ealthword Get Out, Be Active! Blue CareOnDemand SM Where You Go Matters Tiered Prescription Drug List (PDL)

Transcription

1 ealthword spring 2016 Your newsletter from BlueChoice HealthPlan Get Out, Be Active! Blue CareOnDemand SM Where You Go Matters Tiered Prescription Drug List (PDL)

2 Health and Wellness Get Out, Be Active! Ahhh, spring is in the air. There s no better time than the present to get out and get active! Research shows that being outside not only improves your physical health, it can also improve your overall sense of well-being. These tips can help you feel your best in the warm-weather months: Moving for just minutes each day can benefit your health. Choose activities you enjoy to help you stay on track. Here are a few ideas: Biking, hiking and camping: Take advantage of the longer daylight hours and find a park near you. Swimming is not only fun, it s also great exercise. If you or your children need help polishing up your swimming skills, try taking a class at your local gym. Many recreational centers have day camps for you or your children to take part in based on your interests. Pack healthy snacks and stay hydrated! Good, balanced nutrition is the key when being active. Practice sun safety by wearing sunscreen with at least an SPF of 30. Sunburns result in permanent damage that can lead to skin cancer. No matter your skin type, keep it protected. If you have asthma or chronic obstructive pulmonary disease, take steps to avoid your triggers, take controller medications as directed and take your quick-relief medicines when you first notice flare-up symptoms. We re Here for YOU Did you know that you have access to a personal health coach as part of your benefits plan? BlueChoice Health- Plan members with heart failure, heart disease, diabetes, high blood pressure, high cholesterol, asthma, migraine or chronic obstructive pulmonary disease, as well as those who use tobacco products and wish to quit, can enroll in our Great Expectations for Health programs and be paired with a personal health coach who will help them reach their health goals. Our coaching team includes nurses, certified diabetes educators, respiratory therapists, dietitians and more. It s hard to make changes and stick to them. You don t have to do it alone. Wherever you are in your health journey, we can connect you with a coach to help you stay on track. Call us at to connect with a coach. 2 HealthWord Spring 16

3 Health and Wellness Up in Smoke Quitting tobacco is one of the most important things you can do for better health. Not only is it good for your health, it s also good for your wallet. In the United States, a pack-a-day habit costs between $4.74 and $ That s $1,730 per year at the low end and up to $4,344 per year on the high end. Spring Into a Healthier You High cholesterol, high blood pressure and being overweight are major risk factors for heart disease and diabetes. These conditions often have no signs or symptoms. That s why it s important to eat a heart-healthy diet, be physically active and see your doctor regularly. If you have heart disease or diabetes, you should have your cholesterol measured at least once per year, with a fasting test of all your blood fats (lipids). Blood pressure should be measured at every doctor s visit. Work with your doctor to determine your goal levels. Here are some general recommendations for most people: Factor Goal Total cholesterol Less than 200 mg/dl LDL ( bad ) cholesterol Less than 100 mg/dl HDL ( good ) cholesterol 50 mg/dl or higher Triglycerides Less than 150 mg/dl Blood pressure Less than 120/80 mmhg Body mass index (BMI) Less than 25 Kg/m Exercise Minimum of 30 minutes on most days Sodium intake No more than 1,500 mg/day Did you know that losing as little as 10 pounds can make a difference in your health? Here are some quick tips to help you get started: Add more healthful foods like fruits, vegetables, lean protein and whole grains to your diet. Cut back on less healthy options like cake, cookies, fried foods and processed meats (i.e. bacon, lunch meats, etc.) Make an effort to move more every day. If you are among the millions of tobacco users who have tried to quit or are thinking about quitting and are committed to quitting tobacco, here are a few ideas to get you started. 1. Ask yourself: What do I get out of using tobacco? Once the what is identified, you can explore options to fill that need. 2. Ask yourself: What strengths do I have to support me as I free myself from tobacco? 3. Ask yourself: What has prevented me from becoming tobacco-free? 4. Ask yourself: How can I remove the barriers to reach my goal of being free of tobacco? 5. Ask yourself: Where do I see myself in 5 or 10 years if I continue to use tobacco? 6. Ask yourself: Where do I see myself in 5 or 10 years after I become tobacco-free? 7. Ask yourself: What step can I take today to start becoming tobacco-free? There are several prescription and over-the-counter products that can help you quit tobacco products. Talk to your doctor about your options. Or, visit our website and click on the Health & Wellness tab then click on the Great Expectations for Health Programs section. Our Tobacco Cessation program can provide you with helpful information and resources to become tobacco-free! HealthWord Spring 16 3

4 Healthier Lifestyles IT S HERE! Blue CareOnDemand Visit with a doctor 24/7/365! You can now visit with a doctor faster and more easily than ever. With Blue CareOnDemand, you can visit with a doctor via smartphone, tablet or computer, rather than visiting an office or urgent care facility. Doctors will diagnose and write prescriptions as appropriate. When should you use Blue CareOnDemand? If you should see a doctor, but can t fit it into your schedule What types of conditions can Blue CareOnDemand doctors treat? Colds Pinkeye The doctor s office is closed You are too sick to drive You have kids at home You are traveling Flu Fever Rash Ear infection Migraines Download the app via the App Store or Google Play and sign up for Blue CareOnDemand today! Visit Blue CareOnDemand is not available to members located in Alaska, Texas or Arkansas. Doctors cannot prescribe medications via video to members located in Indiana. 4 HealthWord Spring 16

5 What Type of Mental Health Provider Do You Need? Determining the appropriate type of provider for your specific needs is a very important step toward getting the right treatment. You should always check your specific benefits to see which providers your plan covers. Here is some information on each type of provider. Finding the Right Mental Health Care Provider There are many different types of mental health care providers to choose from. The Companion Benefit Alternatives (CBA) provider network includes psychiatrists, psychologists, psychiatric nurses, social workers and counselors. CBA is a separate company that manages behavioral health benefits on behalf of BlueChoice HealthPlan. Psychiatrists (M.D.) Psychiatrists are medical doctors. They can prescribe medication. They can practice talk therapy and hospitalize patients. These doctors treat everything from depression to substance abuse. Psychologists (Ph.D. or Psy.D.) Most psychologists earn a doctoral degree a Ph.D. or a Psy.D. The two main types of psychologists are clinical and counseling. Psychologists can diagnose mental illness. They can also use talk therapy to treat people with a wide range of behavioral health conditions. Usually, psychologists do not prescribe medication. Psychiatric Nurses (NP or CNS) Advanced Practice Registered Nurses (APRNs) are nurse practitioners (NP) and clinical nurse specialists (CNS) who have at least a master s degree in Psychiatric Nursing. They can diagnose people with behavioral health conditions. They can also treat them with talk therapy. Many of these nurses can prescribe medication. Social Workers (LISW-CP) Making the Choice CBA s social workers have a master s or doctoral degree in Social Work. They are licensed to practice independently. They counsel and help people understand the causes of their It s important to choose the right provider someone you trust who makes you feel cared for and has the experience to help you make changes for the better in your life. It may take some time to find the right provider. Feeling comfortable with the provider you choose is crucial to the success of your treatment. When you find the right provider, the results can be truly amazing and life-changing. behavior and life situations. Social workers do not prescribe medication. Counselors (LPC or LMFT) Our counselors are licensed professional, marriage and family therapists. They help people with a variety of mental health and substance abuse conditions. Counselors use talk therapy to help people cope with their conditions. They do not prescribe medication. HealthWord Spring 16 5

6 Healthier Lifestyles Where You Go Matters We want to help you get the right care at the right time in the right place. Routine visits to a primary care physician (PCP) help you and your family stay healthy. For care that revolves around you the patient consider a patient-centered medical home (PCMH). We have several PCMH practices in our network across the state. Visit your health plan s website or call the number on the back of your insurance card to locate a practice near you. If you have a medical need after hours, free-standing Urgent Care facilities are available for your care. Urgent care clinics provide treatment for medical problems that need attention right away but are not life-threatening, or for problems that could get worse if you wait. An urgent care visit usually takes less time than a hospital emergency room and costs you much less. The emergency room (ER) is for very serious, life- or limb-threatening problems. If you have a medical emergency, call 911 or go to the emergency room right away. And remember, Blue CareOnDemand is now available. For more information see page 4. 6 HealthWord Spring 16

7

8 Your Health Plan What is a Tiered PDL? Tiered Prescription Drug List (PDL) You may have noticed that BlueChoice is now offering a new drug list called the Tiered PDL. Many groups have switched to the Tiered PDL, and others will be switching sometime this year when their benefits renew. If your group hasn t switched yet, you are still using the old PDL, called simply the Prescription Drug List. To find out whether the Tiered PDL applies to you now or when it will look at your plan materials. Hopefully, this information will help. First, let s define PDL. The Prescription Drug List for BlueChoice members includes all the drugs covered under your plan. Almost all available prescription drugs are covered, except a handful of excluded drugs and drugs in certain categories that are considered lifestyle drugs. The list of covered drugs is the same for the old PDL and the Tiered PDL. A tier is a copayment level the amount you pay for a certain drug. On the old PDL, copayment levels were based on whether a drug was a generic, preferred or non-preferred brand or a specialty drug. With the Tiered PDL, drugs on different levels don t necessarily fit a description like that. See the chart for more detail. Member Drug Tier Usually Includes Cost $ Tier 1 Lowest-cost prescription generic and some over-the-counter drugs. $$ Tier 2 Prescription generic and some over-the-counter drugs. $$$ Tier 3 Brand drugs that don t have a generic available. Also may include higher-priced generics that have more cost-effective options at lower tiers. $$$$ Tier 4 Brand drugs that have brand or generic options at lower tiers. Also may include higher-priced generics that have more cost-effective options at lower tiers. $$$$$ Tier 5 Specialty drugs that are more effective and lower cost than other specialty drugs that treat the same conditions. Also may include some non-specialty brand or generic drugs that have more cost-effective options at lower tiers. $$$$$$ Tier 6 Specialty drugs that have more cost-effective alternatives at Tier 5. Also may include some non-specialty brand or generic drugs that have more cost-effective options at lower tiers. 8 HealthWord Spring 16

9 How does BlueChoice decide where to place a drug? We work with a committee of independent physicians and pharmacists who advise us on pharmacy-related issues. We assign drugs to a tier based on how well they work (effectiveness) and how much they cost compared to other drugs that treat the same or similar conditions (value). Look at your benefit plan documents to find out how much you will pay when you fill a prescription. On the Go & Still in the Know As a BlueChoice HealthPlan member, you can have health information delivered to your phone with The BlueChoice HealthPlan Wire SM, our text messaging tool. Updates include: How to make the most of your coverage Health and wellness reminders and more! How can you learn more about the Tiered PDL? You can find the Tiered Prescription Drug List on our website at The Tiered PDL will show you the tier for hundreds of drugs, as well as any drug management program requirements, like prior authorization. You can also find a Tiered PDL summary that tells you more about your pharmacy benefit, in general, and lists drugs in many categories, so you can compare drugs at different tiers. To find what tier a particular drug is on, it s best to sign into My Health Toolkit and use the Drug Coverage and Cost Tool in the Prescription Drug section. To get started, simply call HealthWord Spring 16 9

10 Your Health Plan HIPAA Notice of Privacy Practices This is a reminder that our Notice of Privacy Practices is available to you through our website, or to contact us and receive one by mail, please refer to the number found on the back of your member ID card. Member Rights and Responsibilities External Review Procedures We are committed to quickly resolving your concerns and problems. There are state and federal laws that allow you to ask for an external review, in some cases, when we deny payment for a claim. These situations have different guidelines based on various things, such as whether your employer s health care coverage is grandfathered or not under the health care reform law. Please call Member Services to find out your specific options for an external review. The Health Carrier External Review Act, a state law, allows you to ask for an external review in some cases when we deny payment for a claim. If you qualify for an external review, we will inform you in writing and explain the process to follow. For more details about the appeals process, please see your Member Guide or visit us online at As a member, you have certain rights and responsibilities. A summary is available online and updated as needed. If you do not have access to the Web and need a copy of your Member Guide, Prescription Drug List, or Member Rights and Responsibilities, please call the number on the back of your member ID card. Our Member Services department is open Monday through Friday, 8:30 a.m. to 6 p.m. Claims and Benefit Information Want to know if we paid a specific claim, what your benefits are for a specific service or what your copayments and other charges were? Find this information and more when you visit the secure My Health Toolkit section of our website. Women s Health and Cancer Rights Do you know that your coverage, as required by the Women s Health and Cancer Rights Act of 1998, provides benefits for mastectomy-related services? These services include all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses and complications resulting from a mastectomy, including lymphedema. Check your certificate of coverage or individual contract for information on this benefit or call BlueChoice for more information. 10 HealthWord Spring 16

11 How Your Benefits Work Your Guide to MyChoice Individual Coverage MyChoice Individual Health Coverage BlueChoiceSC.com How Your Benefits Work Your Member Guide to Primary Choice Coverage BlueChoiceSC.com Member Guide How Your Benefits Work Your Guide to Advantage Plus Coverage Your Member Guide is a great place to find many important details about your benefits. You can find your specific Member Guide on our website. Go to and select the Members tab. Then choose Resources on the right side of the page and then Member Guides. You can then choose the right Member Guide for your plan. The guide will help you understand your benefits and make the most of your coverage. Here s some of the information in the guide: How to access primary care, specialty care, behavioral health services, hospital services and much more How to get after-hours care, urgent care and emergency care How to find care and coverage when you re outside the service area How to submit a claim yourself How we coordinate benefits How we administer benefits for appropriate services, including our policy on not providing incentives to deny coverage of care or services How we decide what new technology we will include as a covered benefit How to get information on our quality improvement program How to voice a complaint or appeal a decision How our privacy practices work How to get information about network providers qualifications and other provider information How your benefits work Restrictions on benefits you receive outside the system How to get language assistance Prescription Drug Information Get details about medications, price comparisons, your prescription history and up-to-date information on our pharmacy procedures and prescription drug lists. Plus, if your coverage offers a mail-order pharmacy benefit, you can order your refills online. Just go to the Pharmacy section under Benefits in My Health Toolkit. We Leave Medical Decisions to Doctors and Patients! We make decisions about approving services based on the appropriateness of care and in agreement with your plan of benefits. We do not reward providers or other individuals for denying coverage or care. And we do not offer financial incentives to decision-makers to encourage decisions that result in underutilization of care. HealthWord Spring 16 11

12 Post Office Box 6170 Columbia, SC PRSRT STD US POSTAGE PAID PERMIT NO 1240 COLUMBIA SC HealthWord is a publication of BlueChoice HealthPlan. BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association. HealthWord is a newsletter for BlueChoice HealthPlan members. It provides information only and does not replace the advice of your doctor. You always should see your doctor for personal medical advice. Do you have questions about your BlueChoice HealthPlan coverage? Try our website at We re open 24 hours a day here! To contact us, please refer to the number found on the back of your member ID card ealthword spring 2016