Your Choice 3-Tier Network Option Plan

Transcription

1 . Your Choice 3-Tier Network Option Plan

2 Your Top Questions What is Your Choice? Are my doctors in the plan? Are my medications covered by the plan? If I get sick, what do I do? How much will I pay out of my pocket? 2

3 What is Your Choice? Tufts Health Plan offers a comprehensive network of quality primary care providers (PCPs), specialists and hospitals. The Your Choice plan gives you access to our full network of providers* Hospitals and affiliated physicians are grouped into tiers based on quality and cost measures Not all health care providers and hospitals charge the same costs. We ve factored in costs and have separated the providers into tiers *EPO members must stay in-network to have benefits covered. PPO members have out-of-network benefits as well. 10/17/16 3

4 Find a Doctor 1. Go to tuftshealthplan.com 2. Pick your Plan and then Submit 3. Select a provider type, enter your location, and search 4

5 What is Your Choice Can you mix and match? Yes A Tier 1 doctor/provider is typically associated with a Tier 1 hospital system You can go to a Tier 1 doctor and your spouse and children can go to doctors in different tiers Scenario 1 Scenario 2 Dad s PCP is Tier 1, Mom and two kids have Tier 2 PCPs PCP is Tier 1, Specialist is Tier 2 * * EPO members need referrals to see a specialist

6 2017 Services EPO/PPO Copays Service Tier 1 Tier 2 Tier 3 YC PPO Out-of- Network Deductible (per calendar year) Routine Physical Exams (including most preventive screenings) Non-routine Primary Care Physician Office Visits Non-routine Specialist Office Visits Inpatient Hospital Care and Surgery (per admission) 10/17/16 N/A N/A N/A Covered in full $20 $35 $50 $35 $45 $50 $250 $750 $1,500 6 $1,500 Individual $3,000 Family Plan covers 80% after deductible Plan covers 80% after deductible Plan covers 80% after deductible Plan covers 80% after deductible

7 2017 Services EPO/PPO Copays Service Tier 1 Tier 2 Tier 3 Emergency Room Copay (waived if admitted then Tier 1 inpatient copay applies) Day Surgery: at a freestanding outpatient surgery center $150 $200 per admission Day Surgery: at a hospital surgery center $250 $750 $1,500 YC PPO Out-of- Network Plan covers 80% after deductible Plan covers 80% after deductible Diagnostic High-Tech Imaging: at a freestanding imaging center $50 Plan covers 80% after deductible Diagnostic High-Tech Imaging: at a hospital-affiliated imaging center 10/17/16 $50 $250 $450 Plan covers 80% after deductible

8 Your Prescription Drug Coverage Retail: $ Tier 1 Lowest Cost $ Tier 2 Retail: Middle Cost $ Tier 3 Higher Cost $15 $30 $50 Mail: $30 $60 $150 Retail copayments reflect a 30-day supply. For mail, the copayment reflects a 90-day supply. Use CVS Caremark Mail Service Pharmacy for maintenance medications (those you use regularly). 10/17/16 8

9 2017 Out-of-Pocket Maximums Your Choice EPO Your Choice PPO In- Network Your Choice PPO Outof Network Individual $ 5,000 $5,000 $ 5,000 Family $ 10,000 $10,000 $10,000 Your out-of-pocket maximum is the total expense you will have to pay out of your pocket before the plan pays 100% of eligible charges. All medical and Rx copays and coinsurance (for DME) will count toward your outof-pocket maximum. Copays include: o Office visits o Day surgery o High-Tech Imaging (MRIs, CT/CAT scans, PET scans & nuclear radiology) o Emergency room o Inpatient admissions 9

10 What Tier is My Prescription Drug On? tuftshealthplan.com à I am a member à Pharmacy Members covered by our pharmacy benefit may fill prescriptions at any of the more than 68,000 CVS Caremark-participating pharmacies, which include retail chain stores, independent pharmacies, and designated specialty pharmacies. 10

11 Once you find your drug on the list, check to see if it has one of the following program designations: Pharmacy Program Program Code What it means? Prior Authorization Quantity Limitation (PA) (QL) Prior authorization is needed for your treatment. There may be a limit on how much of a drug we will cover for a given period of time. Step Therapy (ST PA ) You may be required to try a certain drug or drugs to treat a specific medical condition before Tufts Health Plan will approve the coverage of another drug to treat the same condition. Designated Specialty Pharmacy (SP) Prescriptions for certain type of specialty drugs must be filled by designated pharmacies. Non Covered (NC) Certain drugs that are experimental, are available over the counter, or have a generic equivalent may not be covered by Tufts Health Plan. New-to- Market Drug Evaluation (NTM) In an effort to make sure the new-to-market prescriptions we cover are safe, effective and affordable, we delay coverage of many new drug products until our Pharmacy and Therapeutics (P&T) Committee and physician specialist have reviewed them. These drugs require prior authorization. 11

12 What s on my ID card? Use your QR code reader App on your smartphone to view a description of your benefits, copayments, etc. These are your copayment amounts Your pharmacy ID# information 12

13 Not All Services Are Tiered Examples of services that are not tiered: Emergency Room (ER) Chiropractic/Spinal Manipulation Speech/Physical Therapy Routine Eye Care Behavioral Health Providers (outpatient) Nutritional Counselors Minute Clinics Please see your benefit document for more specific coverage 10/17/16 13

14 Preventive Services are Not Subject to Cost Sharing Getting preventive care is one of the best ways to keep you and your family happy and healthy. Examples include: Yearly checkups Health screenings Immunizations In order to be covered, preventive care must be received from a doctor or provider in the Tufts Health Plan network. Only certain services qualify as preventive. If you have any questions regarding whether a specific service is considered preventive, please check your benefit document or call Member Services at the number on your ID card. 14

15 Examples of Services That Are Not Covered Cosmetic Surgery Dental care (adult) Long-term care/custodial care Non-emergency care when traveling outside the U.S. Private-duty care Routine foot care Treatment that is experimental, for education or development purposes, or does not meet Tufts Health Plan Medical Necessity Guidelines This isn t a complete list so check your policy or plan document for a list of other excluded services. 10/17/16 15

16 Reducing Your Out-of-Pocket Costs for Procedures Use Free Standing Centers Day Surgery Colonoscopy Day Endoscopy Surgery Cataract Colonoscopy Surgery Endoscopy Cataract Surgery High Tech Imaging* MRIs Computer Tomography Scans (CT) PET Scans Nuclear Radiology If you choose to have these services in a hospital, or a hospitalaffiliated medical facility, you will likely pay more out of pocket than if you receive them in a non-hospital setting. High Tech Imaging requires prior authorization. Some plans might have a copayment for high tech imaging. If you aren t sure, check your Benefit Document. This isn t a complete list of services so check your policy or plan document. 10/17/16 16

17 Minimizing Your Out-of-Pocket Expenses When You re Sick or Injured If you need immediate medical care and are unable to visit your Primary Care Provider (PCP) you have options: Cost Convenient Care Center Usage $ $$ Retail Care Clinic Diagnose and prescribe medications to treat conditions such as strep throat, pinkeye, and infections of the ears, nose and throat. Administer routine vaccinations for flu. Urgent Care Center (May require a referral) Diagnose and treat conditions such as head colds, ear or throat infections and minor trauma (e.g. eye injuries, cuts and burns that do not respond to basic first aid). Back/muscle pain, strain or sprain. Call 911 or go to the nearest emergency room if you think you have a medical condition that could endanger your life or limb if not treated immediately. 17

18 Utilization Management How we use medical guidelines and standards to determine appropriateness of care To help members receive quality health care in an appropriate treatment setting, we provide utilization management (UM). UM includes evaluating requests for coverage by applying medically and necessary coverage guidelines (clinical criteria guidelines) for a determination of the medical necessity and appropriateness of the health care services under a member s benefit plan. Before (prospective): determine whether a treatment is medically necessary before it begins During (concurrent): reviews treatment during the course of care to determine medical necessity After (retrospective): review treatment for medically necessity after treatment is complete You have the right to appeal coverage decisions. If you have any questions about what your specific plan covers, please read your Benefit Document or access your secure member account at mytuftshealthplan.com 10/17/16 18

19 Managing My Plan Online and On-The-Go A secure online site has been created just for your plan. Take time to sign up for mytuftshealthplan.com and you can: ü Check your specific plan benefits ü Search for a doctor in your network ü Find a specialist ü Request prescription refills ü Check on a claim and much more ü Check your deductible status (if applicable) ü View your ID card 19

20 Make Everyday Moments Matter Momentum is our health and wellness program designed to help you become healthy and stay healthy. This includes: Online tools and health coaching to help you live a healthy lifestyle Nurse24 SM to help answer your health questions Special programs for diabetes and heart disease, where you get the support you need to manage your condition 10/17/16 20

21 Momentum Supports You and Your Family What happens if you have a serious condition? Our team of nurse care managers is available to support you with one of our Care Management Programs Our Chronic Condition Management Program supports members with asthma, heart disease, and diabetes to help you manage the condition Our Complex Case Management Program is for members (adults and children) with complex medical conditions who might benefit from working with a nurse case manager (e.g. cancer, stroke, organ transplants, cerebral palsy ) 10/17/16 21

22 Momentum Supports You and Your Family Healthy Birthday: Our Obstetrical Nurse Care Managers support moms at risk for preterm labor or those who have underlying complex medical conditions. Priority Newborn Care: Sometimes parents of new babies especially those with complex medical needs need a little extra help. Our Pediatric Care Managers are available to provide family centered support across all care settings from hospital to home. Transition to Home: Going home after a hospital stay can be overwhelming and challenging. You might need some help to get you back on your feet or someone to talk to about any questions you may have and a Nurse Care Manager can help! 10/17/16 22

23 Take a Moment To Be Healthier Lifestyle Management Program Wellness and Prevention Personal online tools including a Personal Health Assessment (PHA) Preventive care covered in full for routine exams, screenings and immunizations Maternity Care includes pre-natal education and support to ensure mom and baby are healthy Alternative therapy discounts to help inspire life balance and reduce stress 23

24 Nurse24 SM Nurse Line Nurse24 SM members can talk to a nurse 24 hours a day, seven days a week. Have a question about your health? Not sure if you should go to the doctor or ER? Translators are available in more than 200 languages to help you get the answers you need. Call to speak to a registered nurse today! 24

25 Routine Eye Care Eye Care Benefits Routine eye exams and other vision services are covered through the EyeMed Vision Care Network. To receive full coverage for routine eye exams and other vision care services you must visit an optometrist or ophthalmologist in the EyeMed network You will also receive discounts on glasses and contacts from eye care providers in the EyeMed network To find an eye care provider in the EyeMed network or to find out if your eye doctor is in the network, go to tuftshealthplan.com and click EyeMed Vision Care on the left Contact EyeMed Vision Care at

26 Empower Yourself with EmpowerMe Take advantage of EmpowerMe, our treatment cost estimator: Get personalized cost estimates* for office visits, medical tests, lab work, surgical procedures, and more. You ll be able to search for a doctor or service, look up treatments for a condition, and compare providers by quality, cost, and location. EmpowerMe will help you estimate how much you ll need to pay out-of-pocket and will be customized just for you factoring in your specific plan benefits like any copayments, coinsurance, or deductibles that you might have. To use EmpowerMe, sign up for a secure online account at mytuftshealthplan.com. *Estimates are generated by Castlight Health and Tufts Health Plan. The results are estimated costs, and actual costs may differ if the member receives additional services, the members coverage information changes, or the provider bills the service differently. The EmpowerMe tool contains important additional information and disclaimers that members should read carefully when seeking estimates. 10/17/16 26

27 Drive Your Own Health Momentum Let Us Help! Member Discounts Fitness and Exercise Health and Wellness Boys & Girls Clubs, Curves, Appalachian Mountain Club, Fitness Network Mindfulness & Stress Management Program, Acupuncture & Massage, CVS Caremark ExtraCare Health Card, idiet, BrainHQ Nutrition Jenny Craig, Nutrisystem, idiet Nutritional Counseling, DASH for Health Vision Vision Care Network and Eyewear Discounts See mytuftshealthplan.com for more details 10/17/16 27

28 Your Support Member Services Hours: Monday-Thursday: 8 am 7 pm; Fri: 8 am 5 pm Visit tuftshealthplan.com and click Contact Us to send an to Member Services Behavioral Health Hours: Monday-Thursday: 8:30 am 5 pm; Fri: 8 am 5 pm 28