Open Enrollment 2015Non State Employee Health PlanWelcome to Open Enrollment for the State Employee Health Plan. We are glad you could attend this presentation to learn about your health plan offerings for Plan Year (PY) 2015.1Changes for PY 2015Plan B will no longer be offeredMembers will need to select Plan A or C for 2015
Coventry was purchased by AetnaWe will be offering Aetna for 2015
UnitedHealthcare will no longer be offeredMembers will need to select Aetna or BCBS
Salary tiers for employee premiums were eliminated
Open Enrollment will be on a new website: https://sehp.member.hrissuite.com/
There are also some changes for Plan Year (PY) 2015. You will have the option of Plans A or C next year. Plan B is being discontinued due to declining enrollment. Coventry was purchased by Aetna so the plans will now be available from Aetna .UnitedHealthcare will not be offered next year so you will have the option of selecting Plan A or C with Aetna or BCBS of Kansas. The plan member contribution will no longer be by salary tier. Everyone will pay the same rates.
2Changes for PY 2015Plan A Combined Medical & Pharmacy Out Of Pocket (OOP) Maximum Single: $4,750/ Family: $9,500 MedicalDeductible$300/$600Coinsurance 20%OOP Max$2,000/$4,000 Pharmacy Coinsurance20%/35%/60%OOP Max$2,750/$5,500Medical Deductible $300/$600Coinsurance 20%Pharmacy Coinsurance20%/35%/60%Combined OOP MaxMedical & Pharmacy$4,750/$9,50020142015This year the Plan A medical and pharmacy programs have separate out of pocket maximums. For an individual it is $2,000 medical and $2,750 pharmacy. For Plan Year 2015, there will be a combined into one out of pocket maximum for network medical and pharmacy claims of $4,750 for an individual and $9,500 for a family. 3Changes for 2015I.R.S requirements for HDHP deductibles increasedPlan Cs new deductible and OOP Max is:$2,600 single/$5,200 family
Deductible $2,500/$5,000Coinsurance 0%Out of Pocket Max$2,500/$5,000Deductible $2,600/$5,200Coinsurance 0%Out of Pocket Max$2,600/$5,2002014 Network2015 NetworkThe I.R.S has increased the minimum High Deductible Health Plan deductible so the Plan C deductible must be increased to $2,600 and $5,200 to remain in compliance.4Changes for 2015Plan C members that are ineligible for a Health Savings Account (HSA) may now elect a Health Reimbursement Account (HRA)
Members who could elect the HRA include:Members eligible for MedicareMembers who have VA or military benefitsAnyone else not eligible for an HSA
Employer contributes the same amounts as for the HSA
Plan C members currently have a Health Savings Account but there are rules on who can have an HSA. For those members that dont qualify for an HSA, next year they can have a Health Reimbursement Account instead. The State will contribute the same amount of funds into an HRA for these members. The account works a little different than an HSA so lets take a closer look at the HRA.5Health Reimbursement Accounts (HRA) - Vs. - Health Savings Accounts (HSA)HRAHSAMember Eligibility Requirements :Self-employed persons are not eligible for an HRAMust meet IRS eligibility guidelinesWho Contributes:Employer OnlyEmployee & EmployerWho Owns the Money :EmployerEmployeeCarryover Funds:NoYesCoverage Period:Plan YearDoesnt applyExpense Documentation:Substantiation is required by a third party subject to IRS substantiation requirementsEmployee responsible for maintaining documentationPortable:NoYesWith an HRA, the eligibility is much more open and only the self employed are excluded from having an HRA.HRA is an account that only the employer deposits funds into for the employee.The account works similar to an Flexible Spending Account in that:The money does not roll over from year to year.Unspent funds are forfeited at the end of the year. You will have to submit a claim for reimburse to US Bank along with documentation to access the funds.The funds are not portable. 6Changes for PY 2015The Autism benefit had to be modified to comply with HB. 2744Annual dollar limits removed
Applied Behavior Analysis (ABA) services for children under age 7 will be limited to 1,300 hours per calendar year
Children between age 7 but less than 19 years of age, Applied Behavior Analysis (ABA) services will be limited to 520 hours per calendar yearHB 2744 was passed by the 2014 legislature and as a result there are some changes to the Autism rider. The annual dollar limits have been removed. Only Applied Behavior Analysis services are limited to a set number of hours based upon the age of the child.7Changes for PY 2015Coverage of wheelchairs has been enhanced to allow for medically necessary motorized wheelchairs
Coverage for prosthetics has been modified to allow for medically necessary prosthetics with electronic components or processors
The limited coverage for eyeglasses for children with certain eye disorders has been modified to remove the dollar cap
Compounded medication costing over $300 will require prior authorization from CaremarkCoverage has been enhanced to include medical necessary motorized wheelchairs. Prior authorization is recommended.
Coverage for prosthetics has been enhanced to allow for electronic components or processors when medically necessary. Again prior authorization by the health plan is recommended.
The dollar limit on eyeglasses for children with apakia, pseudophakia or corneal transplants has been removed. This coverage is limited to only children with these specific eye conditions and should not be confused with the Superior Vision Plan coverage.
As a result of recent changes in the market, medications that are being compounded by pharmacies for members that are over $300 must be prior authorized by Caremark. 8Performance Drug List The Performance Drug List has been updated to reflect recent generic drug launches
Applies to both Plans A & C
Three drug classes on the Performance Drug List:ACE/ARBs Blood pressure loweringHMGs Cholesterol lowering PPIs Stomach acid reducers
Must try a Generic before using a Non Preferred Brand Name Drug
Generic and Preferred Brands not affected
9The Performance Drug List that has been in place for several years now has been updated to reflect changes in the pharmacy market.The change is in how Non Preferred brand name drugs in three specific classes of prescription drugs are processed. Those three (3) classes of prescription drugs include:cholesterol lowering medications (HMGs), proton pump inhibitors (PPIs, which reduce the production of acid in the stomach), and high blood pressure medications (ACE/ARBs). These three classes of drugs include a large selection of lower costing generic drug options. Before you can purchase a Non Preferred product in these classes, you have to have tried a generic in the class. The system will automatically check your historyThere are a large number of generic available in these classes You will continue to have access to preferred brand name medications and generics.
Performance Drug ListPreferred HMGsGenericamlodipine-atorvastatinatorvastatin (generic Lipitor)fluvastatinlovastatinpravastatinsimvastatin Preferred BrandsCrestorSimcorVytorin
Non Preferred HMGsAdvicorAltoprevLiptruzetLivalo
Cholesterol Lowering AgentsHMG-CoA Reductase Inhibitors (HMGs or Statins)/CombinationsHMGs are the cholesterol lowering products. The performance drug list will only affect You if You try to purchase a non preferred brand name drug listed on the right. Before you can fill a prescription for one of the Non Preferred products on the right side of the screen, the member would have to have tried one of the generic products in the left side column.
The Caremark claims system will review your claims history to see if you have previously purchased a generic in the drug class first. If this is no record of a generic in your history during the preceding 24 months, the pharmacy will receive a message that the claim cannot be processed since the member has not tried the generic first.
If your history shows that you have tried a generic previously, the claim will process without delay. You still be responsible for paying the non preferred drug coinsurance of 60%. 10Performance Drug ListPreferredGenericamlodipine-benzazeprilbenazepril & benazepril HCTcandesartan/candesartan HCTZcaptopril & captopril HCTZenalapril & enalapril HCTZeprosartan fosinopril & fosinopril HCTZirbesartan/irbesartan HCTZlisinopril & lisinopril HCTZlosartan/losartan HCTZmoexipril & moexipril HCTZquinapril & quinapril HCTZramipriltelmisartan HCTZtrandolapriltrandolapril-verapamil ext HCTZvalsartan &valsartan HCTZNon Preferred ARBsEdarbiEdarbyclorTeveten HCT
Blood Pressure Lowering ACE/ARBsACE = Angiotensin Converting Enzyme Inhibitors ARB = Angiotensin II Receptor Antagonists and Direct Renin Inhibitors & CombinationsPreferred BrandsBenicar & Benicar HCTMicardis & Micardis HCTThis side is a little busy because there are so many generic options in the ACE/ARB categories to treat high blood pressure.The definitions for ACE and ARB are listed as well for you. You can see that there are many generic options as well as two preferred products to choose from. If you and your provider elect the three on the lower right side of the screen, you will have to have tried one of the generics first.Remember generics have the lowest member coinsurance of 20% and preferred brands are 35%.The non preferred products cost you the most our of your pocket with a 60% coinsurance. 11Performance Drug ListPreferred PPIsGenericesomeprazolelansoprazoleomeprazoleomeprazole sodium bicarbpantoprazolerabeprazolePreferred BrandDexilant
Non Preferred PPIsPrilosec PacketsProtonix PacketsZegerid powder for oral susp
Stomach Acid ReducersProton Pump Inhibitors (PPIs)For PPIs which are long lasting stomach acid reducers, the Non Preferred brand name drugs are highlighted on the right. The preferred and generic are on the left side of the screen.
There are also a number of quality over the counter products available that may be less expensive then the prescription products and provide the same results. Talk to your doctor about will work for you.12Upcoming Generic ReleasesAbilify ODT Abilify Tabs Aggrenox Aloxi Axert Baraclude Doribax Gleevec Namenda Ortho Tri-Cyclen LoOxytrol Patanol Protopic Relenza Teveten HCT Welchol Susp Welchol Tabs Zyvox Injection Zyvox Susp Zyvox Tabs These are just a few of the drugs scheduled to go generic next year. We encourage members to switch to generic as soon as they are released. Generic drugs save you and the plan money. A full list is posted on the SEHP web site for those interested.13Selecting Your Health PlanPick a plan design (A or C)Which plan design provides the coverage you and your family need?What is the total plan cost? Premiums + Deductible & OOP = ?
Review the Provider Networks Each of the medical vendors uses a different provider network
Open Enrollment is your opportunity to decide how you want to finance your healthcare for the upcoming year. We encourage you to review the plan design options. Look at the coverage and the out of pocket cost of each plan design and select an option, A or C.
Each of our health plan vendors offers their own unique provider networks. Being a network provider means that the health care professional has agreed to accept the vendors allowed charge as payment in full. The provider agrees to write off any difference between what they charge and what the health plan allows.
You are free to use any provider that you wish however if you use a provider that is not part of your health plans networks, it will cost you more out of your pocket. Non network providers do not have to accept the health plans allowed charge and can bill you for the difference.
Make sure you review the networks before deciding on a medical vendor.
14Plan AMedical Coverage2015 - NetworkMedicalDeductible$300/$600Coinsurance 20%2015 - Non NetworkMedical Deductible $500/$1500Coinsurance 50%Pharmacy Coinsurance20%/35%/60%OOP MaxMedical & Pharmacy$4,750/$9,500Combined OOP MaxMedical & Pharmacy$4,750/$9,500
Lets take a closer look at the Plans offered. Lets begin with Plan A.
Plan A has a $300 per person and $600 per family network deductible. A higher deductible applies to Non Network services. After the Deductible, Coinsurance applies to most services and network office visits are subject to Copays. The maximum amount of out of pocket expenses for Network medical and pharmacy services in a year are $4,750 for an individual and $9,500 for a family. You will incur additional out of pocket expense if you also use both Network and Non Network providers as the Non Network benefit accumulates separately from the Network benefits. 15Plan A Prescription Drug PlanDrugsCoverage LevelGeneric20% CoinsurancePreferred Brand Name Drugs35% CoinsuranceSpecial Case Medications25% Coinsurance to a Max of $75 per 30 day supplyNon Preferred Brand Name Drugs60% CoinsuranceDiscount TierYou pay 100% of discount cost. Do not count toward your OOPThere are no changes to the coverage tiers under the Plan A pharmacy program. On Plan A, your prescription drugs are subject to Coinsurance. Generic drugs are your best buy and have the lowest OOP cost.Members should review the preferred drug list options with their providers to find the most cost effective options. You many also want to use the new transparency tools from Castlight and Rx Savings to help you reduce your pharmacy spend.
16Plan CMedical Coverage2015 NetworkDeductible $2,600/$5,200Coinsurance 0%Combined Medical and Pharmacy OOP$2,600/$5,2002015 Non NetworkDeductible $2,600/$5,200Coinsurance 20%Out of Pocket Max$4,100/$8,200The Plan C Deductible was increased this year due to a change in the IRS requirements for High Deductible Health Plans with Health Savings Accounts. The Plan C Deductible is now $2,600 for one person and a maximum of $5200 for the family.
Once you meet your network deductible additional covered medical or pharmacy services are covered in full for the remainder of the calendar year.
Benefits for Network and Non Network providers are subject to separate deductibles and out of pocket requirements. 17Plan C Prescription Drug PlanCovered drugs are subject to the Network Plan C Deductible
After the Deductible, the plan pays covered prescription drugs at 100% of allowed charge
Uses same Preferred Drug List as Plans A
Plan C is a creditable drug plan
Discount Tier drugs are Not Covered drugsOnly eligible for Caremarks negotiated discountDo not count toward OOP Max
18 On Plan C prescription drugs are subject to the overall plan Deductible and then paid at 100% once the deductible has been satisfied. The Preferred Drug List is the same as the one used for Plans A. It is available on Caremark.com.Discount Tier drugs are not considered covered drugs and are only eligible for...