California Enrollment Guide

Transcription

1 Quality health plans & benefits Healthier living Financial well-being Intelligent solutions California Enrollment Guide Your Aetna plan features, and how to enroll Plans effective January 1, CA (1/16)

2 Learn about: Member tools, how to enroll and value-added programs Health/Dental benefits, health/dental insurance and life insurance plans/policies are offered and/or underwritten by Aetna Health of California Inc., Aetna Dental of California Inc. and/or Aetna Life Insurance Company (Aetna). Each insurer has sole financial responsibility for its own products. 2

3 Welcome to your healthy! Whatever your healthy is, we can help you get there. Everyone s healthy is different. For your family, how you define your healthy may include what s healthy for your budget too. We understand that, and that s why we provide multiple benefits and insurance plans that can help you reach your healthy while keeping your financial health on track too. With Aetna, you can choose the path that gets you closer to your healthy. Whether your goal is lower monthly premiums, lower out-of-pocket costs at doctor s visits or easy access to out-of-network care, we have plans that will work hard for you. We know that part of everyone s healthy is knowing that you re making smart choices when it comes to your health care. So we give you the power to do that at every step along the way. Find a doctor online, check the status of a claim and compare out-of-pocket costs before you go. Our tools and resources help make sure your family s well-being is always well-coordinated. And you ll have the right tools to manage your health care for a healthier you. Let s work together to find your healthy. Table of Contents Aetna Navigator secure member website 4 Informed Health Line 5 Walk-in clinics 5 Urgent care 5 No-cost preventive care 6 Disease Management Program 8 Get to know your Aetna prescription drug plan 10 Find doctors and specialists 12 3

4 Aetna Navigator Your secure member website When you need up-to-date information about your health benefits or insurance plan or want information about a particular health condition, here s where you ll find it. Your secure Aetna Navigator website is a single source for online health and benefits information. It s convenient, and easy to use: 1. Go to 2. Click on Log In/Register. 3. Register as a new user, or log in using your secure user name and password. 4. Find a wealth of credible health care information and self-service functions available to you anytime of the day or night from wherever you have Internet access. Your secure website lets you: View information about who is covered on your plan Get an ID card Find doctors, pharmacies or hospitals with our DocFind search tool Check the status of a claim or review an Explanation of Benefits (EOB) Contact Member Services with benefits questions (also available in Spanish) And, if you re interested in learning more about a particular health condition, Aetna Navigator provides credible health information resources. Aetna SmartSource SM search tool delivers relevant health information that s specific to you, based on where you live, your Aetna health plan, and other information. Aetna SmartSource scans our vast resources to bring you, in a single search: --Specialists in your local area --Related medications, treatment options and estimated health costs --Aetna programs that may help you manage your condition --Easy-to-understand health articles and tips Aetna InteliHealth interactive consumer website for credible health, dental and wellness information provided by Harvard Medical School Healthwise Knowledgebase, a user-friendly online information tool that lets you research your own issues and preferences for health information. It also has interactive and streaming videos about topics such as asthma and heart health Use Aetna Navigator s online tools to manage your benefits and help you make more informed health decisions: Hospital Comparison tool helps you decide where to receive care for specific procedures, conditions and diagnoses. You can compare hospitals based on four factors you consider important: 1. Number of patients treated per year 2. Complication rates 3. Mortality rates 4. Length of stay Price-A-DrugSM tool* helps you estimate the cost of prescriptions before you buy Estimate the Cost of Care tool provides average in- and out-of-network costs for certain procedures based on a geographic area Pharmacy benefits summary allows you to locate retail pharmacies; order prescriptions through the Aetna Rx Home Delivery mail-order pharmacy; search and learn about medications; and review the medications available in the Aetna formulary *If included in your plan. 4

5 Informed Health Line Access to a registered nurse 24/7 With our Informed Health Line, you can talk to a registered nurse anytime, day or night. Just call our 24-hour toll-free number (available upon enrollment). While only your doctor can diagnose, prescribe or give medical advice, the Informed Health Line nurses can provide information on thousands of health topics. They can also tell you how to ask the right questions and describe health symptoms more effectively during your next visit to your doctor. Remember, always contact your doctor first with any questions or concerns regarding your health care needs. Walk-in clinics* Looking for a convenient way to get medical care? Consider a walk-in clinic. It s a convenient alternative to the doctor s office. Use them when you have a common ailment and need to see a doctor, but it s after business hours. And walk-in clinics are not just for when you are sick. You might be surprised by the full spectrum of services available at a walk-in clinic, many of which are staffed by physician assistants and nurse practitioners. You ll appreciate: No appointments needed. The name says it all just walk right in. Convenient hours. Some clinics are open seven days a week, with extended evening and weekend hours, just like the ER. Lower prices. You ll pay an average of $44 to $59 per clinic visit** compared to the $550 to $750 average ER price.*** Quicker care. The average ER visit tops four hours, while clinic visits are generally an hour or less. Skilled staff. Clinics are overseen by a doctor, with nurse practitioners or physician assistants onsite. Urgent care If you need care that s more than minor, we also contract with urgent care centers to give you an affordable alternative to the ER, at an average cost break of up to seven times less than your typical ER cost. The sites are staffed with doctors to handle urgent medical matters. And just like retail clinics, evening and weekend hours are available, with no appointments needed. If your medical need is more than urgent for example, characterized by chest pain, trouble breathing, bad bleeding or other symptoms that are serious or put your life at risk you should go straight to your local ER. No appointments needed. Just walk right in. Convenient hours. Some clinics are open seven days a week, with extended evening, weekend and holiday hours, just like the ER. Lower prices. Lower copays and out-of-pocket costs, with prices averaging $110 to$150,** compared to ER costs of $550 to $750.** Less waiting. The average ER visit tops four hours, while urgent care visits are generally an hour or less. Fully staffed by doctors. Clinics are overseen by doctors, with doctors providing the service. Connections with local ERs. If you need more extensive care, you ll be referred to the closest ER. Check your Summary of Benefits and Coverage to get more information about coverage and costs to visit a walk-in clinic or urgent care center. To find the closest walk-in clinic or urgent care center near you, simply log in to Aetna Navigator, select Find A Doctor, Pharmacy or Facility and follow the easy online instructions. *Walk-in clinics do not apply to Aetna Whole Health/PrimeCare Physicians Network members. **Average retail and ER pricing. Based on Aetna average claim costs. For illustrative purposes only. *** Member responsibility may vary based on plan design; for some plans copays apply. Emergency room copays are typically higher than walk-in clinic copays. The Case for Urgent Care (complimentary white paper). Urgent Care Association of America. Available at WhitePaperTheCaseforUrgentCare.pdf. Accessed July 1, California HMO members must contact their medical group or primary care physician for walk-in clinic and urgent care center use. 5

6 No-cost preventive care Coverage for the whole family 6 Your health benefits and insurance plan covers routine screenings and checkups with no cost share as part of preventive care. It also includes counseling you get to prevent illness, disease or other health problems. Many of these services are covered as part of physical exams. These include regular checkups, and routine gynecological and well-child exams. You won t have to pay out of pocket for these preventive visits, when provided in network. But these services are generally not preventive if you get them as part of a visit to diagnose, monitor or treat an illness or injury. Then copays, coinsurance and deductibles may apply. We follow the recommendations of national medical societies about how often children, men and women need these services. Be sure to talk with your doctor about which services are right for your age, gender and health status. Covered preventive services for adults generally include: Screenings for: Abdominal aortic aneurysm (one-time screening for men of specified ages who have ever smoked) Alcohol misuse Blood pressure Cholesterol (for adults of certain ages or at higher risk) Colorectal cancer (for adults over 50) Depression Type 2 diabetes (for adults with high blood pressure) HIV Obesity Tobacco use Syphilis (for all adults at higher risk) Medications and supplements: Aspirin for men and women age 45 and older with certain cardiovascular risk factors Vitamin D supplements for adults age 65 and older with certain conditions

7 Counseling for: Alcohol misuse Diet (for adults with high cholesterol and other known risk factors for cardiovascular and diet-related chronic disease) Obesity Sexually transmitted infection (STI) prevention (for adults at higher risk) Tobacco use (including programs to help you stop using tobacco) Immunizations: Doses, recommended ages and recommended populations vary Diphtheria, pertussis, tetanus (DPT) Hepatitis A and B Herpes zoster Human papillomavirus (HPV) Influenza Measles, mumps, rubella (MMR) Meningococcal (meningitis) Pneumococcal (pneumonia) Varicella (chicken pox) Covered preventive services for children Screenings and assessments for: Alcohol and drug use (for adolescents) Autism (for children at 18 and 24 months) Behavioral issues Cervical dysplasia (for sexually active females) Congenital hypothyroidism (for newborns) Developmental screening (for children under age 3, and surveillance throughout childhood) Hearing (for all newborns) Height, weight and body mass index measurements Lipid disorders (dyslipidemia screening for children at higher risk) Hematocrit or hemoglobin Hemoglobinopathies or sickle cell (for newborns) HIV (for adolescents at higher risk) Lead (for children at risk of exposure) Medical history Obesity Oral health (risk assessment for young children) Phenylketonuria (PKU) (newborns) Tuberculin testing (for children at higher risk of tuberculosis) Vision Medications and supplements: Gonorrhea preventive medication for the eyes of all newborns Iron supplements (for children ages 6 to 12 months at risk for anemia) Oral fluoride for children 6 months to 5 years of age (prescription supplements for children without fluoride in their water source) Counseling for: Obesity Sexually transmitted infection (STI) prevention (for adolescents at higher risk) Immunizations: From birth to age 18 doses, recommended ages and recommended populations vary Diphtheria, pertussis, tetanus (DPT) Haemophilus influenzae type b Hepatitis A and B Human papillomavirus Inactivated poliovirus Influenza Measles, mumps, rubella (MMR) Meningococcal (meningitis) Pneumococcal (pneumonia) Rotavirus Varicella (chicken pox) 7

8 Disease Management Program Personal attention for your health conditions and risks Ready to be your healthiest you? You can get solid support managing your condition with the disease management program. And it s included with your Aetna health benefits and insurance plan, so you can start living healthier today. But these services are generally not preventive if you get them as part of a visit to diagnose, monitor or treat an illness or injury. Then copays, coinsurance and deductibles may apply. You ll learn how to: Manage your condition Lower your risks for new conditions Work better with your doctor Take your medicine safely Find helpful resources Support for more than 35 conditions This includes diabetes, heart disease, cancer, low back pain and digestive conditions. Your condition is likely covered, too. A program that s about you, not your condition Your condition isn t unique. But you sure are. So this program is designed to help you control your condition in ways that work for you. You can: Work with a nurse when it fits your schedule Take online disease management programs to boost your nurse coaching sessions Interact with the program online, by or by phone Call our dedicated disease management line toll-free, 24/7. Work one on one with a registered nurse An Aetna nurse will act as your personal health coach. You choose why, when or how often to speak with him or her. You can work with your coach: Before or after your doctor visits When you re looking for healthier lifestyle choices To understand your doctor s treatment plans Only your doctor can decide on the best care for you. But your health coach is by your side with tips and ideas to help. Manage your condition with online programs You may have access to online disease management programs, too. They can supplement the progress you re making with your nurse. Program topics include: General condition management Low back pain Diabetes Pain management High cholesterol High blood pressure Technology that works for your health and safety You benefit from smart technology that keeps scanning your health plan records. So if you visit the doctor or pick up a prescription, the system knows you did it. It also scans information you or your care team entered into your online personal health record. Then it compares that information with current care guidelines to help you be safer and healthier. This technology can suggest: Stopping or adding a drug Considering a procedure or test not given Thinking about preventive care or wellness options You may also get a call or letter, depending on the situation. What s the program like? Let s say you have diabetes. Here s how a nurse would work with you to manage your condition today and going forward. He or she would: Teach you about diabetes, and answer your questions Send you information by mail or , or point you to online resources Go over your doctor s treatment plan with you Explain possible side effects of your medicine How to start the program If you need help, there are a few ways we ll be able to find you: Your doctor s referral Your medical or prescription claims Our Patient Management staff If you have a condition, or think you re at risk: Put in a request through your Aetna Navigator member website at Call us at

9 Medical overview We will offer the in-state portfolio (MC) and rating structure to out-of-state employees who live in an out-of-state network area. Out-of-state employees who do not live in an out-of-state network area will be eligible for an indemnity plan. Product name Product description PCP required Referrals required Network Health Maintenance Organization (HMO) Each family member selects a primary care physician (PCP) participating in our network. The PCP provides routine and preventive care and helps coordinate your total health care. The PCP refers you to participating specialists and facilities for medically necessary specialty care. Only services provided or referred by the PCP are covered except for emergency, urgently needed care or direct access benefits, unless approved by the HMO before receiving services. Yes Yes HMO Aetna HMO Deductible Aetna Value Network SM HMO Basic HMO Managed Choice (OAMC) Uses all services of the HMO with a unique subset of the HMO network with additional savings by applying a deductible for certain medical services. All the services of the HMO provided by a unique subset of the full HMO network. Aetna Value Network plans offer the same benefits of the Aetna HMO plan, with premium savings when you access this select network of providers. All the services of the HMO provided by a unique subset of the full HMO network. Aetna Basic HMO plans offer the same benefits of the full HMO plans, with premium savings when you access this select network of providers. You can access any participating provider for covered services without a referral. You have the freedom to choose network providers at lower out-of-pocket costs, or non-network providers at higher out-of-pocket costs at any time. Emergency services are covered at the in-network coinsurance/copay level. Yes Yes HMO Deductible Yes Yes Aetna Value Network HMO Yes Yes Basic HMO No No Aetna Open Access Managed Choice POS Savings Plus The Savings Plus network is a subset of the Managed Choice (MC) network in the Savings Plus Service areas. You can access the same types of coverage as other MC plans, but at a lower premium cost. All non-emergency services performed outside of the California Savings Plus network of doctors and hospitals will be paid at the out-of-network benefit level. No No Savings Plus PPO Indemnity You can access any participating provider for covered services without a referral. When you seek health care, you have the freedom to choose either network providers at lower out-of-pocket costs, or non-network providers at higher out-of-pocket costs. Emergency services are covered at the in-network coinsurance/copay level. Employees who live outside the plan s network service area are eligible. You coordinate your own health care and may access any participating provider for covered services without a referral. No No Open Choice PPO No No N/A 9

10 Get to know your Aetna prescription drug plan You are enrolled in a Four Tier, Aetna Value Plus formulary plan Here s what that means to you: Think of tier as a level. Four tier means you could pay four different amounts, depending on the drug you take. A formulary is a list of generic and brand-name drugs that your health plan covers. Your Aetna Value Plus formulary plan covers many drugs but it does not cover drugs on the Formulary Exclusions List. That s because there are just-as-effective and less expensive alternatives available. Your cost depends on your prescription With this health benefits and health insurance plan, the amount you pay depends on the drug your doctor prescribes. It s either a flat fee or a percent of the prescription s price. Or, you will pay the full cost of any drugs on the Formulary Exclusions List. What you pay falls into one of these tiers or levels: Tier One: Preferred Generics You pay the lowest cost for drugs in this level. Tier Two: Preferred Brands You pay a slightly higher cost for drugs in this level. Tier Three: Nonpreferred Generic and Brand Drugs You pay the highest cost for drugs in this level. Tier Four: Preferred and Nonpreferred Specialty Drugs You pay a specific amount for specialty drugs in this level. Specialty drugs may be injected, infused or taken by mouth. Formulary Exclusions List You will pay the full cost of any drugs on this list. To find your exact costs Check your Summary of Benefits & Coverage document. This should be in your enrollment kit. Your pharmacy benefits plan may include a program that encourages you to choose a generic drug over a brand-name drug, in order to help reduce what you pay. This means that if you fill a brand-name drug when a generic is available, that in addition to your standard copay or coinsurance, you must also pay the difference in cost between the brand-name and generic drug. For a summary of your pharmacy benefits plan, including out-of-pocket costs, visit and log in to Aetna Navigator. Or call the toll-free number on your member ID card. Save on your prescriptions Here are some tips to pay less out of pocket for your prescription drugs: Ask your doctor to consider prescribing drugs that are on the Preferred Drug (formulary) List. Ask your doctor to consider prescribing generic drugs instead of brand-name drugs. Check to see if your plan includes our mail-order pharmacy service. Depending on your plan, mail order may save you money. See Aetna Rx Home Delivery in this guide for details. Remind your doctor to check your plan to make sure you get maximum coverage. You may have to get plan authorization for certain drugs This drug coverage review encourages appropriate and cost-effective use of prescription drugs by allowing coverage only when certain conditions are met. Reasons for this approval (called precertification) include: Compliance with dosing guidelines Avoiding duplicate therapies Helping health care providers check that a drug is being used based on generally accepted medical criteria The precertification program is based on current medical findings, FDA-approved manufacturer labeling information, and cost and manufacturer rebate arrangements. Please keep the following in mind: Your doctor must contact us to request approval of coverage for these drugs. If we approve the request, we will notify your doctor. The drug will then be covered at the applicable out-of-pocket cost under your plan. You will also be notified of approvals where the state requires notification to members. If the request is denied, you and your doctor will be notified. You can still purchase the drug, but for the full price. You may have to try one drug before another will be covered This drug coverage review promotes the appropriate use of equally effective but lower-cost drugs first. Prerequisite drugs are FDA-approved and treat the same condition as the corresponding step-therapy drugs. 10

11 Mail order brings drugs you take every day right to your door Your plan includes our Aetna Rx Home Delivery mail-order pharmacy. It fills prescriptions for maintenance medicine. This type of medicine is used regularly to treat conditions like arthritis, asthma, diabetes or high cholesterol. If you need this type of drug, you can get up to a 90-day supply or the maximum supply allowed by your plan, and free delivery right to your mailbox. You also get: Quick, confidential service Free standard shipping Pharmacists who check all prescriptions for accuracy and can answer questions any time Use our specialty pharmacy for drugs that require special handling Aetna Specialty Pharmacy is our in-house specialty pharmacy. It can fill your prescription specialty medicine. These types of drugs may be injected, infused or taken by mouth. Specialty medicine often needs special storage and handling. It must be delivered quickly. And a nurse or pharmacist should monitor you during your treatment. Use Aetna Specialty Pharmacy to get this medicine sent right to your mailbox. You also get: Free delivery that is reliable, secure and sent anywhere you choose Extra help when you need it like injection training and side effect monitoring Proactive outreach to confirm your refills Free standard supplies Nurses and pharmacists who can help you 24 hours a day, every day Over-the-counter drugs may be an option Many health conditions can be treated safely with drugs you can get without a prescription. We call these drugs over the counter because you can buy them at your local stores. You don t have to go to a pharmacy. These drugs have been approved by the FDA as safe and effective, and they often have the same active ingredients as an original prescription version. Always talk to your doctor before taking over-the-counter drugs. Your plan does not cover prescription drugs if a similar drug is available over the counter. This includes drugs like Claritin and Prilosec 20 mg. Please ask your doctor what will work best for you. Limitations and Exclusions Drugs that are not covered under the standard prescription drug benefit program include, but are not limited to: Drugs used for weight loss, including the treatment of obesity unless medically necessary Certain prescribed medications and supplies Nutritional supplements (other than as needed for PKU, prenatal vitamins, etc.) Smoking cessation aids or drugs unless required by California or federal law unless medically necessary Growth hormones unless medically necessary Prophylactic drugs for travel Test agents and devices, other than diabetic test agents Performance, athletic performance, or lifestyle enhancement drugs and supplies Cosmetics or any drugs used for cosmetic purposes or to promote hair growth, including health and beauty aids Replacement for lost or stolen prescriptions For a complete list of what is not covered by your prescription drug plan, refer to your plan documents after enrollment. Find out more Once you are enrolled, log in to Aetna Navigator, at You ll find benefits and claims information, the Preferred Drug List, cost estimates and more. You can also refer to your Summary of Benefits and Coverage (SBC) or call us at the toll-free number on your Aetna member ID card. Claritin is a registered trademark of Schering-Plough HealthCare Products Inc. Prilosec is a registered trademark of AstraZeneca LLP. 11

12 Find doctors and specialists Start your search at (or, if you are already a member, log in to Aetna Navigator). Click on Find a Doctor, Pharmacy or Facility. Use the simple online instructions to perform a general search. You also may search for a particular physician by name, specialty or other options. How to find your California medical plan Some of the names for our California plans appear by their Aetna network names in DocFind. This screen shot is a quick reference guide to identify your plan. (CA) Aetna Whole Health PrimeCare Physicians HMO (CA) Aetna Whole Health PrimeCare Physicians OAMC (CA) Aetna Whole Health SCCIPA (CA) Aetna Whole Health MemorialCare Aetna Basic HMO (available in CA only) Aetna Value Network HMO HMO Deductible Plan (CA members only) HMO Open Choice PPO Managed Choice (MC) POS (Open Access) Savings Plus of California Indemnity To find Aetna Whole Health plans, visit 12

13 How to find your California dental plan Some of the names for our California plans appear by their Aetna network names in DocFind. This screen shot is a quick reference guide to identify your plan. Aetna Advantage TM Dental Dental PPO/PDN 13

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16 Review the material in this brochure and speak with your employer or human resources representative about the choices available to you. We look forward to welcoming you and your family as our newest members! Contact information: HMO Member Services MC/PPO Member Services Visit This material is for information only and is neither an offer or invitation to contract. The models depicted are not Aetna members. An application must be completed to obtain coverage. Rates and benefits vary by location. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health/dental services. If you are in a plan that requires the selection of a primary care physician and your primary care physician is part of an integrated delivery system or physician group, your primary care physician will generally refer you to specialists and hospitals that are affiliated with the delivery system or physician group. Health/dental benefits and health/dental insurance plans contain exclusions and limitations. Not all health/dental services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. Health/dental information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. HealthEquity, Inc. is the custodian of health savings accounts and independently offers Investment services. Aetna receives rebates from drug manufacturers that may be taken into account in determining the Aetna Preferred Drug List. Rebates do not reduce the amount a member pays the pharmacy for covered prescriptions. Aetna Rx Home Delivery refers to Aetna Rx Home Delivery, LLC, a licensed pharmacy subsidiary of Aetna Inc. that operates through mail order. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to Aetna Inc CA (1/16)