Benefits Information State of Oklahoma

Transcription

1 Benef ts Information i State of Oklahoma BlueLincs HMO January 1, 2016

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3 The Choice for Nearly 1 in 3 Americans Your health is everything; we ll help you keep it in shape. Whether you are trying to improve your health or reach the next level of wellness, Blue Cross and Blue Shield of Oklahoma (BCBSOK) is here for you. Through Blue Care Connection, BCBSOK offers online fitness programs and personal health management tools to help you learn more about wellness and how to make healthy choices. Partner with the Leader BCBSOK is the state s oldest and largest private health insurer, providing benefit plans to more than half-a-million Oklahomans. As a Blue Cross member, you have access to one of the largest Oklahoma provider networks. Our easy-to-use online Provider Finder allows you to search online for doctors, dentists, hospitals and other health care providers all with the click of a button. The Oklahoma Community BCBSOK is proud to serve Oklahomans across the state and continually works to improve the health and well-being of the communities where we live and work. We recognize the vital role that community alliances play in filling the gap to a brighter, stronger and healthier future for all Oklahomans by having strong ties to local agencies like the United Way and Oklahoma Caring Foundation. You Have Choices The following pages contain coverage options, tools and resources to keep you informed and help you on your journey to wellness. As you review the products, think carefully about how you and your family will use these benefits. Additional information can be found at bcbsok.com POD

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5 HMO Overview HMOs offer valuable benefits with the security of predictable copayments. An HMO plan helps you manage your health and health care expenses by offering members predictable copayments and no claims or other paperwork to file. When you become an HMO member, you ll choose a primary care physician (PCP) from a network of contracting providers (family practitioner, internist, OB/GYN or pediatrician). You may choose the same or a different PCP for each covered family member. The PCP coordinates your care and helps you make informed decisions, including recommendations for wellness and preventive care. You must coordinate all your care through your PCP to receive benefits. Female members do not need a referral to see a BlueLincs participating OB/GYN for an annual well woman exam. When you or a covered family member needs emergency care, go immediately to the nearest emergency facility. You don t need to find a network physician. However, be sure to have someone notify your PCP of any hospital admission or treatment you receive within 48 hours or as soon as possible. And, if you ever need to change your PCP, you can do so at any time by calling the customer service number listed on the back of your ID card. If you call by the 20th of the month, your change will be effective the first of the following month. Partners in Care: Your PCP s Network Your PCP is part of a limited network of contracting health professionals who work closely together to provide a full range of health care services. When choosing a PCP, you are also choosing a network. In most cases, you ll receive all of your care from the doctors, hospitals and other providers that are part of your PCP s network in order for services to be covered POD

6 Quick and Easy Ways to Find a Doctor in the BlueLincs SM HMO Network Use the Integrated Provider Finder, a reliable and convenient way to locate doctors, dentists and pharmacies in the BlueLincs HMO network. Filter search results by provider type, specialty, network type, ZIP code, language and gender. Get directions from Google Maps, too. It s now faster and simpler to do than ever before! Online Go to bcbsok.com and click on Find a Doctor. The improved search experience means you need fewer clicks and required fields to get your results! See Page 2 and follow the simple steps. On your mobile device Go to bcbsok.com and click on Find a Doctor or Hospital. Register or log in to Blue Access for Members SM to stay connected to claims, your ID card, coverage, prescription reminders and health tips via text messages. On the phone You can also call a Blue Cross and Blue Shield of Oklahoma (BCBSOK) Customer Service Advocate at the toll-free telephone number on the back of your BCBSOK member ID card for help in locating a BlueLincs HMO provider POD bcbsok.com/state 6

7 Follow These Simple Steps: 1 Go to bcbsok.com to find contracting doctors, dentists, pharmacies and other health care providers. 2 Click on Find a Doctor 3 Search for a Provider in Multiple Ways: Search for a HMO Primary Care Physician To locate a Primary Care Physician (PCP) in the BlueLincs HMO network, choose BlueLincs HMO in the Network Type field and Primary Care Physician in the Provider Type field. (Select the box at the bottom to ensure the doctor is accepting new patients.) Click on FIND. Find out if a specific health care provider is in the HMO network Choose BlueLincs HMO in the Network Type field and the <name of your doctor, dentist or group> in the Provider s Name field. Click on FIND. Find a specialty doctor in the HMO network Research a doctor based on a specialty, such as dermatology. As a BlueLincs HMO member, your PCP will provide you with a referral if you need the care of a specialist. Choose BlueLincs HMO in the Network Type field, select the <specialty> in the Provider Type, Specialty field, then insert the <physician s last name> in the Provider s Name field. Click on FIND. Filter your search in the HMO network (by gender, language and more) Choose BlueLincs HMO in the Network Type field, and select the <provider type or specialty (or both)> in the Provider Type field. Click on FIND. From there, you ll be able to narrow your search by geography, hospital affiliation, language or gender. When your search results are successful, click on the provider s name to view detailed information. Note: If you do not have Internet access, please call a Customer Service Advocate at the toll-free telephone number on the back of your identification card POD 7

8 HMO How to receive care when you re away from home As a BlueLincs HMO SM member, you can take advantage of one of two programs when you re away from home. The BlueCard Program is available to you for short trips If you need care while away from home for less than 90 consecutive days, follow these easy steps: 1. Always carry your current HMO ID card for easy reference and access to service. 2. In an emergency, go directly to the nearest hospital. 3. Call your primary care physician or HMO for prior authorization and/or pre-certification, if necessary. Your HMO s number is located on your ID card. 4. To find nearby doctors and hospitals, call BlueCard Access at BLUE (2583) or visit the BlueCard Doctor and Hospital Finder at bcbs.com. 5. When you arrive at the participating doctor s office or hospital, simply present your ID card. Away From Home Care is available to you for long trips The Away From Home Care Program gives you access to a participating HMO and is available for you and your covered dependents in certain areas of the United States when you re away from home for at least 90 days. The program is designed to bring you peace of mind if you: have a child attending school out of state have family members living in different service areas have a long-term work assignment in another state are a retiree with a dual residence Here s how this benefit works: 1. Contact your HMO if you or a covered dependent are going to be away from home for at least 90 consecutive days. 2. Your HMO will advise you if a participating HMO is located in the area where you will be staying. 3. Your Home HMO will work with you to complete a Guest Membership application if a participating HMO is located in the area. 4. Your Host HMO will provide you with a membership ID card, a primary care physician and instructions on how to access your benefits while using your Guest Membership. 5. Call your Host HMO primary care physician for an appointment when you need medical care. Please note that the Host HMO benefits may differ from your Home HMO benefits. The Host HMO will communicate this information to you upon acceptance of your Guest Membership application. The Away From Home Program does not cover every area in the United States. For eligibility information and specific locations where the Away From Home Care Program is available, contact BlueLincs HMO by calling the customer service number listed on the back of your ID card. Important Always remember to carry your current HMO ID card. It contains helpful information for accessing healthcare when you re away from home. No Paperwork or Upfront Costs For your convenience, after you receive care, you should: not have to complete any claim forms not have to pay for medical services other than your usual out-of-pocket expenses (non-covered services, deductible, co-payment and co-insurance Blue Cross, Blue Shield, the Blue Cross and Blue Shield symbols, BlueCard and BlueCard Worldwide are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. bcbsok.com/state POD

9 Health and Wellness Resources

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11 Log in to Blue Access for Members SM (BAM) Your Online Resource Would you like to know when your medical claims are paid and the payment amounts? Do you need to confirm who in your family is included under your coverage? BAM, the secure member portal from Blue Cross and Blue Shield of Oklahoma (BCBSOK), can help. Get immediate online access to health and wellness information, and: Check the status of a claim and your claims history Confirm the family members who are covered under your plan View and print an Explanation of Benefits (EOB) statement for a claim Select an option to stop receiving EOBs by mail Set your preferences to receive notifications for claims status and wellness updates through s or text alerts. Locate a doctor or hospital in the network Request a new or replacement member ID card or print a temporary member ID card Join My Blue Community, a social network for BAM members Use BAM while you re on the go. Register or log in by going to bcbsok.com from your mobile device Web browser for secure and convenient access. It s easy to get started 1. Go to bcbsok.com. 2. Click the Already a Member? tab. Then click the Register Now button in the BAM section. 3. Use the information on your BCBSOK ID card to complete the registration process

12 Find what you need at Blue Access for Members SM (BAM) Jose Martinez Message Center Settings Log Out Feedback Home My Coverage Claims Center My Health Doctors & Hospitals Forms & Documents Help 9 J Contact Us Welcome Jose Martinez Last login 07/17/2012 Message Center You have 4 new messages. 07/14/2012 My Blue Community 07/17/2012 Protecting Your Online Information 07/01/2012 System Maint Test View all messages 6 7 MY COVERAGE Billed AmountPlan Type: PPO+ In Network Benefits Medical Copays LIFETIME MAXIMUM PREAUTHORIZATION PENALTY DEDUCTIBLE PER FAMILY Group Number: P12345 ID Number: $0 PER LIFETIME $75 $5,000 Quick Links My Blue Community Get a Temporary ID Card Manage Preferences Find a Doctor, Hospital or Dentist View all quick links DEDUCTIBLE PER INDIVIDUAL OUT OF POCKET PER FAMILY $2,500 $1,000 View medical benefits >> Prescription Drug Copay Generic - Retail Generic - Mail Formulary Brand - Mail $10.00 $20.00 $60.00 Blue Access for Members Is New and Improved. We ve made Blue Access for Members easier to use. 1. My Coverage: Review benefit details for you and the family members covered under your plan. 2. Claims Center: View and organize details such as payments, dates of service, provider names, claims status and more. 3. My Health: Make more informed health care decisions by reading about health and wellness topics and researching specific conditions. 4. Doctors & Hospitals: Use Provider Finder to locate a network doctor, hospital or other health care provider, and get driving directions. 5. Forms & Documents: Use the form finder to get medical, dental, pharmacy and other forms quickly and easily. 6. Message Center: Learn about updates to your benefit plan, and receive notification of pending and finalized claims via secure messaging. 7. Quick Links: Go directly to some of the most popular pages for information, such as medical coverage, replacement ID cards, manage preferences and more. 8. Settings: Set up notifications and alerts to receive updates via text messaging and , review your member information, and change your secure password at anytime. 9. Help: Look up definitions of health insurance terms, get answers to frequently asked questions and find Health Care School articles and videos. 10. Contact Us: Submit a question and a Customer Service Advocate will respond by phone or through the message center. bcbsok.com/state

13 Blue Access Mobile SM Blue Access Mobile brings convenient, secure access to your mobile phone. From your mobile phone Web browser, you can: SM coverage details, access or request identification (ID) cards, check claims status, manage There is no registration required to access the mobile site. However, BCBSOK members must enter their user name and password to log in to Blue Access for Members. bcbsok.com/mobile POD

14 Condition Management Condition Management Programs Living every day with a chronic health condition can be difficult. Blue Cross and Blue Shield of Oklahoma (BCBSOK) can help you manage your medical condition, change unhealthy behaviors and stay as healthy as possible with our comprehensive Condition Management programs. As part of the Blue Care Connection program and offered at no additional cost, these voluntary programs are designed for people diagnosed with chronic conditions such as asthma, diabetes, heart problems and others. When you enroll, you will have access to the best knowledge, tools and self-care techniques to help you make a difference in your health. Benefits of Participation The Condition Management programs work together with you, your health plan and your doctor to help identify the best ways to manage your chronic health condition and stay healthy. Enrolling in a program can help you: Have fewer, milder symptoms Communicate better with your doctor and your health plan Enhance your self-management skills for improving your health and quality of life Miss fewer days at work Enroll Today - and Take Control To enroll in a Condition Management program, or to find out how one of the programs can help you, please call the Customer Service number on the back of your member ID card. You may be targeted for program participation if you have a chronic health condition or are at risk for medical complications that could be addressed through intervention and counseling. Claims, lab and pharmacy data; preauthorization; health risk assessments; or a doctor referral are some of the factors that help determine if a Condition Management program is right for you. You may also request to be included in these programs. Your doctor plays an important role in treating your condition. Be sure to discuss any issues or concerns you may have with your doctor. Reaching Out to Members at Risk Blue Care Advisors, registered nurses or other health care professionals, may contact you if you have certain health challenges or chronic conditions. Through regularly scheduled health counseling and coaching telephone calls, the advisor can help you identify unhealthy behaviors, set goals, adopt healthier habits and learn to manage medical conditions more effectively. Following nationally recognized practice guidelines, the Condition Management programs* specifically target: Asthma Chronic obstructive pulmonary disease (COPD) Congestive heart failure (CHF) Coronary artery disease (CAD) Diabetes * The health care needs of members are evaluated on an ongoing basis to identify opportunities for additional condition management programs. bcbsok.com/state POD

15 Special Beginnings Maternity Program Special Beginnings can help you better understand and manage your pregnancy. Available at no additional cost, this maternity program supports you from early pregnancy until six weeks after delivery through: Pregnancy risk factor identification to determine the risk level of your pregnancy and appropriate range for ongoing communication/monitoring Educational material including a complimentary book about having a healthy pregnancy and baby Personal telephone contact with program staff to address your needs and concerns and to coordinate care with your physician Assistance in managing high-risk conditions such as gestational diabetes and preeclampsia Special Beginnings Online is an additional resource that provides information for each week of your pregnancy. The site can be accessed through Blue Access for Members SM Take good care of yourself and your baby enroll in Special Beginnings today! Enrollment is easy and confidential. Just call , 8 a.m. 6:30 p.m., CT. Special Beginnings is not a substitute for professional medical guidance. It is important to share any health concerns with your physician POD

16 24/7 Nurseline Around-the-Clock, Toll-Free Support The 24/7 Nurseline can help you figure out if you should call your doctor, go to the ER or treat the problem yourself. Health concerns don t always follow a 9-to-5 schedule. Fortunately, registered nurses are on call at (800) to answer your health questions, wherever you may be, 24 hours a day, seven days a week. The 24/7 Nurseline s registered nurses can understand your health concerns and give general health tips. Get trusted guidance on possible emergency care, urgent care, family care and more. When should you call? The toll-free Nurseline can help you or a covered family member get answers to health problem questions, such as: Asthma, back pain or chronic health issues Dizziness or severe headaches High fever A baby s nonstop crying Cuts or burns Sore throat Plus, when you call, you can access an audio library of more than 1,000 health topics from allergies to women s health with more than 600 topics available in Spanish. Note: For medical emergencies, call 911 or your local emergency services first. This program is not a substitute for a doctor s care. Talk to your doctor about any health questions or concerns. Get the information you need, just when you need it. bcbsok.com/state POD

17 A New Way to Experience Wellness Well ontarget offers personalized tools and resources to help all members no matter where you may be on the path to health and wellness. Well ontarget is designed to give you the support you need to make healthy choices. All while rewarding you for your hard work. Well ontarget Member Wellness Portal The heart of Well ontarget is the member portal, available at wellontarget.com. It uses the latest technology to offer you an enhanced online experience. This engaging portal links you to a suite of innovative programs and tools. Wellness is more than healthy eating and working out. It involves making healthy choices that enrich your mind, body and spirit. onmytime Self-directed Courses Online courses let you work at your own pace to reach your health goals. Learn more about nutrition, fitness, weight management, tobacco cessation and stress. Track your progress as you make your way through each lesson. Reach your milestones and earn Life Points. Health and Wellness Content Health library teaches and empowers through evidence-based, user-friendly articles. Tools and Trackers Interactive tools help keep you on course while making wellness fun. Use food and workout diaries, health calculators and medical and lifestyle trackers. onmyway TM* Health Assessment (HA) The HA features adaptable questions to learn more about you. After you take the HA, you will get a personal wellness report. The confidential record offers tips for living your healthiest life. Your answers will be used to tailor the Well ontarget portal with the programs that may help you reach your goals. Well ontarget is a registered mark of Health Care Service Corporation, a Mutual Legal Reserve Company POD

18 To access the Well ontarget member portal, go to wellontarget.com. Questions about the program? Call Customer Service at Life Points Program ** Life Points will help motivate you to maintain a healthy lifestyle. Earn points by taking part in wellness activities. Points can be redeemed in the new online shopping mall. Real-time granting of points lets you instantly use your points. To earn a larger reward, you can add to your point total at checkout. Fitness Program *** Fitness can be easy, fun and affordable. The Fitness Program is a flexible membership program that gives you unlimited access to a nationwide network of fitness centers. With more than 8,000 participating gyms on hand, you can work out at any place or at any time. Choose one gym close to home and another near your office. Other program perks are: No long-term contract required. Membership is month to month. Monthly fees are $25 per month per member, with a one-time enrollment fee of $25. Automatic withdrawal of monthly fee. Online tools for locating gyms and tracking visits. Access to discounts through a nationwide Complementary and Alternative Medicine (CAM) network of 40,000 health and well-being providers such as massage therapists, personal trainers and nutrition counselors. Sign up for the Fitness Program today! Call toll-free at BLUE (2583), Monday through Friday, 8 a.m. 9 p.m. in any continental U.S. time zone. Onlife Health is an independent company that provides wellness services for the Well ontarget program. * onmyway is registered mark of Onlife Health. ** Life Points Program Rules are subject to change without prior notice. See the Program Rules on the Well ontarget Member Wellness Portal for further information. Your company may have additional reward programs in place to encourage you to take advantage of certain preventive care and wellness activities or for making healthy changes. Check your employee benefits. *** The Fitness Program is provided by Healthways, Inc., an independent contractor which administers the Prime Network of fitness centers.the Prime Network is made up of independently-owned and managed fitness centers. bcbsok.com/state POD

19 Tobacco Cessation and Weight Management Programs A Path to Healthier Living Two of the best things you can do for your health are to lose extra pounds and quit smoking. These are also tough goals to reach on your own but Blue Cross and Blue Shield of Oklahoma (BCBSOK) can help. Through Blue Care Connection, BCBSOK offers two voluntary programs to help you reach your wellness goals at no additional charge. o Tobacco Cessation Program: Provides personal telephone coaching, selfdirected online courses and tobacco cessation resources to help you become tobacco and nicotine free. o Weight Management Program: Offers guidance and support to help you change your behavior and shed the extra pounds through personal telephone motivational coaching, self-directed online courses and weight management resources. I made a commitment to myself to live a healthier lifestyle. This program helped me keep that commitment. On occasion, when I would slip, a follow up call from April helped me be accountable for missing any goals or losing focus. - Member Participant Enroll Today! Call Customer Service at the phone number listed on the back of your member ID card. 19

20 Personal Telephone Wellness Coaching A Wellness Coach will be assigned to help you meet your wellness goals. Your coach will take a look at your lifestyle and habits, and help you figure out what s most important to you and what you need to be successful. Self-Directed Courses You can also choose to take online courses that let you work at your own pace to reach your health goals. Learn more about nutrition, fitness, weight management, tobacco cessation and stress. Track your progress as you make your way through each lesson. BCBSOK members also have access to: o Blue365 Member Discount Program Offers exclusive health and wellness deals to BCBSOK members including discounts from top national and local retailers on fitness gear, gym memberships, family activities, healthy eating options and much more. o Blue Access for Members SM (BAM) Secure member portal from BCBSOK gives you immediate online access to health and wellness information. The My Health tab features information on such topics as: Smoking Cessation Nutrition Fitness Obesity bcbsok.com/state

21 Blue365 Discounts to Make Health and Wellness More Affordable Blue365 is just one more advantage of being a Blue Cross and Blue Shield of Oklahoma (BCBSOK) member. With this program, you may save money on health and wellness products and services from top retailers that are not covered by insurance. There are no claims to file and no referrals or pre-authorizations. Once you sign up for Blue365 at blue365deals.com/bcbsok, weekly Featured Deals will be ed to you. These deals offer special savings for a short period of time. Below are some of the ongoing deals offered to Blue365 members. Davis Vision SM TruVision You may save on eyeglasses as well as contact lenses, exams and accessories. Davis Vision is made up of national and regional retail stores as well as local eye doctors. You may get possible savings on laser vision correction through the TLC/TruVision group. TruHearing Beltone You may get possible savings on hearing tests, evaluations and hearing aids. Discounts may also be available for your immediate family members. Procter & Gamble (P&G) Dental Products You may get savings on dental packages with Oral B power toothbrushes and Crest products. Packages may include items such as an electric toothbrush, mouth rinse, teeth whiteners and floss. Dental Solutions SM You may get dental savings with Dental Solutions. You may receive a dental discount card that provides access to discounts of up to 50 percent at more than 61,000 dentists and more than 185,000 locations.* See all the Blue365 deals and learn more at blue365deals.com/bcbsok

22 CORD:USE CorCell You can protect your family s cord blood at a state-of-the-art laboratory using high-quality cord blood banking practices and technologies. Cord blood contains stem cells (like those in bone marrow) that have the ability to develop into additional cells and can be used to treat possible life-threatening diseases in the future. You may save on cord blood processing and storage fees. Jenny Craig Seattle Sutton s Nutrisystem You may reach your weight loss goals with savings from leading programs. You may save on healthy meals, membership fees (where applicable), nutritional products and services. Retrofit SM Receive 15 percent off Retrofit s online, private weight loss coaching sessions. Retrofit includes the use of a wireless Fitbit device and smart scale, one-on-one videoconferencing with a personal team of experts and unlimited online support. You will enjoy flexibility in scheduling and the ability to meet with coaches anywhere there is an Internet connection. Reebok SKECHERS Reebok, a trusted brand for more than 100 years, makes top athletic equipment for all people, from professional athletes to kids playing soccer. SKECHERS, an award-winning leader in the footwear industry, offers exclusive pricing on select Performance, Sport, Work and Corporate Casual styles. You will enjoy 20 percent off plus free shipping for your online orders. SeniorLink Care With SeniorLink Care, you may find support to help your aging family members or friends lead fulfilling and comfortable lives. From planning care to helping caregivers, SeniorLink Care assists older adults and their loved ones in finding the programs and services they may need most. You can save on a three- or 12-month membership. Handstand Kids Handstand Kids brings the family together in the kitchen, spending more time cooking and eating healthy, delicious meals. The Handstand Kids Cookbook series features the languages and cuisines of Italy, Mexico, China and many other countries. Every book also introduces the language and culture of each country. You may save up to 25 percent on cooking accessories and Cookbook Kits. The relationship between these vendors and Blue Cross and Blue Shield of Oklahoma (BCBSOK) is that of independent contractors. BCBSOK makes no endorsement, representations or warranties regarding any products or services offered by the abovementioned vendors. * Dental Solutions requires a $9.95 signup and $6 monthly fee. ** Proof of Blue Cross and Blue Shield of Oklahoma coverage is needed. The $0 enrollment fee offer is only for new Life Time Fitness members who enroll online at blue365deals.com/bcbsok. A $35 administrative fee applies to all memberships. Monthly dues and taxes may also apply. Members prices, dues and fees may change at any time. Other rules may apply. Always check with the Life Time Fitness club in your area for the most up-to-date offer. Blue365 is a discount program only for BCBSOK members. This is NOT insurance. Some of the services offered through this program may be covered under your health plan. Please check your benefit booklet or call the customer service number on the back of your ID card for specific benefit facts. Use of Blue365 does not change your monthly payment, nor do costs of the services or products count toward any maximums and/ or plan deductibles. Discounts are only given through vendors who take part in this program. BCBSOK does not guarantee or make any claims or recommendations about the program s services or products. You may want to talk to your doctor before using these services and products. BCBSOK reserves the right to stop or change this program at any time without notice. Life Time Fitness Life Time Fitness offers total health fitness to fit your level, interests, schedule and budget. For new members, Life Time Fitness offers a $0 online signup fee.** For more great deals or to learn more about Blue365, visit blue365deals.com/bcbsok. bcbsok.com/state 22

23 It s All About Diabetes Living with diabetes can be a challenge. But maintaining close-to-normal levels of blood sugar has been shown to reduce the risk of diabetes-related problems. Therefore, monitoring your blood sugar levels with a blood glucose meter is important in managing diabetes. Blue Cross and Blue Shield of Oklahoma (BCBSOK) offers certain blood glucose meters to members with diabetes at no additional charge. See other side for details. Choosing a Blood Glucose Meter When choosing a meter, it often comes down to the features you re looking for. Here are a few things to consider when making your choice: How does the meter score for accuracy? Does it come with a control solution or test strip to check for accuracy? Does the meter fit in your backpack, supplies kit or purse? How skillful are you at handling those test strips? You might want to try a meter that uses cartridges instead of individual strips. How much blood does the meter require? Less is better. Do you want to download results to a computer, or them to your doctor s office? Interested in alternative site testing? There are meters that can test samples from various places on the body. Checking Your Blood Glucose Regular blood glucose checks and consistent record-keeping give you a good picture of where you are in your diabetes care. Checks tell you how often your blood glucose levels are in your target range. Your target range is a personalized blood glucose range that you set with your doctor. Once you know how often and when to check, stick to the schedule and check at those times each day. Keep a daily log recording your levels. Then take your log with you when you visit your doctor or other members of your diabetes care team. The information in the log will help them answer your questions. For more information about diabetes, go to bcbsok.com, log in to Blue Access for Members SM and click the My Health tab POD

24 Glucose Meters Are Available to You BCBSOK is offering you a choice of the blood glucose meters below at no additional charge for a limited time to help you manage your condition. This offer is available through December 31, Members with BCBSOK prescription drug coverage should check the prescription drug list (also known as a formulary) to see which test strips for the meters below are listed as preferred brands. Coverage and payment levels for test strips may vary depending on your pharmacy benefit plan. Please review these options and ask your doctor which meter best fits your needs. Roche, the Makers of ACCU-CHEK Products To order an ACCU-CHEK meter, call or visit meters.accu-chek.com. When you call, identify yourself as a BCBSOK member, have your ID card handy, your doctor s name and state and your preferred pharmacy name and city. You can ask to pick up the meter at your local pharmacy or have it shipped directly to you. ACCU-CHEK Nano SmartView System Advanced accuracy with ACCU-CHEK SmartView test strips Small, sleek design to fit in the palm of your hand Brilliant backlit display makes reading your numbers easy anytime, anywhere No coding Meter and strips manufactured in the U.S.A. 1 Offers the ACCU-CHEK Fastclix Lancing Device, proven least painful and easy to use 2 ACCU-CHEK Aviva Plus System Advanced accuracy with ACCU-CHEK Aviva Plus test strips Easy to use right out of the box Large test strip for easier handling by people of all ages No coding Includes ACCU-CHEK Softclix lancing device, with simple, one-handed operation Bayer Blood Glucose Monitoring Systems To order a Bayer meter to be shipped directly to you, call and identify yourself as a BCBSOK member. For more detailed descriptions, visit bayercontour.com. CONTOUR NEXT EZ blood glucose monitoring system The easy-to-use features you want with the proven accuracy you expect Ready to test, right out of the box Easy-to-read display No Coding TM technology makes testing easy by automatically setting the correct code each time a test strip is inserted into the meter Proven accuracy: CONTOUR NEXT test strips deliver results close to those obtained in a professional lab CONTOUR NEXT blood glucose monitoring system Use AutoLog to see the effect of food choices on your blood sugar levels with pre-meal, post-meal and fasting markers Set audible reminders to help you remember to test after eating Personalize high/low target settings to identify trouble spots and get clear summaries and patterns View 7-, 14-, 30- and 90-day trends to get more tracking knowledge and an overview of averages Set your meter to English, Spanish or any of 12 other languages Meter and strips manufactured in the U.S.A. 1 The ACCU-CHEK Nano SmartView and ACCU-CHEK Aviva Plus systems are compatible with all ACCU-CHEK data management tools, including the ACCU-CHEK 360 diabetes management system. You also may download data to your PC with the ACCU-CHEK Smart Pix Device Reader; no additional software required. 1 Using U.S. and imported materials. 2 Ranked high among leading competitors. Data on file. Disclaimer: This information is not intended to be a substitute for professional medical advice. If you are under the care of a doctor and receive advice different from the information contained in this flier, follow the doctor s advice. See your doctor if you are experiencing any diabetes symptoms or health problems. Blue Cross, Blue Shield and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. bcbsok.com/state POD

25 Health Care Reform

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27 The Affordable Care Act: Preventive Services at 100% 1 of 5 Preventive Care Services Covered Without Cost-sharing Without Copay, Coinsurance or Deductible The Affordable Care Act (ACA) requires non grandfathered health plans and policies to provide coverage for preventive care services 1 without cost-sharing (such as coinsurance, deductible or copayment), when the member uses a network provider. Services include certain screenings, immunizations, and other types of care, as recommended by the federal government. Blue Cross and Blue Shield of Oklahoma (BCBSOK) is committed to implementing coverage changes to meet ACA requirements as well as the needs and expectations of our members. General Highlights of Preventive Services Coverage under ACA Applies to group health plans including insured and self-insured plans, as well as individual and family policies. Preventive services are to be covered without any cost-sharing when using a network provider. Costsharing can still be required when using a provider that is not in the BCBSOK provider network. New recommendations can be issued at any time. As new or updated preventive care recommendations or guidelines are issued, employers and insurers have at least one year to implement the new guidelines unless otherwise specified by the government. 2 Plans that cover preventive services in addition to those required under ACA may apply costsharing requirements for the additional services. The regulation references preventive care services with an A or B rating as outlined by the United States Preventive Services Task Force (USPSTF). 1 They are listed in this fact sheet and can be found at: recommendations.htm BCBSOK may apply reasonable medical management techniques to preventive services benefits that may impact frequency, method, treatment or setting for coverage. Plans that are grandfathered, meaning plans that had at least one individual enrolled on March 23, 2010, and have not made certain changes since that date to cause a loss of grandfathered status, are not required to implement some of the new requirements of the Affordable Care Act, including the requirement to cover preventive services with no cost-sharing. For more information visit this BCBSOK web site: Preventive Care Services to Be Offered Without Copay, Coinsurance or Deductible Evidence-based preventive services: The list of ACA required preventive services includes those that are recommended and rated A or B by the USPSTF. Routine vaccinations: A list of immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention are considered routine for use with children, adolescents and adults, and range from childhood immunizations to periodic tetanus shots for adults. Prevention for children: Preventive care guidelines for children from birth to age 21 developed by the Health Resources and Services Administration with the American Academy of Pediatrics. Services include regular pediatrician visits, developmental assessments, immunizations, and screening and counseling to address obesity. Publication Date: 10/01/

28 The Affordable Care Act: Preventive Services at 100% 2 of 5 Prevention for women: The regulation mandates coverage for certain preventive care measures for women. These recommendations include annual well-woman visits and all FDA-approved methods of contraception, among other things. 2 Billing and Office Visits If a recommended preventive service or item is billed separately from an office visit, then costsharing may be applied to the office visit. Covered Preventive Care Services 1 Depending on the particular health plan, coverage may be provided for the following preventive services without cost-sharing. 1 This list may not include all of a particular plan s covered services. BCBSOK members can call Customer Service at the number on their member ID card for details on how these benefits apply to their coverage and the most up-to-date list of covered preventive services, including those paid without any cost-sharing. If a recommended preventive item or service is not billed separately from an office visit and the primary purpose is preventive care, then costsharing requirements may not be imposed with respect to the office visit. If a recommended preventive item or service is not billed separately from an office visit and the primary purpose of the office visit is not preventive care, then cost-sharing may be applied to the office visit. BCBSOK s Focus on Prevention Laying the groundwork for a healthy tomorrow means disease prevention and early detection. Many chronic diseases and conditions can be prevented and/or managed through early detection. Preventive screenings are an important way to track your health and avoid chronic conditions before they become more serious. BCBSOK encourages you to take full advantage of your preventive care benefits and other available wellness resources. After completing a health screening, take appropriate steps to improve your health. Talk with your physician about ways to improve your health. There is no better time than now to get started and head off potential health problems before they begin. Children and Adolescents Well-child exam Examples of services included as part of a well-child exam include history and physical exam, measurements of height, weight and body mass index (BMI), hearing screening 4, iron supplementation for those at risk of anemia, vision acuity test 5, developmental and behavioral assessments, prescription of fluoride if water source is deficient in fluoride (see dental caries prevention below), evaluation of need for a dentist visit, counseling about health risks such as sexually transmitted infections, and obesity counseling and tobacco use intervention and cessation counseling. Immunizations Diphtheria, Tetanus, Pertussis Haemophilus influenzae type B Hepatitis A Hepatitis B Human Papillomavirus (HPV) Influenza (Flu) Measles, Mumps, Rubella Meningococcal Pneumococcal Inactivated Poliovirus Rotavirus Tetanus, diphtheria, & acellular pertussis 4 Publication Date: 10/01/

29 The Affordable Care Act: Preventive Services at 100% 3 of 5 Varicella (Chickenpox) Screening tests Screening for hearing loss, hypothyroidism, sickle cell disease and phenylketonuria (PKU) in newborns Hematocrit or hemoglobin screening Obesity screening and counseling Lead screening Dyslipidemia screening for children at higher risk of lipid disorder Tuberculin testing Depression screening Screening for sexually transmitted infections (STIs) HIV screening Cervical dysplasia screening Skin cancer behavioral counseling Dental Caries Prevention fluoride varnish for all infants and children starting at age of primary tooth eruption; oral fluoride supplementation starting at age 6 months for children whose water supply is fluoride deficient Preventive treatments Gonorrhea preventive medication for eyes of all newborns Adults Preventive exam Examples of services included as part of a preventive exam include history and physical exam, measurements of height, weight and body mass index (BMI). Immunizations Hepatitis A Hepatitis B Human Papillomavirus (HPV) Haemophilus influenzae type b (Hib) Influenza (Flu) Measles, Mumps, Ruebella Meningococcal Pneumococcal Tetanus, Diphtheria, Pertussis Varicella (chickenpox) Zoster Screening tests Abdominal Aortic Aneurysm screening Blood pressure screening Cholesterol screening Colorectal cancer screenings using fecal occult blood testing, sigmoidoscopy or colonoscopy 3 Depression screening Diabetes screening for adults with high blood pressure Falls prevention for adults age 65+ in community dwellings, including physical therapy and Vitamin D supplementation for this purpose Hepatitis B screening Hepatitis C infection screening HIV screening and counseling Lung cancer screening Obesity screening Sexually transmitted infection (STI) screenings (chlamydia, gonorrhea, syphilis) Publication Date: 10/01/

30 The Affordable Care Act: Preventive Services at 100% 4 of 5 Health Counseling Alcohol misuse screening and counseling Healthy diet Obesity Prevention of sexually transmitted infections (STIs) Tobacco use cessation (Includes Prescription One or more products within the categories approved by the FDA for use in smoking cessation) Use of aspirin to prevent cardiovascular disease Use of folic acid Skin cancer behavioral counseling for young adults (up to age 24) Women Only Annual well woman visit Breast cancer prevention medication Breast cancer screening/ Screening mammography Cervical cancer screening including Pap smear Osteoporosis screening Genetic counseling and evaluation for BRCA testing where family history is associated with an increased risk Human Papillomavirus (HPV) DNA test Counseling related to chemoprevention of breast cancer Breastfeeding 9 Intimate partner violence counseling and screening Contraception 6 Contraception 6 The following contraceptive items and services are generally covered without cost-sharing when provided by a health care provider in the BCBSOK network. Prescription 7 One or more products within each of the categories approved by the FDA for use as a method of contraception Over-the-counter Contraceptives available approved by the FDA for women (foam, sponge, female condoms) when prescribed by a physician The morning after pill Medical devices such as IUD, diaphragm, cervical cap and contraceptive implants Female sterilization 8 including tubal ligation Specifically for Pregnant Women Alcohol misuse screening and counseling Anemia screening Bacteriuria screening Rh Incompatibility screening Note: this test is to be repeated Gestational diabetes screening Hepatitis B screening HIV screening Screenings for Sexually Transmitted Infections (STIs) including chlamydia, gonorrhea, and syphilis Tobacco use and cessation counseling Venipuncture for pregnancy required labs Publication Date: 10/01/

31 The Affordable Care Act: Preventive Services at 100% 5 of 5 Footnotes 1 ACA requires non-grandfathered health plans and policies to provide coverage for preventive care services without costsharing only when the member uses a network provider. This includes preventive care services as follows: Evidence-based items/services rated A or B in the current recommendations of the U.S. Preventive Services Task Force Routine immunizations for children, adolescents and adults recommended by the Advisory Committee on Immunization Practices of the Centers for Disease control and prevention Evidence-informed preventive care and screenings for infants, children, and adolescents in the comprehensive guidelines of the Health Resources and Services Administrations Evidence-based preventive care and screenings for women described in the comprehensive guidelines of the Health Resources and Services Administration 2 New recommendations can be issued at any time. A new recommendation must be covered beginning on the first plan or policy year that is one year after the recommendation is issued. Non-grandfathered plans/policies are required to cover these services beginning with plan/policy years starting on or after Aug. 1, Anesthesia also covered as preventive 4 Further evaluation recommended as a result of a hearing screening test is not considered preventive and may not be covered at 100%. 5 Vision acuity test to detect amblyopia (lazy eye), strabismus (cross eye), and defects in visual acuity in children younger than age 5 years. Normal vision screening and further evaluation recommended as a result of an acuity test are not considered preventive and may not be covered as preventive. 6 ACA regulations provide for an exemption from the requirement to cover contraceptive services for certain group health plans established or maintained by organizations that qualify as religious employers. Also, federal regulatory agencies have established an accommodation for religious affiliated eligible organizations, in which case separate payment may be available for certain contraceptive services. 7 Prescription coverage for contraception may vary according to the terms and conditions of your health plan s pharmacy benefit. Please call the customer service number on the member ID card for coverage details. 8 Certain restrictions may apply; copay, coinsurance or deductibles may be required. Call the number on the back of the member ID card for more information. Hysterectomies are not considered part of the women s preventive care benefit. 9 Breastfeeding Breastfeeding specialist/nurse practitioner with staterecognized certification who is in your provider network Breastfeeding support and counseling by a trained in-network provider while you are pregnant and/or after you ve given birth Breast pumps (manual, electric and hospital grade)* The Blue Cross and Blue Shield (BCBS) implementation of preventive services without cost-sharing under the Affordable Care Act (ACA) previously covered manual breast pumps only. Effective April 15, 2013, BCBS expanded its coverage to include electric and hospital gra de breast pumps. This coverage applies to non-grandfathered plans and policies and expands the breastfeeding support options available to members without costsharing (some limitations or restrictions may apply). As of May 1, 2014, breastfeeding supplies (electric and hospital grade breast pumps) will be covered when obtained through an out-of-network provider, where coverage was previously excluded. Coverage may not be at 100% no cost share. Some limitations and restrictions may apply based on the group coverage for preventive services. Contact a BCBS representative or call the number located on the back of the member ID card for more information. Blue Cross and Blue Shield of Oklahoma, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Publication Date: 10/01/

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33 Prescription Drug Information

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35 Prior Authorization Program Blue Cross and Blue Shield of Oklahoma is working to find ways to manage the rising cost of prescription drugs. Your benefit plan uses tools, such as prior authorization, that can help control costs for everyone. What is prior authorization? The prior authorization program encourages safe and cost-effective medication use. The program applies to certain high-cost drugs that have the potential for misuse. Before medications included in the prior authorization program can be covered under your benefit plan, your doctor will need to get approval through Blue Cross and Blue Shield of Oklahoma. If you are already taking or are prescribed a drug that is part of the prior authorization program, your doctor can submit a prior authorization request form so your prescription can be considered for coverage. Your doctor can find prior authorization forms on the provider website at bcbsok.com. Doctors may also call with questions, or to get a form. How does the program work? If the prior authorization request is approved: You will pay the appropriate amount based on your prescription drug benefit when you fill your prescription. Treatment decisions are always between you and your doctor. If the prior authorization request is not approved: The medication will not be covered under your prescription drug benefit. You can still purchase the medication, but you will be responsible for the full cost. Or, you can talk to your doctor to find out if another drug might be right for you. Remember, treatment decisions are always between you and your doctor. As always, the appeal rights provided by your benefit plan are available to you. Why are only certain drugs included in the program? ram? The program s goal is to promote safe, effective medication use. Therefore, the prior cost- authorization program includes drugs that are not only high-cost but sometimes are misused. Growth hormone is one example. These drug products are meant to treat growth hormone deficiency and other medical conditions. However, growth hormone is sometimes used to increase muscle mass and for its antiaging effects, which may not be medically necessary POD

36 What should I do if I take a drug that is part of the program? If you are already taking a medication that becomes part of a prior authorization program for your prescription drug benefit: your doctor will need to submit a prior authorization request for your prescription before you can continue to receive coverage for the drug. If you start taking a medication that is included in the prior authorization program for your prescription drug benefit: your doctor will need to submit a prior authorization request before the drug can be covered under your benefit plan. What medications are included in the prior authorization program? The box above right shows examples of drug categories which may be included in the prior authorization program. To see a sample list of drugs in these categories, go to bcbsok.com/member/ prescriptiondrugs and scroll down to the Prior Authorization/Step Therapy Program section. If you have questions about the prior authorization program, or to find out if a particular drug is included in the program, call the number on the back of your ID card. Drug Categories Which May Be Included in the Prior Authorization Program* Androgens/Anabolic Steroids Antifungal Agents Erectile Dysfunction Narcolepsy Specialty Medications * Categories may be added or removed and the program may change from time to time. Tools such as prior authorization encourage safe and cost-effective medication use, and help manage the rising cost of prescription drugs for everyone. The prior authorization program encourages safe and cost-effective medication use. bcbsok.com/state POD

37 Step Therapy Program Blue Cross and Blue Shield of Oklahoma is working to find ways to manage the rising cost of prescription drugs. Your benefit plan uses tools, such as step therapy, that can help control costs for everyone. What is step therapy? The step therapy program encourages safe and cost-effective medication use. Under this program, a step approach is required to receive coverage for certain high-cost medications. This means that to receive coverage you may need to first try a proven, cost-effective medication before using a more costly treatment, if needed. Remember, treatment decisions are always between you and your doctor. Don t more expensive drugs work better? Not necessarily. A higher cost does not automatically mean a drug is better. For example, a brand drug may have a less-expensive generic or brand alternative that might be an option for you. Generic and brand drugs must meet the same standards set by the U.S. Food and Drug Administration for safety and effectiveness. Work with your doctor to determine which medication options are best for you. How does the program work? The step therapy program requires that you have a prescription history for a first-line medication before your benefit plan will cover a secondline drug. A first-line drug is recognized as safe and effective in treating a specific medical condition, as well as being cost-effective. A second-line drug is a less-preferred or sometimes more costly treatment option. Step 1 When possible, your doctor should prescribe a first-line medication appropriate for your condition. Step 2 If your doctor determines that a first-line drug is not appropriate for you or is not effective for you, your prescription drug benefit efit will cover a second-line ne drug when certain conditions are met. Work with your doctor to determine which medication options are best for you POD

38 What should I do if I take a drug that is part of the step therapy program? If you are already taking a medication that is part of the step therapy program: you may not be affected. Call the number on the back of your ID card to find out. If you start taking a medication that is included in a step therapy program for your prescription drug b e n e fi t : your doctor will need to write you a prescription for a first-line medication or submit a prior authorization request for the prescription before you can receive coverage for the drug. Your doctor can find prior authorization forms on the provider website at bcbsok.com. Doctors may also call with questions, or to get a form. What medications are included in the step therapy program? The box above right shows examples of drug categories that may be included in the step therapy program. To see a sample list of drugs in these categories, go to bcbsok. com/member/prescriptiondrugs and scroll down to the Prior Authorization/Step Therapy Program section. If you have questions about the step therapy program, or to find out if a particular drug is included in the program, call the number on the back of your ID card. Drug Categories Which May Be Included in the Step Therapy Program* Cholesterol Depression Diabetes Proton Pump Inhibitors Specialty Medications * Categories may be added or removed and the program may change from time to time. Tools such as step therapy encourage safe and costeffective medication use, and help manage the rising cost of prescription drugs for everyone. The step therapy program ram encourages safe and cost-effective medication use. bcbsok.com/state POD

39 Understanding Quantity Limits on Prescription Medications Information for Members Q: What is a quantity limit? A: Your pharmacy benefit typically provides coverage for prescription drugs based on a 30-day supply. A quantity limit is a specific quantity of medication eligible for coverage as a 30-day supply or a 90-day mail-order supply. Quantity limits provide a clinical baseline for the recommended amount of medication that should be dispensed over a certain period of time. Limits are based upon FDA and manufacturer dosing recommendations, nationally recognized clinical guidelines and Blue Cross and Blue Shield of Oklahoma (BCBSOK) Pharmacy Advisory Committee review. For drugs covered under your benefit, medication quantities prescribed within these limits are automatically covered by your pharmacy benefit. Q: Why does my prescription benefit include quantity limits? A: Quantity limits for prescription medications play an important role in helping to keep health care affordable by improving the quality of pharmaceutical care, minimizing your health risks and assuring appropriate utilization when medications are dispensed. Quantity limits for prescription medications play an important role in helping to keep health care affordable by improving the quality of pharmaceutical care, minimizing your health risks and assuring appropriate utilization when medications are dispensed. Q: How will quantity limits affect me? A: When you present a prescription to the pharmacist for a medication that is included under your benefit and subject to quantity limits, that prescription will immediately be covered if the quantity requested is at or below the allowed amount. If your prescription exceeds the quantity limit, the pharmacist will receive an online message that explains your pharmacy benefit limit for that specific medication. At this point, you can ask your pharmacist to fill your prescription for the exact quantity your benefit provides coverage for. Or if you prefer, and your medication is listed in the Quantity Limits section of the formulary posted at bcbsok.com, you can wait and ask your doctor to request coverage approval for a greater quantity. If your prescription exceeds the usual recommended amount, you will need approval from BCBSOK to exceed your benefit limit. You can ask your physician to fax or mail a Quantity Override Request Form to BCBSOK to request coverage for additional medication. The easiest way for your physician to obtain a Quantity Override Request Form is by visiting our website at bcbsok.com and clicking on the Provider section. If additional program information is needed, call the customer service number listed on the back of your ID card. Q: What happens after my doctor submits an Override Request Form? A: Physician requests are reviewed by both a clinical pharmacist and medical director within three business days after receiving a completed form. Override approvals are sent to you and your physician s office. Your physician is responsible for letting you know if your request was approved. Once approved, your benefit will provide coverage for an additional, specified quantity of medication for a clinically appropriate period of time POD

40 Denial notifications are mailed to both you and your physician. The notification letter includes the reason for denial and specific appeal information. Q: What if my request is not approved? A: If your request is denied, your physician may send an appeal to BCBSOK on your behalf. The appeal should include any helpful clinical information that would support why an additional quantity is medically necessary. All required appeal information, including the appropriate BCBSOK mailing address is included with each letter of denial. Appeals may be sent to: Customer Service Appeals Coordinator P.O. Box 3283 Tulsa, OK As always, if you have a prescription for quantities in excess of your pharmacy benefit, you still may obtain those additional quantities, but you will be financially responsible for the full cost of the extra amount of the covered drug. Q: What medications have quantity limits? A: Examples of drug categories subject to quantity limits are: and Flovent) A complete drug list including the quantity limits that apply is available on our website at bcbsok.com. You may also obtain quantity limit information by calling the BCBSOK Customer Service number located on the back of your ID card. Q: If my medication has quantity limits, is there an alternative medication I can take? A: Talk to your doctor about what other treatment options may be available for you. Be sure to also discuss your quantity limits. Q: How are the medications subject to quantity limits determined? A: A team of pharmacists and physicians reviews categories of medications that are potentially over-prescribed, may not be intended for daily use or require routine monitoring to assure safety and good results. The reviewers take into consideration FDA dosing guidelines, nationally recognized clinical guidelines written by specialists and other generally accepted standards of practice when determining drug categories appropriate for quantity limits. Q: What if I m going on vacation? A: If you are going on vacation, you may request a one-time vacation override by calling the BCBSOK customer service number listed on the back of your ID card. Important: while you may receive an early prescription refill, you will still have to wait the appropriate number of days before your next refill will be covered. For more information on the drug formulary, please contact customer service at the toll-free phone number listed on the back of your BCBSOK member ID card. bcbsok.com/state POD

41 Prim Delivers Prim , the mail-service pharmacy trusted by your health plan, delivers your long-term (or maintenance) medicines right where you want them. No driving to the pharmacy. No waiting in line for your prescriptions to be filled. Savings Prim delivers up to a 90-day supply of long-term medicines. This can reduce what you pay out-of-pocket, and includes free standard shipping. Convenience Prescriptions are delivered to the address of your choice, within the U.S. You can order from the comfort of your home either online, over the phone or through the mail. Or, you can have your doctor fax or e-prescribe your order. You can receive up to a 90-day supply of long-term medicine at a time. You can ask for refills online or over the phone. Plain-labeled packaging protects your privacy. Service You can receive notification by or phone your choice when your prescription is received and when your orders are sent. Member service agents are available 24/7. Licensed, U.S.-based pharmacists are available seven days a week. Choose to receive refill reminder notifications by phone or . Standard delivery is included at no additional cost. Prim pharmacies are located in the U.S. Prim will call or when your prescription is received, when it ships and when it is due for a refill POD

42 Getting Started with Prim Existing Prescriptions You can request that Prim contact your doctor to transition your prescription. Visit bcbsok.com and log into Blue Access for Members SM (BAM). Click on My Coverage tab, Prescription Drugs on the left and then Prime Therapeutics in the center. C li c k Go to MyPrim .com. Select Transition Prescriptions from Retail to Prim and fill out the online form. Or, call Prim at Medicines take about 8 days to deliver after Prim receives approval from your doctor. New Prescriptions Mail your prescription or have your doctor fax or e-prescribe. Ask your doctor for a prescription for a 90-day supply of each of your long-term medicines. Or, ask your doctor to fax or e-prescribe your order to Prim . If you need to start your medicine right away, request a prescription for a one-month supply to fill at a local retail pharmacy. To print a Prim New Prescription Order Form, go to bcbsok.com/member/prescriptiondrugs. From there, scroll down to the Prim Prescriptions Delivery Service Forms section. Or, call Prim at Mail your prescription, completed order form and payment to Prim . Medicines take about 8 days to deliver after Prim receives and verifies your order. Refills Are Easy Refill dates are shown on each prescription label. You can choose to have Prim remind you by phone or when a refill is due. Choose the reminder option that best suits you. Online Visit bcbsok.com to refill a prescription or renew an expired prescription. Log into BAM and click on My Coverage tab, Prescription Drugs on the left and then Prime Therapeutics in the center. Then click Go to MyPrim .com. Select Refill to choose the medicine you would like to refill. Over the Phone Call the Prim automated refill system at Through the Mail Complete and mail the Refill Prescription Order Form sent with your order. Remember to allow time for your refill order to be received and processed. Questions? To learn more, visit bcbsok.com. Prim is a mail-order pharmacy service operated by Prime Therapeutics LLC, a pharmacy benefit management company. Blue Cross and Blue Shield of Oklahoma (BCBSOK) contracts with Prime Therapeutics to provide pharmacy benefit management and mail-order pharmacy services. BCBSOK, as well as several other independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics. Prim is a registered trademark of Prime Therapeutics LLC. bcbsok.com/state POD

43 Specialty Medications Blue Cross and Blue Shield of Oklahoma (BCBSOK) has arranged for Prime Therapeutics Specialty Pharmacy* to support members who need specialty medication and help them manage their therapy. Specialty drugs are often prescribed to treat chronic, complex health problems, such as multiple sclerosis, hepatitis C and rheumatoid arthritis. These drugs are typically received by injection, but may be topical or taken by mouth. Specialty drugs frequently call for careful adherence to a treatment plan and have special handling or storage needs and may not be stocked by retail pharmacies. Examples of Self-administered Specialty Medications The chart below shows some conditions self-administered specialty drugs may be used to treat, along with sample medications. This list is not all-inclusive and may change from time to time. Visit bcbsok.com to see the up-to-date list of specialty drugs. Some specialty drugs must be given by a health care professional, while others are approved by the U.S. Food and Drug Administration (FDA) for self-administration. Medications that call for administration by a professional are often covered under your medical benefit. Your doctor will order these medications. Coverage for self-administered specialty drugs is usually provided through your pharmacy benefit. Your doctor should write or call in a prescription for self-administered specialty drugs to be filled by a specialty pharmacy. Your plan requires that you get specialty drugs through Prime Specialty Pharmacy to receive the highest level of benefits. If you choose to use a pharmacy outside Prime Specialty Pharmacy, your benefits may be reduced or your medication may not be covered. Condition Osteoporosis Cancer (oral) Growth Hormones Hepatitis C Multiple Sclerosis Rheumatoid Arthritis/Psoriasis Sample Drugs** Forteo Gleevec, Nexavar, Sprycel, Sutent, Tykerb Genotropin, Humatrope, Norditropin, Omnitrope, Tev-Tropin Copegus, Infergen, Intron-A, Pegasys, Peg-Intron Avonex, Betaseron, Copaxone, Rebif Enbrel, Humira, Kineret

44 Support in Managing Your Condition: Prime Specialty Pharmacy Through Prime Specialty Pharmacy, you can have your covered, self-administered specialty drugs delivered straight to you, or to your doctor s office. When you get your specialty drugs through Prime Specialty Pharmacy, you get support in managing your therapy at no additional charge including: o Convenient delivery of drugs to you or your doctor s office o Information about your particular condition and about managing potential medication side effects o Syringes, sharps containers and other supplies with each shipment for self-injectable drugs o 24/7/365 customer service phone access Ordering Through Prime Specialty Pharmacy To start using Prime Specialty Pharmacy, call MEDS (6337). If you currently use a self-administered specialty drug, you can have your existing prescription transferred to Prime Specialty Pharmacy. If you have a new prescription, Prime Specialty Pharmacy can give you more information about submitting the prescription or having your doctor do so. Your doctor may also order officeadministered specialty drugs through Prime Specialty Pharmacy. Call Prime Specialty Pharmacy at MEDS (6337) to order. Have your ID card and the following information ready: o Name, address, phone number o Name of medication o For existing prescriptions, your current pharmacy s name and phone number, and the prescription number o Doctor s name, phone and fax numbers Receiving Specialty Medications Since many specialty drugs have unique shipping or handling needs, shipments will be arranged with you through Prime Specialty Pharmacy. Medications are shipped in plain, secure, tamper-resistant packaging. Before your scheduled refill date, you may be contacted to: o Confirm your drugs, dose and the delivery location o Check any prescription changes your doctor may have ordered o Discuss any side effects you may be having If you need support, you can reach Prime Specialty Pharmacy at MEDS (6337). Certain coverage exclusions and limitations may apply, based on your health plan. Check your benefit materials for details, or call the number on the back of your ID card with questions. *Prime Therapeutics Specialty Pharmacy LLC (Prime Specialty Pharmacy) is a wholly owned subsidiary of Prime Therapeutics LLC, a pharmacy benefit management company. Blue Cross and Blue Shield of Oklahoma contracts with Prime Therapeutics to provide pharmacy benefit management, prescription home delivery and specialty pharmacy services. Blue Cross and Blue Shield of Oklahoma, as well as several other independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics. **Third-party brand names are the property of their respective owners. BLUE CROSS, BLUE SHIELD and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. bcbsok.com/state

45 Q&A Prescription Drug List What is a prescription drug list (formulary)? The Blue Cross and Blue Shield of Oklahoma (BCBSOK) drug list (also known as a formulary), which your prescription drug benefit plan is based on, is a regularly updated list of preferred drugs selected based on the recommendations of a committee comprised of individuals from throughout the country who hold a medical or pharmacy degree. U.S. Food and Drug Administration (FDA)- approved drugs are chosen based their safety, cost and how well they work. The drug list includes all generic drugs and a select group of brand drugs. Why should I use the drug list? Your copayment/coinsurance amount for covered preferred brand drugs is usually lower than for non-preferred brand drugs. You have benefits for most covered medicines that are not on the drug list, but you may pay more out of pocket. The drug list is a reference for your doctor when prescribing medicines. But it is solely up to you and your doctor to decide the medicine that is best for you. What are the advantages of using generic drugs? Generics are recognized as safe and effective medicines. Generics often cost less than a brand medicine. A generic can usually be substituted for a brand drug if it has the same active ingredients, the same strength and dosage form and produces the same results. Talk to your doctor or pharmacist to find out if a generic drug is available and right for you. How do I know if a drug is on the drug list and what my cost will be? The other side of this flier lists some commonly prescribed generic and preferred brand medicines. If a drug you are looking for is not on the list, search the drug list at bcbsok.com or call the number on the back of your ID card. Your prescription drug benefit plan and whether the drug is on the drug list will determine the amount you may pay out of pocket. To find out what you will pay, visit bcbsok.com or call the number on the back of your ID card. What are dispensing limits? Based on FDA-approved dosage regimens and manufacturer s research, certain drugs have dispensing limits. This means that these drugs have a limit on how much medicine can be filled per prescription or in a given time span. For example, coverage for the osteoporosis drug Actonel (risedronate) is limited to 30 tablets per 30 days because the FDA-approved labeling states that the recommended dose is one 5 mg oral tablet taken daily. What if I have questions? Call the number on the back of your ID card, 24 hours a day/7 days a week, or visit bcbsok.com POD

46 July 2015 Commonly Prescribed Preferred Drugs This list is a sample of commonly prescribed generic and preferred brand drugs. Refer to the BCBSOK Prescription Drug List at bcbsok.com for a more comprehensive and up-to-date list. The online drug list is updated quarterly. The drug list may contain medications not covered under your prescription drug benefit plan. In addition, prescription versions of over-the-counter (OTC) medications may not be covered based on your prescription drug benefit plan. If you have questions about your prescription drug benefit, call the number on the back of your ID card. ANTIHYPERTENSIVES Angiotensin Converting Enzyme (ACE) Inhibitors and Combinations benazepril benazepril/hydrochlorothiazide captopril enalapril enalapril/hydrochlorothiazide fosinopril fosinopril/hydrochlorothiazide lisinopril lisinopril/hydrochlorothiazide moexipril moexipril/hydrochlorothiazide perindopril quinapril quinapril/hydrochlorothiazide ramipril trandolapril Angiotensin II Receptor Antagonist (ARBs) and Combinations BENICAR BENICAR HCT candesartan candesartan/hydrochlorothiazide irbesartan irbesartan/hydrochlorothiazide losartan losartan/hydrochlorothiazide telmisartan telmisartan/hydrochlorothiazide valsartan valsartan/hydrochlorothiazide Beta Blockers and Combinations acebutolol atenolol atenolol/chlorthalidone bisoprolol bisoprolol/hydrochlorothiazide carvedilol INNOPRAN XL labetolol metoprolol succinate ext-release metoprolol tartrate nadolol pindolol propranolol ext-release PROPRANOLOL SOLN propranolol tabs TIMOLOL TABS Calcium Channel Blockers and Combinations amlodipine amlodipine/atorvastatin amlodipine/benazepril amlodipine/valsartan diltiazem diltiazem ext-release felodipine ext-release nifedipine ext-release verapamil 80 mg, 120 mg verapamil ext-release ASTHMA / COPD ADVAIR DISKUS ADVAIR HFA albuterol 0.63 mg/3ml, 1.25 mg/3ml albuterol inhal soln, 0.083%, 0.5% albuterol syrup, tabs ANORO ELLIPTA ASMANEX ATROVENT HFA BREO ELLIPTA budesonide COMBIVENT RESPIMAT cromolyn inhal soln DULERA FLOVENT DISKUS FLOVENT HFA FORADIL AEROLIZER INCRUSE ELLIPTA ipratropium inhal soln ipratropium/albuterol levalbuterol montelukast PROAIR HFA PROAIR RESPICLICK QVAR SPIRIVA SYMBICORT terbutaline theophylline ext-release VENTOLIN HFA zafirlukast CHOLESTEROL atorvastatin cholestyramine choline fenofibrate delayed-release colestipol CRESTOR fenofibrate fenofibrate micronized fenofibric acid delayed-release gemfibrozil lovastatin niacin ext-release pravastatin simvastatin WELCHOL DEPRESSION amitriptyline bupropion bupropion ext-release citalopram clomipramine desipramine doxepin bcbsok.com/state POD

47 July 2015 Commonly Prescribed Preferred Drugs duloxetine delayed-release escitalopram fluoxetine fluvoxamine imipramine mirtazapine nortriptyline caps paroxetine paroxetine ext-release phenelzine sertraline tranylcypromine trazadone venlafaxine venlafaxine ext-release caps venlafaxine ext-release tabs, 37.5 mg, 75 mg, 150 mg metformin ext-release OSM nateglinide NOVOLIN 70/30 NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG MIX 70/30 ONGLYZA pioglitazone pioglitazone/metformin repaglinide ROCHE TEST STRIPS VICTOZA DIABETES acarbose BAYER TEST STRIPS BYDUREON glimepiride glipizide glipizide ext-release glipizide/metformin GLUCAGON EMERGENCY KIT glyburide glyburide/metformin glyburide, micronized INVOKAMET INVOKANA JANUMET JANUMET XR JANUVIA JARDIANCE KOMBIGLYZE XR LANTUS LEVEMIR metformin metformin ext-release Preferred brand drugs are shown in all CAPITAL LETTERS. Generic drugs are shown in lower-case type. Drug trademarks and servicemarks are the property of their respective third-party owners POD

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50 bcbsok.com/state A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association