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1 P L A N Y E A R M E D I C A L I N T E L L I G E N C E H E A L T H A N D W E L L N E S S G U I D E WELLNESS PROGRAM THAT WORKS - MEDICAL INTELLIGENCE DATA ANALYTICS PUT INTO ACTION A MEMBERCENTRIC PROGRAM JUST FOR YOU! Wellness Program that Works! Medical Intelligence Care Management Features» Preventive/Routine Care Benefits» Notification Process» 2014 Calendar Year Biometric Screenings» Continued Stay Review» 2015 Calendar Year Biometric Screenings» Medical Intensive Care Management» Personal Health Profile» Discharge Planning and Outcome Improvement Protocol» Sample Personal Health Record Centers of Excellence Network Providers Healthy Initiatives Engagement Resources HEDIS Population Health Sample Integrated Medical Home Model of Care Sample Medical Intelligence Care Management Correspondence Researchers estimate that disease management and lifestyle management programs lowered health costs by $136 per member per month, mostly due to a 29% reduction in hospital admissions and/or readmissions. Dedicated to Services Measuring the Patient Healthcare Experience by Managing the Integrity of the Healthcare Dollar Optimized by Efficient Performance Based Outcome Resource Contact Information Accessible Hours TML MultiState Intergovernmental Employee Benefits Pool (IEBP) 1821 Rutherford Lane, Suite 300 Austin, Texas PO Box Austin, Texas Customer Care Helpline: (800) :30 AM - 5:00 PM Central Secured Customer Care Visit click on the Login button click on Online Customer Care under the My Tools menu 8:30 AM - 5:00 PM Central TML MultiState IEBP Internet Website: Twenty-four (24) hours Medical Notifications: (800) :30 AM - 5:00 PM Central Professional Health Coaches: Professional Health Coaches will answer basic health and medication questions and assist Covered Individuals with the Healthy Initiatives Incentive Program. Covered Individuals may enroll in professional health coaching. (888) :30 AM - 6:00 PM Central or Scheduled Appointment Spanish Line: (800) Where to Mail Paper Medical Claims: TML MultiState IEBP PO Box Austin, Texas After Hours and/or Weekend Medical and Mental Healthcare Call 911 or immediately go to the emergency department. Emergencies: Page 1 of 65 TML MultiState IEBP (Rev )

2 TABLE OF CONTENTS Wellness Program that Works!... 3 Healthy Initiatives Health Plan w/disclaimer - Take Charge of Your Health... 3 Preventive/Routine Care Benefits (Calendar Year Effective January 1, 2015) Calendar Year Value Added Patient Protection Affordable Care Act (PPACA) Wellness Benefit Services Calendar Year Value Added Patient Protection Affordable Care Act (PPACA) Wellness Benefit Services... 8 Personal Health Profile Population Health Engagement Healthy Living Resources Gaps in Care Sample Personal Health Record Healthy Initiatives Engagement Resources Medical Intelligence Care Management Features Multidisciplinary Medical Management How the Notification Process Works Notification Requirements Continued Stay Review Medical Intensive Care Management Discharge Planning and Outcome Improvement Protocol Centers of Excellence Network Providers Adult Transplants Pediatric Transplants Bariatric HEDIS Population Health Sample Healthy Initiatives Integration into Medical Home Model of Care Sample Medical Intelligence Care Management Correspondence Page 2 of 65 TML MultiState IEBP (Rev )

3 WELLNESS PROGRAM THAT WORKS! Healthy Initiatives Health Plan w/disclaimer - Take Charge of Your Health 1 The Healthy Initiatives HealthPlan encompasses wellness, medical management, chronic care management, and professional health coaching services to provide resources for the covered individual who is personally health engaged. Many of the leading causes of death and illness can be effectively managed through early detection, proper medical treatment, pharmacological management, and behavioral intervention and support. The program includes age and gender based biometric screenings, a Health Power Assessment, a personal health record and an incentive program for Healthy Initiatives calendar year compliance. The biometric screenings will be paid at 100% of the network fee or at the usual, reasonable and customary rate for nonnetwork providers. To be considered as an eligible preventive/routine care benefit, the provider s bill must designate or outline a routine diagnosis code. The interface of medical, prescription lab and health risk assessment information is critical to TML MultiState IEBP's (IEBP) s ability to provide the membership with appropriate professional healthcare support. The Healthy Initiatives HealthPlan works with the covered individual to identify solutions to healthcare concerns. IEBP s Healthy Initiatives HealthPlan should assist in patient care compliance and the promotion of healthy living guidelines for the employee and dependent population. IEBP will implement integrated data and reporting along with customized supportive services that help covered individuals achieve behavior changes and long-term healthy lifestyles. Preventive/Routine Care Benefits (Calendar Year Effective January 1, 2015) The following calendar year biometric screenings will be processed for network reimbursement at 100% of network allowable. Non-network provider eligible billings will be subject to usual and reasonable charges and are subject to the non-network deductible and benefit percentage. To be considered as an eligible preventive/routine care benefit, the provider s bill must designate or outline a routine diagnosis code. These measures represent important areas for quality improvement by assessing the use of services that are recommendations from the U.S. Preventive Services Task Force (USPSTF) and other national organizations. Access your Personal Health Record and Health Power Assessment by signing in at 1 Disclaimer: Affirmative Statement. Utilization Management (UM) decision making is based only on appropriateness of care and service and existence of coverage, IEBP does not specifically reward practitioners or other individuals for issuing denials of coverage, and financial incentives for UM decision makers are not encouraged to make decisions that result in underutilization. Page 3 of 65 TML MultiState IEBP (Rev )

4 Sample Healthy Initiatives Confirmation Letter If you are 18 years of age or older, upon completion of your calendar year biometrics and health power assessment you will receive a $ healthy initiatives incentive check, a healthy initiatives confirmation letter, and a personal health profile. Page 4 of 65 TML MultiState IEBP (Rev )

5 Colon-Rectal Exam Benefit The following will be processed for network reimbursement at 100% of network allowable. Non-network provider eligible billings will be subject to usual and reasonable charges and are subject to the non-network deductible and benefit percentage. To be considered as an eligible preventive/routine care benefit, the provider s bill must designate or outline a routine diagnosis code. This benefit will include routine and diagnostic colon-rectal examinations. Colon-Rectal examination - coverage for medically-recognized screening examination for the detection of colorectal cancer. This includes: colonoscopy (performed every ten (10) years); or» biopsy/polyp removal during preventive colonoscopy plans will be included in the 100% of network allowable cost flexible sigmoidoscopy (examination of the large intestine) performed every five (5) years. This Benefit excludes coverage for virtual colonoscopies. Preventive/routine care benefits also includes: General Health Panel Rubella Screening TSH Screening for Visual Acuity Well Baby Care/Well Child Care Bone Density Screening TB test Hearing Screening Basic Metabolic Test PAP Smear Mammograms Venipuncture Women's Reproductive Health Urinalysis Skin Cancer Counseling Annual Examination Prostate Specific Antigen (PSA) Autism Screening eighteen (18) and twenty-four (24) months of age Immunizations The following network eligible immunizations and administrative fees are reimbursable at 100% of the allowable. Non-network eligible billings will be subject to usual and reasonable charges and are subject to the non-network deductible and benefit percentage. Allergy injections and expenses related to routine newborn care are not considered as part of this benefit. To be considered under this benefit, the provider s bill must designate a routine diagnosis code. This list is a guideline. Immunizations/Inoculations DT (Diphtheria and Tetanus Toxoids) Hepatitis A & Hepatitis B Td (Tetanus) booster MMR (Measles, Mumps, Rubella) MMR booster Poliomyelitis Vaccine Oral Polio Varicella Vaccine (Chicken Pox) Influenza Pneumococcal (Pneumonia) Rotovirus Any other immunization HPV (Genital Human Papillomavirus) HIB (Hemophilus Influenza B) required by federal or state DtaP Diphtheria, Tetanus Toxoids and Pertussis Zosatavax (Shingles Vaccine) law or regulation Pediarix (Diphtheria and Tetanus Toxoids and Acellular Pertussis Absorbed, Hepatitis B (Recombinant) and Inactivated Poliovirus Vaccine Combined) You re Never Too Old to Get Immunized! Growing up does not mean we grow out of our need to be immunized or vaccinated for diseases that cause infection. Our immune systems become weaker as we grow older, making it easier to catch infections. As adults, it is also important we do not spread infections to young children, babies, or persons with weakened immune systems, such as those receiving chemotherapy for cancer. The following are the 2014 recommendations from the Centers for Disease Control and Prevention. Always check with your provider for updated recommendations and call IEBP Member Services at for benefit verification. Immunization Recommendation Date Flu shot Annual Td/Tdap (Tetanus/Diphtheria and Pertussis) Every 10 years Varicella or Chickenpox If you didn t get chickenpox or the vaccine as a child Human Papillomavirus/HPV2 or HPV4 Persons years of age unless vaccinated earlier Zoster/ Shingles Age 60 > if you had chickenpox as a child Measles/Mumps/Rubella (MMR) Adults born after 1957 who did not receive the vaccine Pneumococcal or Pneumonia Vaccine Age 65> If you have a chronic disease then doctor may recommend at earlier age Hepatitis A Vaccine Review your risk factors with your doctor Page 5 of 65 TML MultiState IEBP (Rev )

6 Immunization Recommendation Date Hepatitis B Vaccine Review your risk factors with your doctor 2014 Calendar Year Value Added Patient Protection Affordable Care Act (PPACA) Wellness Benefit Services Services Provider Billing Tips* Comments PREVENTIVE SERVICES FOR CHILDREN Alcohol screening and behavioral counseling interventions to reduce misuse by adolescents Educational Services provided by IEBP; Professional Health Coaches at no charge Autism screening for children at 18 and 24 months 96110, S0302 Developmental screening for children under age 3, and surveillance throughout childhood Behavioral assessments for children of all ages Medically necessary services are subject to the Medical plan cost share Blood Pressure screening for children of all ages Inclusive to the office visit or other primary service billed Cervical Dysplasia screening for sexually active females G0101, G0123-G0124, G0143- G0145, G0147-G0148, Q0091, , , 88150, , , , P3000- P3001 Congenital Hypothyroidism screening in newborns, (0-90 days) 84437, Dental check up Lab services must be obtained from a Preferred Lab Network provider Dental exams are ineligible under the medical plan. Dental screenings are paid as preventive benefits under the medical plan Depression screening in children and adolescents 99420, G0444 Medical History for all children throughout development , Height, Weight, and Body Mass Index measurements for all children Dyslipidemia screening for children at higher risk of lipid disorders 80061, 82465, 83718, 83719, 83721, Lab services must be obtained from a Preferred Lab Network provider Fluoride Chemoprevention supplementation to prevent dental caries for preschool children older than six months of age whose primary water source is Available under the Prescription Drug plan with a $0 copay deficient in fluoride Gonorrhea prophylactic ocular topical medication for all newborns Hearing screening for all newborn and children , , V5008 Hematocrit or Hemoglobin, (anemia) screening for children 85014, Lab services must be obtained from a Preferred Lab Network provider Hemoglobinopathies or sickle cell disease screening for newborns (0-90 days) , , 83051, S3850 Human Immunodeficiency Virus (HIV) screening for adolescents at an increased risk for HIV infection Lab services must be obtained from a Preferred Lab Network provider Iron supplementation for asymptomatic children Available under the Prescription Drug plan with a $0 copay Lead screening for children Lab services must be obtained from a Preferred Lab Network provider Metabolic screening for newborn and infants (ages 0-90 days) S3620, 84030, 82017, 82136, 82261, 82775, 83020, 83498, 83516, 84437, Obesity screening and counseling for children and adolescents G0447, , G G0271, S9470 Phenylketonuria, (PKU) screening for newborns, (0-90 days) 84030, S3620 Sexually Transmitted Infection (STI) high-intensity behavioral counseling for all G0445 sexually active adolescents with increased risk for STI Skin Cancer Counseling for children and young adults Tuberculosis screening (PPD Test) for children Vision screening to detect amblyopia, strabismus and defects in visual acuity in Eye exams and glasses are ineligible under children younger than age five (5) the medical plan PREVENTIVE SERVICES FOR ADULTS Abdominal Aortic Aneurysm one-time screening by ultrasonography in men ages who have ever smoked Alcohol Misuse screening and behavioral counseling interventions to reduce alcohol misuse by adults in a primary care setting Aspirin for the prevention of cardiovascular disease for men age 45 to 79 years 76700, 76705, 76770, 76775, G0389 Educational Services provided by IEBP; Professional Health Coaches at no charge Available under the Prescription Drug plan Page 6 of 65 TML MultiState IEBP (Rev )

7 Services Provider Billing Tips* Comments with a $0 copay Blood Pressure screening for all adults Inclusive to the office visit or other primary service billed Cholesterol screening for adults if at increased risk of coronary heart disease 80061, 82465, 83718, 83719, 83721, Lab services must be obtained from a Preferred Lab Network provider Colorectal Cancer screening using sigmoidoscopy or colonoscopy 82270, 82272, 82274, G0104, G0106, , Lab services must be obtained from a Preferred Lab Network provider 45333, 45338, 45339, G0105, G0120-G0122, G0328, , , 45378, , Depression screening for adults 99420, G0444 Type 2 Diabetes screening in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm HG , Lab services must be obtained from a Preferred Lab Network provider Dietary counseling for adult patients with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease. (Intensive counseling can be delivered by primary care clinicians or by referral to other specialists, such as nutritionists or dietitians.) Human Immunodeficiency Virus (HIV) screening for all adults at an increased risk for HIV infection Obesity screening and intensive counseling and behavioral interventions to promote sustained weight loss for obese adults Sexually Transmitted Infections (STI) prevention and counseling for all for adults with increased risk for STI , G0270-G0271, G0446-G0447, S Lab services must be obtained from a Preferred Lab Network provider G0447, , G G0271, S9470 G0445 Syphilis screening for adults at increased risk Lab services must be obtained from a Preferred Lab Network provider Tobacco Use screening for all adults Lab services must be obtained from a Preferred Lab Network provider Tobacco cessation interventions for those adults who use tobacco products Educational Services provided by IEBP; Professional Health Coaches at no charge, provided by IEBP Vitamin D supplementation to prevent falls in community-dwelling adults age 65 years and older who are at an increased risk for falls Available under the Prescription Drug plan with a $0 copay PREVENTIVE SERVICES FOR WOMEN WOMEN S HEALTH Anemia screening on a routine basis for asymptomatic pregnant women 85013, 85014, Lab services must be obtained from a Preferred Lab Network provider Bacteriuria urinary tract or other infection screening for pregnant women at weeks gestation or at the first prenatal visit, if later Lab services must be obtained from a Preferred Lab Network provider BRCA genetic counseling for certain women with increased risk of breast cancer Breast Cancer annual to biennial mammogram screening Screening: G0202, 77052, 77057, R0403 Other mammography: 77051, 77055, 77056, G0204, G0206 Breast Cancer Chemoprevention counseling for women at high risk 96040, S0265, , , , Breast feeding support and counseling and access to breast feeding supplies for pregnant and nursing women Support and Counseling: S9443, Breast Pumps & Supplies E0602 E0604, A4261 A4286 Cervical Cancer screening (pap smears) at least every three (3) years G0101, G0123-G0124, G0143- G0145, G0147-G0148, Q0091, , , 88150, , , , P3000- P3001 Chlamydia Infection screening for all sexually active non-pregnant women age 24 and younger and for all pregnant women age 24 and younger and for older pregnant women who are at an increased risk Contraception: Food and Drug Administration approved contraceptive methods, sterilization, and patient education and counseling Medically necessary Home Services for counseling and DME equipment in excess of $1,000 must be notified Lab services must be obtained from a Preferred Lab Network provider Lab services must be obtained from a Preferred Lab Network provider Counseling: Fitting/Removal of Contraceptive Device: 11976, 11981, 11982, 11983, Eligible contraceptive devices, supplies and generic birth control pills available under the Prescription Drug plan with a $0 copay Page 7 of 65 TML MultiState IEBP (Rev )

8 Services Provider Billing Tips* Comments 57170, 58300, Abortifacient drugs are not covered. Sonogram to detect placement Contraceptive Device J7300, J7302, J7306, J7307 Women s surgical sterilization procedures and coil device are subject to the Medical plan cost share. Contraceptive Injection and Admin Fee J1050, Domestic and interpersonal violence screening and counseling for all women Folic Acid supplements for women who may be become pregnant Available under the Prescription Drug plan with a $0 copay and prescription order Gestational diabetes screening for women weeks pregnant and those at , Lab services must be obtained from a high risk for developing gestational diabetes Preferred Lab Network provider Gonorrhea screening all sexually active women, including those who are Lab services must be obtained from a pregnant Preferred Lab Network provider Hepatitis B Virus screening for pregnant women at their first prenatal visit 87340, Lab services must be obtained from a Preferred Lab Network provider Human Immunodeficiency Virus (HIV) screening for all pregnant women Lab services must be obtained from a Preferred Lab Network provider Human Papillomavirus (HPV) DNA Test every three years for women with Lab services must be obtained from a normal cytology results who are 30 or older Preferred Lab Network provider Osteoporosis screening for women age 51 and over 76977, , 77083, G0130 Rh(D) blood typing and antibody testing for all pregnant women during their Lab services must be obtained from a first visit for pregnancy-related care and repeated Rh(D) antibody testing for Preferred Lab Network provider all unsensitized Rh (D)-negative women at 24 to 28 weeks gestation, unless the biological father is known to be Rh (D)-negative repeat services Rubella Screening for all women of child bearing age Lab services must be obtained from a Preferred Lab Network provider Tobacco Use screening for all women Lab services must be obtained from a Preferred Lab Network provider Tobacco cessation interventions for women who use tobacco products Educational Services provided by IEBP; Professional Health Coaches at no charge, provided by IEBP Sexually Transmitted Infections (STIs) counseling for all sexually active G0445 women Syphilis screening for all pregnant women Lab services must be obtained from a Preferred Lab Network provider Well women visits to obtain recommended preventive services , , , * Services are subject to appropriate bundling rules and network fee schedules or usual and reasonable for out of network providers ** Healthy Initiatives Medical Plan Benefits have to be billed as routine for 100% of network preferred lab fee schedule or usual and reasonable for out of network provider The TML MultiState Intergovernmental Employee Benefits Plan is a non-federal governmental health plan that has elected to be exempted from the HIPAA Title I prohibitions against discriminating against individual participants and beneficiaries based on health status. Therefore, the rules regarding Nondiscrimination and Wellness Programs in Health Coverage in the Group Market do not apply to this plan Calendar Year Value Added Patient Protection Affordable Care Act (PPACA) Wellness Benefit Services Services PREVENTIVE SERVICES FOR CHILDREN Alcohol screening and behavioral counseling interventions to reduce misuse by adolescents Autism screening for children at 18 and 24 months Developmental screening for children under age 3, and surveillance throughout childhood Behavioral assessments for children of all ages Blood Pressure screening for children of all ages 96110, S0302 Cervical Dysplasia screening for sexually active females G0101, G0123-G0124, G0143- G0145, G0147-G0148, Q0091, Comments Educational Services provided by IEBP; Professional Health Coaches at no charge Medically necessary services are subject to the Medical plan cost share Inclusive to the office visit or other primary service billed Lab services must be obtained from a Preferred Lab Network provider Page 8 of 65 TML MultiState IEBP (Rev )

9 Services , , 88150, , , , P3000- P3001 Congenital Hypothyroidism screening in newborns, (0-90 days) 84437, Dental check up Comments Dental exams are ineligible under the medical plan. Dental screenings are paid as preventive benefits under the medical plan Depression screening in children and adolescents 99420, G0444 Medical History for all children throughout development , Height, Weight, and Body Mass Index measurements for all children Dyslipidemia screening for children at higher risk of lipid disorders 80061, 82465, 83718, 83719, 83721, Lab services must be obtained from a Preferred Lab Network provider Fluoride Chemoprevention supplementation to prevent dental caries for preschool children older than six months of age whose primary water Available under the Prescription Drug plan with a $0 copay source is deficient in fluoride Gonorrhea prophylactic ocular topical medication for all newborns Hearing screening for all newborn and children , , V5008 Hematocrit or Hemoglobin, (anemia) screening for children 85014, Lab services must be obtained from a Preferred Lab Network provider Hemoglobinopathies or sickle cell disease screening for newborns (0-90 days) , , 83051, S3850 Human Immunodeficiency Virus (HIV) screening for adolescents at an increased risk for HIV infection Lab services must be obtained from a Preferred Lab Network provider Iron supplementation for asymptomatic children Available under the Prescription Drug plan with a $0 copay Lead screening for children Lab services must be obtained from a Preferred Lab Network provider Metabolic screening for newborn and infants (ages 0-90 days) S3620, 84030, 82017, 82136, 82261, 82775, 83020, 83498, 83516, 84437, Obesity screening and counseling for children and adolescents G0447, , G G0271, S9470 Phenylketonuria, (PKU) screening for newborns, (0-90 days) 84030, S3620 Sexually Transmitted Infection (STI) high-intensity behavioral counseling G0445 for all sexually active adolescents with increased risk for STI Skin Cancer Counseling for children and young adults Tuberculosis screening (PPD Test) for children Vision screening to detect amblyopia, strabismus and defects in visual acuity in children younger than age five (5) Eye exams and glasses are ineligible under the medical plan PREVENTIVE SERVICES FOR ADULTS Abdominal Aortic Aneurysm one-time screening by ultrasonography in 76770, 76775, G0389 men ages who have ever smoked Alcohol Misuse screening and behavioral counseling interventions to reduce alcohol misuse by adults in a primary care setting Educational Services provided by IEBP; Professional Health Coaches at no charge Aspirin for the prevention of cardiovascular disease for men age 45 to 79 years Available under the Prescription Drug plan with a $0 copay Blood Pressure screening for all adults Inclusive to the office visit or other primary service billed Cholesterol screening for adults if at increased risk of coronary heart disease 80061, 82465, 83718, 83719, 83721, Lab services must be obtained from a Preferred Lab Network provider Colorectal Cancer screening using sigmoidoscopy or colonoscopy 82270, 82272, 82274, G0104, G0106, , 45333, 45338, 45339, G0105, G0120-G0122, G0328, , , 45378, , Depression screening for adults 99420, G0444 Type 2 Diabetes screening in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm HG Dietary counseling for adult patients with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease. (Intensive counseling can be delivered by primary care clinicians or by referral to other specialists, such as nutritionists or dietitians.) Lab services must be obtained from a Preferred Lab Network provider , Lab services must be obtained from a Preferred Lab Network provider , G0270-G0271, G0446-G0447, S9470 Page 9 of 65 TML MultiState IEBP (Rev )

10 Services Comments Human Immunodeficiency Virus (HIV) screening for all adults at an increased risk for HIV infection Lab services must be obtained from a Preferred Lab Network provider Obesity screening and intensive counseling and behavioral interventions G0447, , G to promote sustained weight loss for obese adults G0271, S9470 Sexually Transmitted Infections (STI) prevention and counseling for all G0445 for adults with increased risk for STI Syphilis screening for adults at increased risk Lab services must be obtained from a Preferred Lab Network provider Tobacco Use screening for all adults Lab services must be obtained from a Preferred Lab Network provider Tobacco cessation interventions for those adults who use tobacco products Educational Services provided by IEBP; Professional Health Coaches at no charge, provided by IEBP Vitamin D supplementation to prevent falls in community-dwelling adults age 65 years and older who are at an increased risk for falls Available under the Prescription Drug plan with a $0 copay PREVENTIVE SERVICES FOR WOMEN WOMEN S HEALTH Anemia screening on a routine basis for asymptomatic pregnant women 85013, 85014, Lab services must be obtained from a Preferred Lab Network provider Bacteriuria urinary tract or other infection screening for pregnant women at weeks gestation or at the first prenatal visit, if later Lab services must be obtained from a Preferred Lab Network provider BRCA genetic counseling for certain women with increased risk of breast cancer Breast Cancer annual to biennial mammogram screening Screening: G0202, 77052, 77057, R0403 Other mammography: 77051, 77055, 77056, G0204, G0206 Breast Cancer Chemoprevention counseling for women at high risk 96040, S0265, , , , Medications for risk reduction of breast cancer in women who are at increased risk for breast cancer and at low risk for adverse medication effects: Tamoxifen or Raloxifene Available under the Prescription Drug plan with a $0 copay Breast feeding support and counseling and access to breast feeding supplies for pregnant and nursing women. Breast Feeding Support and Counseling: S9443, Breast Pumps & Supplies E0602 E0604, A4261 A4286 Cervical Cancer screening (pap smears) at least every three (3) years G0101, G0123-G0124, G0143- G0145, G0147-G0148, Q0091, , , (One pump per pregnancy) Medically necessary Home Services for confined bed rest for counseling and DME equipment in excess of $1,000 must be notified. Breast pump manual and breast pump electric are eligible no cost share pumps. Hospital Grade breast pumps will require medical necessity per notification approval if charges are in excess of the $1, Lactation classes are paid at no cost share, if receive lactation classes in the home the services must be medically necessary per notification approval. Breast feeding support, supplies and counseling services will require network providers (sample: network DME providers include: Lucina Care, (888) ) to access the no cost share benefit. For a list of current network breast pump suppliers, go to and login: 1. Click the "Provider Search" link found in the Benefit Information menu on the top. 2. Click on the "Search the Choice Plus Network" button under United Choice Plus Network 3. Click the "Nationally Contracted Facilities and Equipment Vendors" link under Facilities Breast pump replacement non-disposable accessories are reimbursed at no cost share: A4281 tubing for breast pumps, A4282 adaptor for breast pumps, A4283 cap for breast pump bottle, A4284 breast shield and splash protector, A4285 polycarbonate bottle for use with breast pump, A4286 locking ring Lab services must be obtained from a Preferred Lab Network provider Page 10 of 65 TML MultiState IEBP (Rev )

11 Services Chlamydia Infection screening for all sexually active non-pregnant women age 24 and younger and for all pregnant women age 24 and younger and for older pregnant women who are at an increased risk Contraception: Food and Drug Administration approved contraceptive methods, sterilization, and patient education and counseling Comments 88150, , , , P3000- P Lab services must be obtained from a Preferred Lab Network provider Counseling: Fitting/Removal of Contraceptive Device: 11976, 11981, 11982, 11983, 57170, 58300, Eligible contraceptive devices, supplies and generic birth control pills available under the Prescription Drug plan with a $0 copay Abortifacient drugs are not covered. Ultrasound to detect placement 76830, 76856, Contraceptive Device J7300, J7301, J7302, J7306, J7307 S4981, S4989 Women s surgical sterilization procedures and coil device are subject to the Medical plan cost share. Contraceptive Injection and Admin Fee J1050, J0155, J0156, Domestic and interpersonal violence screening and counseling for all women Folic Acid supplements for women who may be become pregnant Available under the Prescription Drug plan with a $0 copay and prescription order Gestational diabetes screening for women weeks pregnant and , Lab services must be obtained from a Preferred Lab those at high risk for developing gestational diabetes Network provider Gonorrhea screening all sexually active women, including those who are Lab services must be obtained from a Preferred Lab pregnant Network provider Hepatitis B Virus screening for pregnant women at their first prenatal 87340, Lab services must be obtained from a Preferred Lab visit Network provider Human Immunodeficiency Virus (HIV) screening for all pregnant women Lab services must be obtained from a Preferred Lab Network provider Human Papillomavirus (HPV) DNA Test every three years for women Lab services must be obtained from a Preferred Lab with normal cytology results who are 30 or older Network provider Osteoporosis screening for women age 51 and over 76977, , G0130 Rh(D) blood typing and antibody testing for all pregnant women during Lab services must be obtained from a Preferred Lab their first visit for pregnancy-related care and repeated Rh(D) antibody Network provider testing for all unsensitized Rh (D)-negative women at 24 to 28 weeks gestation, unless the biological father is known to be Rh (D)-negative repeat services Rubella Screening for all women of child bearing age Lab services must be obtained from a Preferred Lab Network provider Tobacco Use screening for all women Lab services must be obtained from a Preferred Lab Network provider Tobacco cessation interventions for women who use tobacco products Educational Services provided by IEBP; Professional Health Coaches at no charge, provided by IEBP Sexually Transmitted Infections (STIs) counseling for all sexually active G0445 women Syphilis screening for all pregnant women Lab services must be obtained from a Preferred Lab Network provider Well women visits to obtain recommended preventive services , , , * Services are subject to appropriate bundling rules and network fee schedules or usual and reasonable for out of network providers ** Healthy Initiatives Medical Plan Benefits have to be billed as routine for 100% of network preferred lab fee schedule or usual and reasonable for out of network provider Personal Health Profile Biometrics & Personal Health Profile Overview General Biometric Screening results Tracking your Biometric Screening results are a helpful tool in managing your health and could be considered your score card. Upon completion of your biometrics and Health Power Assessment your personal health profile is developed. Compare your health score card from year to year. Page 11 of 65 TML MultiState IEBP (Rev )

12 My Health Score at a Glance Biometric Screening Normal Range Date: Result: Date: Result: Heart Rate / Pulse: beats/minute Blood Pressure: Normal: <120/80 Pre-hypertension: /80-89 Hypertension-Stage1: /90-99 Hypertension-Stage2: >159/99 Body Mass Index (BMI): Normal: Overweight: Obese: Morbid Obesity: 40 > Total Cholesterol: Desirable: <200 Borderline High: High: >240 Total Cholesterol Ratio (TC/HDL): <= 4.5 LDL Cholesterol (Bad): Optimal: <100 Near Optimal: Borderline High: High: Very High: >189 HDL Cholesterol (Good): Low: 40 Desirable: High: >59 Triglycerides: Normal: <150 Borderline High: High: Very High: >500 Comprehensive Metabolic Blood Panel: See reference values on Lab Results Glucose, serum (blood) Normal: Pre-diabetes: Diabetes: 126 => Thyroid Stimulating Hormone (TSH): Hemoglobin A1C (HgbA1c): Normal Range: <5.6% Pre-diabetes: % Diabetes: >6.5% Mammogram: Negative Well Woman Check Up/PAP: Negative Prostate Specific Antigen (PSA): < Age 50 - less than 2.5 Age less than 3.5 Age less than 4.5 Age 70 > - less than 6.5 Fecal Occult Blood Test: Negative Note: Normal ranges for laboratory tests may vary slightly among different laboratories. Talk to your attending physician about your results. Heart Health Biometrics Heart disease remains the number one cause of death in the United States for both men and women. Living a healthy life may reduce your risk of heart disease (which includes coronary artery disease, hyperlipidemia, and high blood pressure). Commonly ordered provider services monitor the health of your heart include: Heart Rate/Pulse: Is the number of heart beats per minute. A lower heart rate suggests better cardiovascular fitness and more efficient heart function. Blood Pressure: Blood pressure is the force of blood pushing against the walls of the arteries as the heart pumps blood. If this pressure rises and stays high over time, it can damage the body in many ways. High blood pressure is a serious condition that can lead to coronary heart disease, heart failure, stroke, kidney failure and other health problems. Total Cholesterol: Cholesterol is a waxy substance that is produced in the liver or may be consumed in food. The body produces the necessary amount of cholesterol to make hormones, vitamin D, and digestive substances. When excess amounts of cholesterol are present in the blood stream, it begins to be deposited on the artery walls resulting in the narrowing of the arteries and decreasing blood supply to the heart. Often, an individual with high cholesterol does not have any signs or symptoms; it may result in raising your blood pressure. Page 12 of 65 TML MultiState IEBP (Rev )

13 LDL Cholesterol: LDL cholesterol is referred to as bad or lousy cholesterol as excess amounts leads to plaque growth and atherosclerosis. Higher levels of LDL cholesterol increase your chance of a heart attack. Eating a diet lower in saturated fat and cholesterol and high in fiber and plant based (vegetables/fruits/beans/legumes) can lower help lower LDL level. Aerobic physical activity also lowers LDL and increases HDL. HDL Cholesterol: HDL cholesterol is referred to as healthy or good cholesterol. HDL cholesterol acts to remove bad cholesterol from the blood stream. A high HDL level reduces your risk of heart disease; low levels of HDL increases your risk of heart disease. HDL levels can be raised by aerobic physical activity, becoming tobacco free and maintaining a healthy weight. Triglycerides: Triglycerides is another type of fat in your blood. High levels can raise your risk of heart disease and maybe a sign of metabolic syndrome. Triglycerides are usually caused by: obesity, poorly controlled diabetes, hypothyroidism, kidney disease, and alcohol. Certain medications may also raise triglycerides. Comprehensive Metabolic Profile Biometrics This blood test measures: glucose, electrolytes (sodium, potassium, chloride, calcium, carbon dioxide), kidney function (BUN, creatinine, egfr) and liver function (albumin, total protein, AST (SGOT), ALT (SGPT). Kidney Health: The kidneys filter water and waste products from the blood to form urine. Commonly ordered labs that monitor kidney function are part of the comprehensive metabolic profile, specifically sodium, potassium, blood urea nitrogen (BUN), serum creatinine, and calcium. It is important to talk to your attending physician about your results. Endocrine Health: The endocrine system is made up of eight major glands in the body. The glands produce hormones which help regulate body functions such as digestion, breathing, body temperature, reproduction, elimination, blood circulation, sexual function, mood and growth and development. Diabetes is one of the most common diseases of the endocrine system. Commonly ordered labs that monitor endocrine health are glucose, hemoglobin A1C, thyroidstimulating hormone (TSH) and prostate specific antigen (PSA). It is important to talk to your attending physician about your results. Glucose, serum (blood): This measures the amount of sugar or glucose in your blood. It is a test that can diagnose diabetes or determine how well diabetes is controlled. Liver Health: The liver is an organ that has many functions including: metabolizing the food, beverages, medications, over the counter medications and supplements that we ingest, makes proteins, excretes bile and stores glycogen/ Vitamins D, A, B12 and trace elements. Commonly ordered labs that monitor liver function are part of the comprehensive metabolic profile, specifically albumin, total protein, ALT (SGPT), and AST (SGOT). It is important to talk to your attending physician about your results. Population Health Engagement Population Health Engagement supports members 18> in all stages of health. This program provides information to the Covered Individual regarding healthy lifestyle choices and management of chronic disease states. The program offers personalized professional coaching to support the healthy lifestyle of change and plan of action. Online tools and educational material(s) are available to the Covered Individual. The population health engagement team consists of an interdisciplinary team of licensed professional nurses, licensed professional counselors and registered dietitians. The Personal Health Engagement Program includes: Opt In Enrollment method by which members call the professional health coaching line and request a professional healthcare coach or agree to coaching upon receiving an outreach call or letter. Healthcare providers may refer their patient to a professional health coach or they can call in a referral to (888) Case Findings Case Findings are currently done monthly for each program. A Case Finding identifies members for each disease management program based on medical, prescription and/or lab value claim data information. The information is stratified into risk index. Once the information is stratified, the Multidisciplinary Medical Care Management Service Team can effectively identify the covered individuals that could benefit from a personal health coach. The program provides resources that support the covered individual s healthy lifestyle choices in areas of nutritional, emotional, social, intellectual, financial and spiritual well-being. Page 13 of 65 TML MultiState IEBP (Rev )

14 Case Finding Summary Report The information obtained on a Case Finding data run is analyzed. A case finding report is generated with a breakdown of risk index. The information may be sorted by age and gender stratification, co-morbidities, adherence to practice standards and medication usage. IEBP will implement the integrated data and reporting along with customized supportive programs that help plan members achieve behavior change and long term improve health. The Multidisciplinary Medical Care Management Team works with the covered individuals and educates them on healthy lifestyle behavior, cost effective medication options, physician visit preparation, patient s rights, understanding provider network options and consumer healthcare education. Telephonic Outreach Program Based on the clinical stratification, the covered individuals will be identified as potential high risk for diabetic or cardiovascular personal healthcare coaching. The telephonic criteria identifies from 20% to 30% of the members for telephonic intervention. Educational Mailings IEBP s cover letter includes the name and number of their Multidisciplinary Medical Care Management Health Coach and the invitation for members to call if they would like additional information. Modules of Care Modules provide an organized collection of information needed by members to help them achieve a desired health goal. Modules ensure that material is presented completely and in a coherent fashion to help members understand their disease(s) process(es). Modules provide evidence based guidance for coaching sessions thus aiding coaches in focusing on the member s educational needs and stated goal. Modules/practice guidelines arose from frequently stated health goals such as quitting smoking, losing weight, or managing diabetes as well as the medical conditions reflected in the IEBP demographics. At present time, modules include: Asthma, COPD, Diabetes, High Cholesterol, High Blood Pressure, Risk of Alcohol Use, Tobacco Cessation, and Weight Loss. Wheel of Life (WOL) Wheel of Life is a tool that is used for the member to rate 12 areas of life that may be affecting healthy lifestyle choices. The areas rated include: physical health, mental health, spirit health, relationship with significant other, relationship with children, relationship with extended family, home/physical environment, job/career satisfaction, financial health, recreation/leisure time fun, and continued learning/personal growth. Healthy Living Resources Healthy Living Guides Located on our website at Click the "Health Resources" link found in the Health & Wellness menu at the top. List of Health Guides Alcoholism Grieving and Your Health Neuropathy Asthma Healthy Eating Osteoarthritis Page 14 of 65 TML MultiState IEBP (Rev )

15 List of Health Guides Back Pain Healthy Eyes Osteoporosis Bariatric Surgery Healthy Pregnancy Physical Activity Celiac Disease Hyperlipidemia Rheumatoid Arthritis Chronic Fatigue Syndrome (CFS) Hypertension Skin Cancer Prevention Chronic Obstructive Pulmonary Disease (COPD) Irritable Bowel Syndrome Sleep Chronic Pain Ischemic Heart Disease Sleep Apnea Coronary Artery Disease (CAD) Men s Health Smoking Cessation Depression Mental Health Stress Management Financial Health Migraine Headaches Suicide Prevention Gout Multiple Sclerosis Type 2 Diabetes Weight Management Healthy Living Fact Sheets Located on our website at Click on the "Health and Wellness Tip of the Month" link on the first page. Month Health Topic October Breast Cancer Tobacco Cessation November Diabetes Smoking Cessation December Managing the Season in Emotional and Physical Health Asthma January Eye Health (glaucoma/cataract/retinopathy) Chronic Obstructive Pulmonary Disease (COPD) February Heart Disease Women s Health March Colorectal Cancer Depression April Skin Cancer Prevention May Hypertension June Men s Health July Dental Health August Childhood Immunizations (flu/pneumonia/tetanus/shingles) September Eat Right and Exercise Professional Health Information Line Professional Health Coaches will answer basic health and medication questions and assist covered individuals with the Healthy Initiative Incentive Program. Covered individuals may enroll in professional health coaching by calling IEBP Chronic Care Professional Health Coaching Performance Based Outcomes Healthcare Transparency solidified by Optimized Performance Based Outcome Ease of access, performance based outcome and healthcare costs are the complex challenge of the healthcare benefit delivery and payor system. IEBP is strategically reviewing the ongoing and predictive data analytics to ensure employee engagement in health resources are updated and customized to meet the needs or the IEBP membership. Healthy Initiatives Letter Campaign Percent of Covered Individual Engagement in Health from July April 2014 Compliance April 2014 Trend Desired Direction Pool Mini Colorectal Screening 39.2% 46.0% Cervical Screening 65.2% 72.4% Breast Screening 68.2% 71.1% Hyperlipidemia- Lipid profile within 12 mos. 82.5% 89.0% Diabetes- A1C within 12 mos. 74.2% 84.1% Diabetes- Lipid profile within 12 mos. 70.8% 83.1% Diabetes- annual screening for nephropathy 81.0% 81.9% Diabetes- screening for retinopathy 25.1% 26.7% IVD-Without lipid profile within 12 mos. 29.5% 17.6% CAD-Without lipid lowering drugs 25.2% 41.5% COPD-Without Spirometry Testing 57.9% 77.3% Asthma-Without inhaled corticosteroids Asthma-Adults-With inhaled corticosteroids 91.1% 93.3% Asthma-Peds-With inhaled corticosteroids 91.1% 95.7% Positive Fecal Occult Results 0.038% (3 out of 77) Compliance in July 2012 Compliance in July 2013 Pool Mini Pool Mini Colorectal Screening 39.3% 44.7% 38.6% 42.6% Cervical Screening 55.1% 58.7% 64.7% 71.6% Page 15 of 65 TML MultiState IEBP (Rev )

16 Compliance in July 2012 Compliance in July 2013 Pool Mini Pool Mini Breast Screening 51.9% 57.9% 64.1% 67.7% Hyperlipidemia- Lipid profile within 12 mos. 70.1% 72.8% 86.6% 90.5% Diabetes- A1C within 12 mos. 70.3% 74.1% 73.2% 83.6% Diabetes- Lipid profile within 12 mos % 78.9% 72.4% 82.4% Diabetes- annual screening for nephropathy 51.9% 57.3% 80.9% 79.4% Diabetes- screening for retinopathy 20.1% 23.2% 23.4% 25.1% IVD-Without lipid profile within 12 mos. 29.8% 27.1% 26.7% 20.2% CAD-Without lipid lowering drugs 25.8% 28.5% 26.0% 36.3% COPD-Without Spirometry Testing 63.2% 79.2% 62.2% 76.1% Asthma-Without inhaled corticosteroids 33.9% 36.5% 13.4% 16% Asthma-Adults-With inhaled corticosteroids 66.1% 63.5% 86.6% 84.0% Asthma-Peds-With inhaled corticosteroids New Indicator Positive Fecal Occult Results 0.05% (16 out of 279) 0.05% (20 out of 374) Other Health Related Screening Tests Thyroid Stimulating Hormone (TSH): This is a screening test to see if the thyroid gland is working properly. Hemoglobin A1C- is a test that can diagnosis diabetes (type 1 or type 2); it also used to determine how well diabetes is controlled. Diabetics are often tested every 6 months or sooner. Prostate Specific Antigen (PSA): This is a blood test used for screening men for prostate cancer. Body Mass Index: The body mass index is a calculation based on your height and your weight. It does not take into account your gender, muscle mass, or body frame size. Health risks increase as your BMI rises above 25. Colorectal Screening: Colorectal cancer doesn t have any symptoms until the late stages. Early screening tests may lead to earlier diagnosis and treatment. Commonly ordered screening tests include a fecal occult blood test, colonoscopy, or flexible sigmoidoscopy. It is important to talk to your attending physician about which screening test is appropriate for you. Eye Exam Screening: Persons age 50 or older should have an annual comprehensive dilated eye exam. These tests can help detect age related diseases in early stages and make sure that you are seeing your best. It is important for diabetics of any age to get a checked for retinopathy. Oral Cancer (mouth & gums) Screening: This screening test is generally performed by a dentist; a doctor may also do this. The dentist looks in your mouth, gums, tongue and lips for signs of lesions. Regular visits to your dentist are recommended. Skin Cancer Screening: Examine your skin regularly for any growths, discolorations, or changes in moles or beauty marks. You should consider seeing a dermatologist for skin cancer screening if your or a family member have a history of skin cancer, especially melanoma. Women s Health Screening: Women have additional screening tests. o Mammogram - screening x-ray of the breast used to check for breast cancer o Well women check up/pap - screening test for cervical cancer o Bone Density - test to assess bone density and diagnose osteoporosis. Women that are post menopausal may experience thinning of the bones. There are not any symptoms of thinning of the bones until you fracture a bone. Healthy Lifestyle Habits Healthy Lifestyle Habits can improve your quality of life and add years to your life. Personal health behavior engagement activities include: Be physically active for 30 minutes per day Maintain a healthy weight If overweight, reduce weight gradually by: Increasing intake of fruits, vegetables, whole grains, lean proteins, fish, nuts, and seeds Decreasing intake of high fat and processed meats and dairy products Decreasing intake of trans fat, hydrogenated oils, and sodium Decreasing sweets and beverages that are high in sugar Choosing water instead of sweetened beverages Be tobacco free Limit alcohol intake; recommendations for men is two drinks per day and one drink per day for women Page 16 of 65 TML MultiState IEBP (Rev )