActiveCare 1, 2 and 3: There are no benefit changes to the ActiveCare 1, 2 and 3 PPO plans, and the premium rates will remain the same—no rate increase. What you will see is an emphasis on health and wellness. Blue Cross and Blue Shield of Texas invites ActiveCare 1, 2 and 3 plan participants to “Experience. Wellness. Everywhere.” and take advantage of some new programs.Effective April 1, 2008, Blue Cross and Blue Shield of Texas will introduce several new plan features for the ActiveCare 1, 2 and 3 plans. Blue Care Connection lifestyle and condition management, 24/7 Nurseline, Personal Health Manager (PHM), and Live Chat are now available to all ActiveCare 1, 2 and 3 plan participants, including those that are currently enrolled as well as those enrolling for the new plan year.
9 PPO Network for ActiveCare 1, 2 and 3 Largest PPO network in the stateIncludes over 50,000 physicians and over 400 hospitals in TexasAvailable in all 254 Texas countiesAdvantages to using network providersReceive highest level of benefitsNo claims to fileNo balance billingNeed to locate a Network Provider?Before we talk about the new plan features, let me take a moment to review the PPO plan options and tell you about the network of doctors and hospitals for the ActiveCare 1, 2 and 3 plans. Administered by Blue Cross and Blue Shield of Texas, the PPO network for TRS-ActiveCare is the largest network of its kind in the state of Texas. It offers access to over 50,000 physicians and more than 400 hospitals in Texas and is available in all 254 counties.Employees have the freedom to choose their own doctor at the point of service. No Primary Care Physician (PCP) or referrals required. Each time an employee or eligible dependent needs health care, he or she needs to decide whether to see an in-network provider or an out-of-network provider.With in-network providers:Receive highest level of benefitsNo claims to file in most cases (network provider will usually file the claims)No balance billing; network providers cannot bill for costs exceeding the allowable amount.With non-network providers:Receive non-network level of benefits (reduced level from network)May have to file own claimsMay be billed for charges exceeding the BCBSTX allowable amount.Even if you visit a non-network doctor, you may still save money using a ParPlan physicianBlue Cross and Blue Shield of Texas contracts with many non-network doctors and hospitals. These providers accept the Blue Cross and Blue Shield of Texas allowable amounts for covered services and cannot bill you more. In most cases they will file claims, too.Need to locate a network or ParPlan physician or hospital?Log onto to TRS-ActiveCare Web site: and select the ActiveCare Plans 1, 2 and 3, then select the link for Provider Locator. Or, go to: and select the tab for Doctors and Hospitals.
10 Plan Overview ActiveCare 1 ActiveCare 2 ActiveCare 3 Deductible (individual/family)$1,100/$3,000$500/$1,500NoneOut-of-Pocket Maximum$2,000/$6,000$1,000 per individualCoinsurance(Plan pays/participant pays)80%/20%Office Visit Copay20% after deductible$25 for primary$35 for specialist$20 for primary$30 for specialistDeductibles: The set amount of out-of-pocket expense, if applicable, that must be paid for health care services by the covered person before the plan begins to share costs. For example, ActiveCare 1 has a $1,100 deductible, which must be met before the plan pays any benefits. ActiveCare 3 has no deductible to meet when using network providers for health care services.Out-of-Pocket Maximum: If you reach your plan’s out-of-pocket maximum, the plan then pays 100% of any eligible expenses for the remainder of the plan year. Office visit copays continue after the out-of-pocket maximum is reached. Copays and deductibles do not apply to the out-of-pocket maximums for the ActiveCare 1, 2 and 3 plans.Coinsurance: The percentage of medical expenses that you and the plan share. For example, the coinsurance amount when using network providers for all plans is “80/20.” This means that the plan pays 80% and the plan participant pays 20% after any applicable deductible.Copayments: The set amount you pay for certain medical services and prescription drugs at the time of service. Note: For ActiveCare 2 and 3, the copay depends on whether the doctor is “primary” or a specialist. Primary means care provided by family practitioners, internists, OB/GYNs, and pediatricians. All other physicians are specialists.Illustrates benefits when network providers are used. Non-network benefits are also available; see Enrollment Guide for more information.
11 Plan Overview ActiveCare 1 ActiveCare 2 ActiveCare 3 Preventive CareRoutine physicals*Well-woman exams*Routine mammograms *Eye exams*Well-baby examsImmunizationsHearing examsPSA screeningsColorectal screeningsOsteoporosis screenings* Services limited to one per person per plan year$0 copay up to $500 per person, per plan yearRemaining charges subject to deductible and coinsurance$25 for primary$35 for specialistIncludes all preventive care services billed with an office visit by a network doctorCoinsurance applies when no office visit is billed or when services are performed outside the office(deductible waived)$20 for primary$30 for specialist(no deductible)TRS‑ActiveCare encourages preventive care and maintenance of good health. Covered services under this benefit must be billed by the provider as “preventive care.” As written in the Benefits Booklet for the ActiveCare 1, 2 and 3 plans (available online), preventive care benefits include, but are not limited to:Routine physical exams (limited to one physical exam per plan year for persons age two and over and one well-woman exam per plan year; benefits are not available for routine physical exams performed on in inpatient basis, except for the initial examination of a newborn child)Routine mammograms (one per plan year)Immunizations (injections for allergies are not considered immunizations)Well baby exams (after newborn’s initial examination and discharge from the hospital)Vision exams (one per plan year)Hearing examsProstate (PSA) screeningsColorectal cancer screeningsOsteoporosis screeningsBone density screeningsRoutine colonoscopyUnder ActiveCare 1, the plan pays 100 percent up to the first $500 per person per plan year for preventive care services. Claims in excess of $500 will be subject to deductible and coinsurance. For ActiveCare 2, the copay, when billed with an office visit by a network doctor, is $25 when using a primary physician and $35 when using a specialist. ActiveCare 3 features a $20 office visit copay for a primary physician and $30 copay for a specialist when billed with an office visit by a network doctor. There is no plan year maximum benefit for preventive care services for ActiveCare 2 or ActiveCare 3 and there’s no deductible to meet when using a network provider for preventive care services. Coinsurance applies when no office visit is billed or when services are performed outside the office.Illustrates benefits when network providers are used. Non-network benefits are also available; see Enrollment Guide for more information.
12 Health and Wellness Programs Blue Cross and Blue Shield of Texas invites ActiveCare 1, 2 and 3 plan participants—existing and new—to “Experience. Wellness. Everywhere.” The ActiveCare 1, 2 and 3 plans have included lifestyle and condition management programs for some time; however, effective April 1, 2008, all three PPO plans will include Blue Care Connection: enhanced health and wellness features and programs to help plan participants achieve a healthier life.Blue Care Connection®Health and Wellness ProgramsTRS-ActiveCare is administered by Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association. Blue Cross and Blue Shield of Texas provides claims payment services only and does not assume any financial risk or obligation with respect to claims.
13 24/7 Nurseline Advice anytime. New!Advice anytime.Round-the-clock health and the wellness advice from licensed professionalsAdvice isn’t just needed from 9 to 5. 24/7 Nurseline is here to help.Nurses provide health advice and information about high fevers, earaches, cuts and bruises and moreAudio health library on topics such as kicking the smoking habit and ways to get a good night’s restWith the 24/7 Nurseline, ActiveCare 1, 2 and 3 plan participants can access round-the-clock health advice and information by calling a toll-free number. They talk to nurses who have many years of clinical experience in settings such as emergency room and urgent care, hospital care and family care. Participants can call as often as they like.When a plan participant calls the 24/7 Nurseline, he or she can also access an Audio Health Library of more than 1,200 pre-recorded health messages on topics such as:Kicking the smoking habitWays to get a good night’s restManaging high blood pressureGetting a grip on stressAsthma and self managementHow to manage a sore throat24/7 Nurseline services are available in English and Spanish.The phone number to call for 24/7 Nurseline is It is printed in the Enrollment Guide and will be included on ID cards issued after the enrollment periods for ongoing account maintenance.This service will be available April 1, 2008 to existing ActiveCare 1, 2 and 3 plan participants.24/7Available in English and Spanish
14 Personal Health Manager New!Your online wellness experience begins here:Take a Health Risk AssessmentImprove your health with the “Eat Right” nutrition plannerCreate a fitness plan to suit your personal health goals and needs with “Get Fit”By logging on to Blue Access for Members through the TRS-ActiveCare Web site or through ActiveCare 1, 2 and 3 plan participants can access the Personal Health Manager for the following:Complete a health risk assessmentParticipate in online programs to improve health, fitness and nutrition, including access to the Eat Right nutrition planner and ability to create a “Get Fit” physical fitness plan.Personal Health Manager also has programs to:Ask health and wellness questions and receive secure responses from: Ask A Nurse, Ask A Trainer, Ask A Dietitian or Ask A Life Coach. For example, plan participants can ask health questions, ask for advice about diet and exercising, or how to cope with a stressful situation.Search an online health care encyclopedia. Participants will find comprehensive articles on specific conditions with helpful illustrations, personal stories, glossary and animated instructionsReceive daily news on health topicsCreate a personal health record – A secure, confidential record where participants can maintain medical history information on each family member, such as vaccination records, X-ray prints, lab reports, etc. Plan participants can input health information through , fax or phone. Participants can share access with health providers or other designated individuals.Earn Blue Points – a reward program that motivates plan participants to engage in healthy activities. ActiveCare 1, 2 and 3 plan participants earn points every time they use Personal Health Manager to track a fitness workout, report a meal, use any “Ask A” feature, take advantage of any component of the For Your Health section (interactive programs that help members strive toward a healthier lifestyle). Participants can redeem points for reward items.Click on the Personal Health Manager icon on Blue Access®for Members
15 “Ask-A” Online Advisor Expert advice at your fingertips. Our “Ask-A” feature is here to help.Ask the experts.Expert advice from licensed professionals via the Personal Health ManagerAsk a Nurse:Interact online with a Blue Care Advisor on non-emergency, health-related questions using the secure “Ask a Nurse” feature.Ask a Trainer, Dietitian or Life Coach:Send questions about fitness, nutrition, or managing stress.The “Ask-A” features of the Personal Health Manager are very popular. Using the Ask-a features, plan participants can interact online with a nurse, trainer, dietitian or life coach to ask non-emergency health related questions or questions about fitness, nutrition or managing stress.The service is confidential and secure, and plan participants will receive an response to their inquiry within one business day.CONFIDENTIAL AND SECUREReceive a response within one business day
16 Blue PointsSM Incentives ActiveCare 1, 2 and 3 plan participants and their covered dependents accumulateBlue PointsSM in the Personal Health Manager.Stay motivated.Earn Blue PointsSM in the Personal Health ManagerComplete designated health and wellness activitiesReport completed activities in the Personal Health ManagerTrack your available balanceRedeem earned Blue PointsSM for a variety of items!Just like with the New Year’s resolutions we all make, sometimes it’s just tough to follow through on our good intentions.That’s where incentives come into play. By offering rewards for making changes in health care choices and for participating in the programs provided, that little extra incentive may be all that is needed to get plan participants headed down the right wellness path.Rewards may influence participants to change behavior by participating in specific health behavior activities.The incentives can help control future health care costs if acute care episodes are avoided, or through the prevention of/and or early intervention in chronic diseases.Blue Points will be available April 1, Points can be redeemed for gift cards, exercise equipment and much, much more! (Reward value is up to $99 per calendar year per participant.) Unused points roll over to the following year and do not expire.
17 Weight Management and Tobacco Cessation Self-Paced ApproachOnline tools and resources via the Personal Health ManagerSecure outreach to keep members on trackTobacco Cessation ProgramSupport for members who want to quitWeight Management ProgramSupport for a Healthier YouPersonalized Lifestyle Management SupportCounseling and coaching with licensed Wellness CoachesMotivational toolkit24/7 NurselineReferrals when appropriateBCBSTX offers online tools to help ActiveCare 1, 2 and 3 plan participants address their smoking cessation and weight management issues in a self-paced, personalized, interactive way. Using a series of interactive s, the tools guide participants through steps designed to help them reach their goals, continuously adjusting the message to meet the participant's needs, according to desire to change, progress made, etc.For participants that meet certain criteria and exhibit a readiness to change, there’s more. These participants receive interactive coaching through telephonic outreach and use of the online tools. Coaches are trained in engaging plan participants by using cognitive behavioral approaches to help the person gain insight into his or her health issues (or unhealthy lifestyles such as smoking, overeating, not exercising, etc.). Coaches work with participants to set goals and track progress toward those goals over time. Coaches are certified professionals (licensed professional counselors, licensed social workers, etc.).BCBSTX may contact the plan participant for outreach based on HRAs completed through Blue Access for Members or other screening information available. Plan participants may also self-refer by calling toll-free If the participant meets the criteria for lifestyle management support, he or she will have the benefit of the telephonic coaching. The plan participant will also receive a motivational tool kit. The weight management kit includes a travel fitness kit (resistance band, jump rope, multi-function pedometer), fitness wheel, fast food slide guide, body tape measure, fitness journal, and program guide. The criteria is a BMI of 25 or greater. The smoking cessation kit includes sugar-free gum, quit smoking without gaining weight wallet card, The Little Book of Quitting by Allen Carr, meditation CD, bounce-back ball and program guide.
18 Expecting? Special Beginnings® Program Special Beginnings is a confidential, full-featured program helping you to better understand and manage your pregnancy.A pregnancy risk assessment to determine the risk of your pregnancy and provide you with close monitoring through a series of follow-up calls from an experienced obstetrical nurse.A welcome packet full of congratulatory gifts including:Baby bath and soap samplesCleansing clothsNursing padsCoupons for baby productsMagazines that help you learn more about pregnancy and parentingIn , TRS-ActiveCare paid over $31 million in maternity claims, representing about 5% of all claims paid.The Special Beginnings prenatal program is currently available to all ActiveCare 1, 2 and 3 plan participants at no additional charge. Last year, 997 cases were referred to the program; 156 enrolled and completed the program and of those, 66 or 42% were identified as moderate to high risk.The program helps mothers take better care of themselves and their babies. The program assesses pregnancy risk level and provides close monitoring through a series of phone calls from an experienced obstetrical nurse. The program is available from pregnancy through six weeks after delivery. To enroll or ask questions about the Special Beginnings program, call
19 Live Chat Secure Online Customer Service New!Send inquiries to customer service viaImmediate access to BCBSTX customer advocatesAvailable Monday – Friday, 7 a.m. to 10 p.m. (CT)Effective April 1, 2008, BCBSTX will introduce “Live Chat,” a secure online service that will allow ActiveCare 1, 2 and 3 plan participants to send inquiries to customer service via . With “Live Chat,” participants will have immediate access to BCBSTX customer advocates from 7 a.m. to 10 p.m. (Central Time), Monday through Friday.
20 What if I Have Questions? Personalized ServiceCall the TRS-ActiveCare customer service team for:Claim questions/statusNetwork provider informationMembership and eligibilityMedical coverage questionsInquiries (telephone and )ID card requestsTransition of care informationHelp with online tools!See slide.Customer Service
21 Blue Access® for Members Online Member Management Tool Check claim status, view and download EOBs (Explanations of Benefits)Order additional ID cards, and print temporary IDSend secure messages to BCBS Customer AdvocatesMonthly health articlesLinks to health information and wellness tools and resourcesBlue Access for Members is a secure portion of the BCBSTX Web site that ActiveCare 1, 2 and 3 plan participants to access their personal membership and claims information.Plan participants may:check the status of a claimview Explanations of Benefits; prevent EOB mailingsreceive notification when claims are filedconfirm covered dependentsorder additional or replacement ID cards and print a temporary ID cardsend an inquiry to Customer ServiceBlue Access is also the doorway to other health benefits tools, such as:Treatment Cost AdvisorHospital comparison toolPersonal Health ManagerHealth risk assessment
22 Prescription Drugs ActiveCare 1, 2 and 3 Let’s discuss the prescription drug benefits administered by Medco for the ActiveCare 1, 2 and 3 plans.Prescription DrugsActiveCare 1, 2 and 3
23 Your Medco Prescription Drug Plan Your TRS-ActiveCare health plan has two prescription drug componentsBlue Cross and Blue Shield of Texas manages your medical plan expenses, including prescription drug expenses under ActiveCare 1Medco manages your prescription drug plan expenses for ActiveCare 2 and 3Your medical expenses are those related to doctor visits, hospital care, lab tests, etc.Your prescription expenses are those related to medications you fill at your local retail pharmacy or through the Medco By Mail mail-order pharmacy.
24 Your Medco Prescription Drug Plan Medco has its own mail-order pharmacy – Medco By Mail – which delivers medications to your home at a lower costMedco’s mail-order pharmacies fill about 2 million prescriptions per week through a highly automated process that is % accurate and is 23 times more accurate than a retail pharmacy** “Dispensing Error Rate in a Highly Automated Mail-Service Pharmacy Practice”; Nov. 2007, Pharmacology, a peer-reviewed journal of the American College of Clinical Pharmacy
25 Specific Rx Benefit Information If you are taking a long-term medication, filling your prescriptions through Medco’s mail-order pharmacy provides several benefits:You receive a 90-day supply of your medication at a lower copayYou have access to Specialist Pharmacists who receive additional training in conditions such as asthma, diabetes, heart disease and moreWhile retail pharmacists know the medications you fill at one pharmacy, Medco’s Specialist Pharmacists have a complete view of all of your medications so they know if there are potential safety issues and will contact you and your doctor to discuss these issuesYou have access to specialist pharmacists whether you fill your prescription at a retail pharmacy or at Medco By MailYour medication questions can be answered by calling
26 Prescription Drug Benefits ActiveCare 1ActiveCare 2ActiveCare 3Drug Deductible(per person, per plan year)Subject to $1,100 plan year deductible$50Retail Short-Term(up to 30-day supply)Generic/Preferred Brand/Non-Preferred Brand100% of the discounted cost at the time of purchase; 80% will be reimbursed by Blue Cross and Blue Shield of Texas after deductible$10$25*$45*$40*Retail Maintenance(after second fill, up to 30-day supply)$15$35*$60*$55*Medco by Mail(up to 90-day supply)$20$62.50*$112.50*$100*Here’s an overview of the prescription drug benefits for the ActiveCare 1, 2 and 3 plans. Blue Cross and Blue Shield of Texas administers the benefit for ActiveCare 1. The drug benefits for ActiveCare 2 and 3 are administered by Medco.Note: This chart illustrates benefits when network providers are used. Non-network benefits are also available; see Enrollment Guide for more information.* If you obtain a brand-name drug when a generic equivalent is available, you are responsible for the generic copayment plus the cost difference between the brand-name drug and the generic drug. Chart illustrates benefits when network pharmacies are used. Non-network benefits are also available; see Enrollment Guide for more information.
27 Prescription Drug Benefits ActiveCare 2 and 3: Applying the DeductibleExample 1—Claim cost less than $50 DeductibleTotal CostDeductible AppliedCopayDeductible RemainingFirst Fill$37$13Second Fill$13 + copay$0The deductible must be satisfied on a per member (as opposed to household) basis. That is, everyone must meet the deductible before any copays start applying.This example provides an overview of how deductible and copays are applied on a drug that costs less than $50.Once the deductible is satisfied, the member pays the applicable copayMember-paid cost differences between a brand-name drug and a generic equivalent do not apply to the deductibleMember cost share will not exceed the cost of the medication
28 Prescription Drug Benefits ActiveCare 2 and 3: Applying the DeductibleExample 2—Claim cost more than $50 DeductibleTotal CostDeductible AppliedCopayDeductible RemainingFirst Fill$100$50$25$0Next FillAnd here’s an example that illustrates a claim that costs more than the deductible.Once the deductible is satisfied, the member pays the applicable copayMember-paid cost differences between a brand-name drug and a generic equivalent do not apply to the deductibleMember cost share will not exceed the cost of the medication.
29 Information Resources TRS Web site –Pharmacy Benefit HighlightsList of maintenance medicationsFAQsDownload formsMedco Member Web site –Prior Authorization ListFormulary InformationLocate a Participating PharmacyHealth and Wellness InformationMy Rx Choices® / Price a MedicationOnline OrderingCustomer Service NumberBenefits BookletMany of these lists are ever changing and the best way to have up to the minute information is to access the Medco Web site and use the tools available to price a medication, view whether or not a drug is covered, and explore alternatives. For example, formularies are reviewed quarterly as new drugs enter the marketplace and generics come to market.Prior authorization is a program required by law and designed to ensure the safety of patients. The following information is reviewed to assure an appropriate coverage decision is made: diagnosis, indications for prescribed drug use, dosing, duration of therapy, patient drug profile and potentially dangerous drug interactions.
30 My Rx Choices® Your online savings tool Lower your cost for prescriptions with My Rx ChoicesFeatures include:Personal assessment of cost-saving opportunities based on your prescription plan and medications that you or covered family members take on an ongoing basis.Best-value alternatives based upon greatest cost savings to you presented in order from highest value to memberBrand-to-generic and retail-to-mail compare options availableEasy-to-understand explanations of complicated conceptsThe average amount saved by My Rx Choices users is $294!Your doctor knows which medications are right for you but you may not know how much they cost. My Rx Choices provides you with available lower-cost options so that you and your doctor can make the most informed decisions based on health and cost.Simply visit You’ll to take a moment to register before using this service. You can also callMy Rx Choices is a tool on medco.com that allows members to comparison shop appropriate therapies.Unless allowed by law, a prescription will not be changed without approval from the prescriber.
31 My Rx Choices Available through Customer Service or on www.medco.com The My Rx Choices home page allows the user to:Select a patient (pre-populated with all covered household members)Select a drug to compare from a pre-populated list of prescriptions for the user.Your potential savings are clearly presented.Results include the best-cost therapy in this class with associated pricing information and annualized savings for the selected drug, Prilosec, and other lower-cost alternatives.Lower cost alternatives are generic omeprazole at retail or mail and Prilosec via mail.The tool makes recommendations and provides alternatives based on prescription cost, generic availability, and the availability of other drugs in the class.Call or visit
32 My Rx ChoicesMedco can facilitate on generic equivalents received through mail orderThe tool also works if you’re registered but don’t yet have any drugs in history. Simply enter in the drug name and My Rx Choices calculates alternate drugs and relative cost.
33 My Rx ChoicesMembers may print a kit to discuss lower-cost alternatives with their doctorResults include the best-cost therapy in this class with associated pricing information and annualized savings for the selected drug, Prilosec, and other lower-cost alternatives.Lower cost alternatives are generic omeprazole at retail or mail and Prilosec via mail.
34 More about Your Rx Benefits Refill your medication at when you use Medco By MailSign-up for “Refill Reminders” atSpeak to a specialist pharmacist about the medications you are taking for a specific conditionSend s to Customer Service and to Medco pharmacists through the Medco member Web siteFifty percent of mail order refills are placed via medco.com.
35 Medco Tour of Champions An endorsement campaign featuring six Olympic gold medalists – each with a chronic or complex conditionPromotes Specialist Pharmacists as providing a higher level of care for people with chronic and complex conditions like asthma and diabetesCampaign runs through 12/08Jackie Joyner-Kersee Track & Field 3 gold medals AsthmaBob Beamon Long Jump – 1 gold medal DiabetesGreg Louganis Diving – 4 gold medals HIV positiveBruce Jenner Decathlon – 1 gold medal ArthritisPeggy Flemming Figure Skating – 1 gold medal Breast cancer survivorMark Spitz Swimming – 9 gold medals High cholesterolEach athlete is touring the country and appearing in print ads in support of the benefits of Medco Specialist Pharmacists.
36 Cost for Health Coverage Your Cost for CoverageChapter 1581, Texas Insurance Code, authorizes funding to help active employees who are TRS members—those making retirement contributions to the Teacher Retirement System of Texas—pay for TRS-ActiveCare coverage. Each district is required to contribute at least $150 per month per active TRS member for coverage. The state will contribute $75 per month per active TRS member. That’s a minimum of $225 per month to help you pay for health coverage.Cost for Health CoveragePlan Year
37 Coverage Categories Employee Only Employee and Spouse Employee and Child(ren)Employee and FamilyEmployees will be asked to select a coverage category.The coverage category determines who will be covered under the TRS-ActiveCare plan as well as how much the coverage will cost.Employees can select:Employee-only coverageEmployee and spouse coverageEmployee and child or children coverage, orEmployee and family coverage.All covered dependents must be on the same plan option as the employee.
38 Monthly Cost of Coverage Page 35 of the Enrollment GuideThis chart appears on page 35 of your Enrollment Guide. It shows the total cost for each of the TRS-ActiveCare plan options.
39 Application to Split Premium Married couples working for different participating entities may “pool” fundsOptionalRequires an Application to Split Premium form to be completed by both employees and both employersIf a husband and wife work for different participating entities and which to “pool” funds, an Application to Split Premium must be completed. For the husband and wife who choose this option, the cost of coverage will be split between and billed to the two employers. Each employer will be billed 50% of the total cost of coverage. The entity employing the spouse who declined coverage will consider the employee as covered under a group health plan for funding purposes.Each employee and their Benefits Administrator must complete their portion of the Application to Split Premium form which is available on the TRS-ActiveCare Web site, This form should be submitted to Blue Cross and Blue Shield of Texas with the Enrollment Application and Change Form.This form should not be used by employees working for the same entity.
40 How to Enroll 2008-2009 Plan Year Even though this is a paper enrollment, we think you will find that we have made enrolling as easy as possible.Note to speaker: Some districts/entities may offer electronic enrollment through an interactive voice response (IVR) or Web-based system. If so, your employees may not need to submit an Enrollment Application and Change Form. You will need to provide your employees with instructions on how to enroll for health benefits in your district/entity.How to EnrollPlan Year
41 How to Enroll 2 Complete an Enrollment Application and Change Form Available in the Enrollment GuideAlso available onlinePlease be sure to read you enrollment guide about your plan options to help you choose the right health plan for you and your family. Then, complete an Enrollment Application and Change Form available in the center of the guide and online.All Enrollment Application and Change Forms should be signed, dated and submitted to the Benefits Administrator before the end of the enrollment periods—by May 16, 2008 (Spring Enrollment), August 31, 2008 (Summer Enrollment) or within 31 days after an enrollment event. (Special rules apply to newborns; refer to the enrollment guide for more details).3 Sign, date and submit form to your Benefits Administrator1 Choose your health plan
42 How to EnrollIf you do not wish to make changes to your current health benefit plan, you do not need to submit an enrollment application formYou will be enrolled in the same plan you selected for at the same level of coverageTo decline coverage: You must complete and submit a form – even if you have declined coverage beforeFor new coverage or changes, you will need to complete and submit an Enrollment Application and Change Form.If you enrolled in and don’t wish to make changes to your current health benefit plan, you are not required to enroll again. If no form is returned, you will automatically be enrolled in the same plan elected for at the same level of coverage. Please pay close attention to any benefit changes from last year as you make your plan choices. The premium contribution will be adjusted to reflect the new rate on September 1, 2008.If you are declining coverage, you must complete an application—even if you’ve declined coverage before.
43 Can Changes in Coverage Be Made After Your Application Has Been Submitted? Changes can be made up to the end of your enrollment periodPlan choices will remain in effect through August 31, 2009 unless there’s a special enrollment event such as:Marriage or divorceBirth, adoption or placement for adoption of a childA child marries or reaches age 25A court order to provide health coverage for an eligible childLoss of coverageChanges must be made within 31 days after the event date (special rules apply to newborns)New application must be submitted for any changeChanges can be made up to the end of your enrollment period.(Note to speaker: Insert the day and date of the end of your enrollment period.)Plan choices will remain in effect through August 31, 2006 unless there’s a special enrollment event. An employee can enroll for coverage or change the dependents he or she covers during a plan year if the employee has a special enrollment event such as:Marriage or divorce (if the divorce results in a loss of other coverage)Birth, adoption, or placement for adoption such that the employee has a legal obligation to support the childA child marries or reaches age 25A court orders the employee to provide health coverage for an eligible child (A court order on anyone other than the employee does not require the plan to provide dependent coverage.)The employee or the covered dependent loses other health insurance coverage (and the employee originally declined TRS-ActiveCare coverage in writing because of coverage under another health benefit plan)Any TRS-ActiveCare change must be made within 31 days of the special enrollment event. (Special rules apply to newborns; see enrollment guide.)A new application must be submitted for any change; additional applications are available from your Benefits Administrator and the Web site.
44 Cafeteria Plan Vendor(s) Making a change through the Section 125 vendor does not automatically generate a change to coverage under TRS-ActiveCareAll changes to TRS-ActiveCare must be signed, dated and submitted on an Enrollment Application and Change FormIf you submit a change to a third party vendor administering your entity’s Section 125 cafeteria plan, be sure you also submit an Enrollment Application and Change Form to your Benefits Administrator. Making a change through a third party vendor for a Section 125 cafeteria plan does not automatically generate a change to TRS-ActiveCare.
45 Are There Preexisting Condition Exclusions? Pre-x does not apply to employees that initially enroll when the district/entity begins participating in TRS-ActiveCare or to new hires who enroll within 31 days after their actively-at-work dateIf covered at any time since 2002, pre-x may apply if employee is hired by another participating district/entity (or rehired by same district/entity) unless gap in coverage is less than 63 days and the employee has proof of prior creditable coverageA 12-month pre-x condition waiting period may apply due to:A special enrollment eventA future plan enrollment period (to be determined by TRS for each plan enrollment period)A transfer to another participating district/entity (or rehire) if the employee or any covered dependent has any remaining preexisting waiting period or a gap in coverage greater than 63 daysPre-x waiting period may be reduced by creditable coverageThe Enrollment Guide has been revised to clarify the TRS rules regarding preexisting waiting periods and creditable coverage. (Preexisting condition exclusions do not apply to HMO plan enrollees)Preexisting condition exclusions do not apply to employees that initially enroll when the district/entity begins participating in TRS-ActiveCare or to new hires who enroll within 31 days after their actively-at-work date. If the employee was covered under TRS-ActiveCare at any point in time since its inception in 2002, preexisting limitation exclusions may apply if the employee is hired by any other participating district/entity (or rehired by the same participating district/entity), unless the gap in coverage is less than 63 days and the employee has proof of prior creditable coverage. A 12-month preexisting condition waiting period may apply to employees or dependents enrolling in ActiveCare 1, 2 or 3 due to:A special enrollment eventA future plan enrollment period (to be determined by TRS for each plan enrollment period)A transfer to another participating district/entity (or rehire) if the employee or any covered dependent has any remaining preexisting waiting period or a gap in coverage greater than 63 days.A preexisting condition waiting period may be reduced by creditable coverage. Most health coverage is creditable coverage, including, but not limited to, coverage under a group health plan, HMO, an individual health policy, COBRA, Medicaid, or Medicare. It is important that information about prior coverage be provided by attaching a certificate of creditable coverage to the Enrollment Application and Change Form. Gaps in prior coverage may impact creditable coverage. If the certificate of coverage reveals a gap in coverage exceeding 63 days, it cannot be counted toward the preexisting condition waiting period.A certificate of creditable coverage will be generated and mailed to TRS-ActiveCare participants upon termination. Additional or duplicate certificates of creditable coverage may be obtained by contacting the health plan’s Customer Service.Note: Pregnancy is not considered a preexisting condition.
46 Important Notice Supplemental Coverage TRS does not offer or endorse any supplemental coverage for any of the health coverage plans available under TRS-ActiveCareTo obtain information about any coverage that claims to be a companion or supplement to any TRS-ActiveCare plan, employees should contact:The organization making such offering and/orThe Texas Department of Insurance (TDI) or the TDI Consumer Helpline (800)Note: TRS does not offer, nor does it endorse, any form of supplemental coverage for any of the health coverage plans available under TRS-ActiveCare. To obtain information about any coverage that is purported to be a companion or supplement to any TRS-ActiveCare plan, employees should contact the organization making such offerings and/or the Texas Department of Insurance (TDI) at or the TDI Consumer Helpline at (800)
47 Your TRS-ActiveCare ID card will be mailed to your home ActiveCare 1, 2 and 3New ID cards will not be issued to current participants unless changing plans; new enrollees will receive new cardsHMO plansAll HMO participants will receive new cards (except for Scott and White Health Plans)Each individual covered under the plan will receive a cardYour TRS-ActiveCare ID card will be mailed to your home. If an employee submits an Enrollment Application and Change Form by May 16, 2008, he or she will receive a new ID card by September 1, If an employee submits an application or change after May 16, he or she may not receive an ID card until October 1.Existing enrollees in the ActiveCare 1, 2 and 3 plans will NOT receive new ID cards since there were no plan changes that affected the ID cards. If a current participant changes plans, a new ID card will be issued. All new enrollees in these plans will receive new cards.All employees enrolled in FirstCare Health Plans , Legacy Health Solutions, Mercy Health Plan and Valley Baptist Health Plans will receive new identification cards for the plan year. (Scott and White Health Plans will issue cards to new enrollees only.)ActiveCare 1, 2 and 3: Employees with employee-only coverage will receive one card; employees with employee and spouse or employee and children or family coverage will receive two cards. Additional cards may be ordered from Customer Service at no charge.HMO plans: Each individual covered under the plan will receive a card.All ID cards include a unique identification number instead of a Social Security Number (SSN). New cards will be mailed to employees by September 1, You may receive multiple cards. For example: If you receive a new ID card and subsequently make a change during the summer (August) enrollment period, an updated card will be sent after the change is processed.
48 Enrollment Support Dedicated Customer Service ActiveCare 1, 2 or (Blue Cross and Blue Shield of Texas and Medco)FirstCare Health PlansLegacy Health SolutionsMercy Health PlansScott and White Health PlanValley Baptist Health PlansThere are plenty of resources to help employees learn more about TRS-ActiveCare and enroll for coverage.These numbers are listed in your enrollment guide.
49 Enrollment Support Available Online Enrollment guide (English and Spanish)Downloadable forms (enrollment application, split premium, claim form, etc.)Provider locatorFrequently asked questionsThe Web is an excellent source for additional information. Log on to view the following:Enrollment guide (English and Spanish, Large Print)Downloadable forms (enrollment application and change form, application for split premium, etc.)Provider locatorFrequently asked questions
50 Thank you for attending QuestionsThank you for attending