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Presented by: Joannie Nilan

HIGH OPTION. Presented by: Joannie Nilan. How We Change for 2012 Section 2. Page 10. Weight Management Program Managed by CIGNA/CareAllies: 1-800-582-1314 - Prompt 6 No participation requirements

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Presented by: Joannie Nilan

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  1. HIGH OPTION Presented by: Joannie Nilan

  2. How We Change for 2012Section 2. Page 10 Weight Management Program • Managed by CIGNA/CareAllies: 1-800-582-1314 - Prompt 6 • No participation requirements • $0 copay for in-network office visits to a registered Dietician/Nutritionist • Health and Wellness Coaches to assist with individual needs and guidance • Workbook and Tool Kit to keep you on track and motivated

  3. How We Change for 2012Section 2. (continued…) • Plavix has been added to the list for Pharmacogenomic Testing for prescription drug therapies for certain conditions. • Anti-platelet drug used to assist in blood clotting • Out-of-Network Routine Gynecological visits for pap test • One annually • Standard out-of-network rate

  4. How We Change for 2011Section 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

  5. FactsSection 1. Page 8 • FFS / Non-PPO • 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 • 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-of-pocket

  6. FactsSection 1. Page 9 • Vendors • CIGNA – Medical PPO Vendor and Precertification Vendor • 6,100 hospitals • 815,000 providers • Precert • ValueOptions - Mental Health and Substance Abuse Vendor • 4,000 facilities • 62,000 providers • Precert

  7. FactsSection 1. (continued…) • Medco – Prescription Drug Vendor • 66,000 pharmacies • RX • Personalized Medicine • Specialty Drugs • Precert some drugs

  8. How to Get CareSection 3. Page 11 • ID Cards/Health Benefits Election Form / Electronic Confirmation Letter • Precertification • Inpatient Stays • Surgeries • Cosmetic, Transplants, Morbid Obesity, Organic Impotence • Rehabilitative Therapy (PT/OT/ST)

  9. How to Get CareSection 3. (continued…) • Infusion and Growth Hormone Therapy • Nursing Visits • DME • High Tech Radiology/Imaging • Mental Health and Substance Abuse • Some Drugs

  10. Your CostSection 4. Page 18 *Of plan allowance and any difference between our allowance and billed amount

  11. BenefitsSection 5. Pages 28 5 (a). Medical Services and Supplies • Diagnostic and Treatment • Physician visits in office and other locations • Lab, X-ray and other diagnostic tests such as… • Blood test, urinalysis, pathology, EEG and EKG

  12. BenefitsSection 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)

  13. BenefitsSection 5. Page 29 • Adult - Preventive Care • After age 12 one routine exam per person every two calendar years • Office visit • Lab tests: comprehensive metabolic panel, lipid panel and urinalysis

  14. BenefitsSection 5. (continued…) • Women age 18 or older, one routine GYN visit for Pap smear – PPO and in 2012 Non-PPO • Member pays $18 co-payment if rendered by a PPO provider • Non-PPO provider the member pays 30% of the Plan allowance and the difference between the allowance and the billed charge – deductible applies.

  15. BenefitsSection 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 • Sigmoidoscopy and Colonoscopy screenings starting at age 50

  16. BenefitsSection 5. (continued…) • Prostate cancer screenings • Routine Pap smear • Abdominal aortic aneurysm screening • Routine mammograms with age restrictions • Adult immunizations recommended by the CDC

  17. BenefitsSection 5. Page 30 • Children - Preventive Care • Childhood immunizations recommended by the American Academy of Pediatrics • Well child physical exams and lab tests through age 12 • One screening for Amblyopia and Strabismus ages 2 – 6 • One screening of premature infants for Retinopathy

  18. BenefitsSection 5. Page 31 • Maternity Care • 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 • Coverage for specific services see Plan Brochure • Maximum Plan payout of $2500 annually

  19. BenefitsSection 5. (continued…) • Family Planning • 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

  20. BenefitsSection 5. Page 32 • Allergy Care • Testing and treatment including materials • Allergy Shots • Treatment Therapies • Chemotherapy, Radiation • Dialysis • Respiratory and Inhalation • IV and Growth Hormone (Require Approval) • Drugs used are covered under the Prescription Drug benefit

  21. BenefitsSection 5. Page 33 • Physical, Occupational and Speech Therapy • Limited to 60 Combined Visits per Calendar Year • Pre-authorization is Required • Non-Covered: Maintenance Therapy, Exercise Programs, etc.

  22. BenefitsSection 5. Page 33 • Hearing Services • One exam and testing for hearing aids every 2 years • Vision Care • Internal ocular lenses / first contact lenses to correct impairment • Non-covered • Eyeglasses and contact lenses • Eye exercises • Refractive surgery

  23. BenefitsSection 5. Page 34 • Routine Foot Care • Only covered for a metabolic or peripheral vascular disease, such as diabetes • Orthopedic and Prosthetic Devices • Leg, arm, neck and back braces • Artificial limbs, eyes • External breast prostheses, surgical bras following a mastectomy • Internal devices, joints, pacemakers and surgically implanted breast implant following a mastectomy • Pre-authorization is recommended • Non covered items: • orthopedic/corrective shoes, arch and lumbosacral supports, foot orthotics, corsets, stockings, support hose

  24. BenefitsSection 5. Page 35 • Hearing Aids • No Deductible • $1500 Benefit every 3 years • Durable Medical Equipment (DME) • Pre-certification Required • Covered: • Oxygen and Dialysis equipment • Hospital beds and wheelchairs • Ostomy supplies • Crutches and walkers

  25. BenefitsSection 5. (continued…) • 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 communication-impaired individual

  26. BenefitsSection 5. Page 36 • Home Health Services • Preauthorization is Required • Performed by a RN, LPN or LVN • 25 Visit Limit per Calendar Year • Maximum Plan Benefit of $90 per Day

  27. BenefitsSection 5. (continued…) • Chiropractic Services • 12 Visit Limit per Calendar Year • Acupuncture by a MD or DO

  28. BenefitsSection 5. Page 37 • Educational Programs • Limited to the CIGNA Tobacco Cessation Program • Program is 100% Voluntary • Enhanced PPO Benefit • Managed by CIGNA/CareAllies • Easy Enrollment • Telephonically or online • Compliance Requirement • 4 Counseling sessions of 30 minutes each

  29. BenefitsSection 5. (continued…) • Tobacco Cessation Benefits • Enhanced benefit immediately upon enrollment • Coverage for 2 quit attempts per year • Prescription and over-the-counter medications for Nicotine Replacement Therapy • No Lifetime Limit

  30. BenefitsSection 5. Page 38 5 (b). Surgical and Anesthesia Services • Surgery • A comprehensive range of services for operative procedures including pre and post operative care • Pre-certification required for • organ transplant • cosmetic surgery • surgery for morbid obesity and • organic impotence • Anesthesia

  31. BenefitsSection 5. Page 45 5 (c). Hospital or Other Facility and Ambulance • Inpatient Hospital • 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 • Non PPO hospital confinements have a $300 per admission fee • Calendar year deductible does not apply

  32. BenefitsSection 5. (continued…) • Room and Board • Private rooms covered for isolation to prevent contagion • 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

  33. BenefitsSection 5. (continued…) • Non-covered Items: • Any part of admission not medically necessary • Custodial Care • Personal Convenience Items • Private Duty Nurses

  34. BenefitsSection 5. (continued…) • Non-covered Facilities: • Nursing Homes • Skilled Nursing • Residential Treatment • Day and Evening Care • Schools

  35. BenefitsSection 5. Page 46 • Cancer Centers of Excellence • Higher level of benefits • Member responsibility is only 5% of the Plans allowance when using a designated facility • Managed by CIGNA/CareAllies: 1-800-582-1314

  36. BenefitsSection 5. Page 47 • Outpatient Hospital or Ambulatory Surgery Center • Operating, recovery and other treatment rooms • Prescribed Drugs • Diagnostic Lab Test and X-rays • Blood and Administration • Pre-surgical Testing • Supplies • Anesthetics

  37. BenefitsSection 5. Page 47 • Hospice Care • Annual Benefit • $3,000 outpatient • $2,000 inpatient • $200 bereavement per family unit • Ambulance • Local professional ambulance service when medically necessary • Ambulance service for routine transport is not covered

  38. BenefitsSection 5. Page 48 5 (d). Emergency Services and Accidents • Accidental Injury • Bodily injury sustained solely thru violent, external and accidental means • Broken Bones • Animal Bites • Poisonings • Medical Emergency • Sudden and unexpected onset of a condition • Heart Attack • Stroke • Sudden inability to breathe

  39. BenefitsSection 5. Page 49 Accidental Injury: • Within 24 hours our member pays • nothing if rendered by a PPO provider • only the difference between our Allowance and the billed charge by a Non-PPO provider • After 24 hours our member pays • $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

  40. BenefitsSection 5. (continued…) Medical Emergency: • Outpatient Facility Charges in an Urgent Care Center our member pays • 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 • Outpatient Medical or Surgical Services and Supplies, Other Than Urgent Care Center our member pays • 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

  41. BenefitsSection 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

  42. BenefitsSection 5. Page 52 5 (f). Prescription Drug Benefit Medco Health Administers Our Drug Plan • Generic • Generic is chemically equivalent to Brand • Normally dispensed • Brand • Prior authorization is recommended • Higher member responsibility

  43. BenefitsSection 5. Page 55 • Non-Network Retail • 30 day supply • 50% of the cost of the drug • $8.00 minimum • Network Retail • 30 day supply • Generic = $8.00 co-pay • Brand = 25% coinsurance with minimum of $8.00 and $200 maximum out-of-pocket • Refill Restrictions • Only 2 fills of the same prescription • All other fills are at the non-network rate

  44. BenefitsSection 5. (continued…) • Mail Order • 90 day supply • Generic = $15.00 co-pay • Brand = 25% coinsurance with $12.00 minimum and $600 maximum out-of-pocket • Drugs Requiring Preauthorization • Organic Impotence • Cosmetic Purposes • Recommended for Brand Name

  45. BenefitsSection 5. (continued…) • Personalized Medicine • Voluntary Program • Pharmacogenomic test for drug therapies • Tamoxifen (for breast cancer) • Warfarin (anticoagulant) • Plavix (antiplatelet)

  46. BenefitsSection 5. Page 57 5 (g). Dental • Accidental Injury to Teeth • 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 Dental • Two office visits per calendar year – Includes: Exam, Cleaning, X-rays of all types, Fluoride Treatment, Fillings and Simple Extractions

  47. BenefitsSection 5. Page 58 5(h). Special Features Flexible Benefits Option 24-hour Nurse Line TDD line for hearing impaired Wellness Review and Reward Program

  48. BenefitsSection 5. (continued…) Disease Management – SmartSteps • Voluntary Program • Variety of Services to Manage Chronic Conditions • Cardiac • Diabetes • Managed by CIGNA/CareAllies: 1-800-582-1314

  49. BenefitsSection 5. Page 59 Diabetes Management Program • Managed by CareAllies: 1-800-582-1314 • Compliance Requirements: Members must have one annual: • Diabetic nephropathy and retinopathy screening • Annual labs that include • LDL and HDL cholesterol test • Triglycerides test • Serum Creatinine test Must have: • AIC blood test every 6 months • Services by a PPO provider every 6 months for diabetes • Coach contact once a quarter • Take prescription regularly

  50. BenefitsSection 5. (continued…) • 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.

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