Self-Insured Schools of California: Schools Helping Schools

Schools Helping Schools SISC III SELF-INSURED SCHOOLS OF CALIFORNIA ACCESS+ HMO PLAN Self-Insured Schools of California: Schools Helping Schools 2012 Enrollment Guide 2012 Enrollment Guide

Schools Helping Schools SISC III SELF-INSURED SCHOOLS OF CALIFORNIA SISC is a Joint Powers Authority administered by the Kern County Superintendent of Schools Office Christine Lizardi Frazier, Superintendent Our philosophy Schools Helping Schools Pooling resources provides schools with a more stable long-term insurance solution than purchasing from commercial carriers that may be competitive today and out of reach tomorrow. SISC provides a very cost-effective rate environment which reflects its commitment to preventing losses and controlling costs. This keeps millions of dollars in the classroom that would have otherwise been paid out in premiums. Members in our board of directors are elected by member districts. All board members are employees of school districts. This ensures that SISC policies are set with the best interests of schools in mind. All SISC administrative personnel are employees of the school system. We do not receive sales commissions. Our fiduciary responsibility is to our members not a profit margin. Our ethics SISC believes ethically responsible organizations serve not only their members but all stakeholders: employees, employers, providers, vendors, and local communities. SISC s commitment is to demand standards of behavior which support professional practices. All decisions must take into account and reflect a concern for the interests of all stakeholders. Our goal SISC strives to provide the best coverage and service to our members while keeping costs affordable and stable. California-based, not-for-profit health plan Blue Shield offers the responsiveness and stability of an established, not-for-profit health plan. We have been part of California s healthcare landscape since 1939, and throughout our history, have sustained long-term, innovative relationships with our clients. We remain passionate about not only improving the health and wellness of our members, but also giving back to the communities where we live and work, as demonstrated by our continued support of the Blue Shield of California Foundation.

Schools Helping Schools SISC III SELF-INSURED SCHOOLS OF CALIFORNIA We re here to help If you have any questions, simply contact your dedicated Blue Shield Member Service team at (800) 642-6155 for personal assistance, from 7 a.m. to 7 p.m., Monday through Friday. Learn about the Blue Shield Access+ HMO plan Choosing a Personal Physician (Primary Care Physician) is one of the keys to using an HMO plan. HMO members must access covered services through a network of physicians and facilities as directed by their Personal Physician. Exceptions include emergencies and urgent care received outside of a member s Personal Physician s service area. The Access+ HMO plan may be a good choice and a cost-efficient way to maintain your health if you and your family go to the doctor often. Choosing a Personal Physician: When you enroll in the Access+ HMO plan for the first time, you will need to choose a Personal Physician for you and your enrolled dependents. If you are already a Blue Shield Access+ HMO member, your Personal Physician will not change. As a member, you have the option to choose a different Personal Physician and medical group for each enrolled family member. If you choose a Personal Physician you have already seen, please let Blue Shield know that you are an existing patient. When enrolling in the HMO plan, you will need your Personal Physician s provider number and medical group/ Independent Practice Association (IPA) number. See page 4 to learn how to find these numbers and search for a Personal Physician through the Blue Shield website. If you do not select a Personal Physician at the time of enrollment, Blue Shield will automatically assign a Personal Physician to you and your enrolled family members. You can change your Personal Physician by calling Member Services at (800) 642-6155. Key features of the Access+ HMO plan Choosing a doctor Access to specialists Out-of-pocket costs Select a Personal Physician to coordinate all your medical care. You cannot go outside the Blue Shield network except in emergencies. Get a referral from your Personal Physician or self-refer to specialists within your Personal Physician s medical group or IPA for a higher copayment.* Pay a copayment for covered services. * To use this option, members must select a Personal Physician who is affiliated with a medical group or IPA that is an Access+ provider group, which offers the Access+ Specialist feature. Members should then select a specialist within that medical group or IPA. Access+ SpecialistSM visits for mental health services must be provided by an MHSA network participating provider. Behavioral health Your behavioral health benefits include inpatient and outpatient mental health and substance abuse care for issues such as: Depression Alcohol/drug abuse Mental illness Marriage and family counseling The services are provided by Blue Shield s mental health service administrator (MHSA) network. HMO members only have access to MHSA network providers. Care away from home Through the BlueCard Program, Access+ HMO members can access emergency and urgent care services across the country and around the world. You can receive urgent care services from any provider; however, using the BlueCard Program can be more cost-effective and eliminate the need for you to pay for the services when they are rendered and submit a claim for reimbursement. You can locate a BlueCard provider at any time by calling (800) 810-BLUE or by going to the Find a Provider section of blueshieldca.com/sisc. The Away From Home Care program gives students, long-term travelers, workers on extended out-of-state assignments, and families living apart the convenience and flexibility of coverage for extended periods across the country. To learn more about Away From Home Care and whether your family is eligible, call your Blue Shield Member Services team at (800) 642-6155. Please note that Away From Home Care is not available in all areas and states, and benefits from the host plan may differ from the Access+ HMO plan. blueshieldca.com/sisc 3

Find a network provider Blue Shield s HMO network is one of the largest in California, with more than 35,000 physicians and 290 hospitals. If you don t have access to the Internet or need help, simply contact your dedicated Blue Shield Member Services team at (800) 642-6155 for personal assistance or to request a provider directory. It s easy to find a HMO network provider online Go to blueshieldca.com/sisc. Select Find a Provider. Under Find an Access+ HMO Network Provider, choose the provider you are looking for. You will be directed to the Blue Shield website where you can enter your city and state or ZIP code to find providers near a specific location. Find out your provider s quality of care rankings You can easily access quality scores, efficiency indicators, patient satisfaction scores, and cost information for many HMO medical groups and hospitals. To see a provider s performance profile, simply click on the name of the doctor, HMO medical group, or hospital from your search results. How to find the provider and medical group/ipa numbers for your Personal Physician (needed when you enroll in the Access+ HMO plan for the first time) Follow the steps above to find an HMO provider. Under Filter Results (to the left), select Doctors, then HMO Personal Physician. Click on the physician s name. On the next screen you can find the physician s provider and medical group/ipa numbers. 4 Blue Shield of California

Understand your pharmacy benefits Medco Pharmacy Benefits With the HMO plan, you can save on your long-term medications like those used to treat an ongoing condition such as high blood pressure or high cholesterol by ordering them through the Medco Pharmacy. Your plan can save you money when you fill your prescription by mail order instead of using a retail pharmacy. Get up to a 90-day supply delivered directly to you with free standard shipping! Multiple safety and advanced quality checks are in place to make sure you get the right medication. You have 24-hour phone access to pharmacists who are ready to help you and available to focus exclusively on your medications. You can easily order refills online, over the phone, or by mail. Medco Specialist Pharmacists at the Medco Pharmacy are available by phone 24/7 to help you understand and manage medications used to treat a wide variety of conditions. If you have any questions about your pharmacy benefits through Medco, call (800) MEDCO-MAIL or (800) 633-2662, 24 hours a day, seven days a week. Save money on generic prescriptions at Costco SISC has partenered with Costco to offer HMO plan members the option to fill generic prescriptions at Costco for a $0 copayment. You do not need to be a Costco member to use the Costco pharmacy. It s simple to fill generic prescriptions at Costco; just follow the steps below: 1. Take your prescription for a generic medication to a Costco Pharmacy. 2. Present the pharmacist with your HMO member ID card. Note: Some narcotic pain medications and cough medications are excluded. blueshieldca.com/sisc 5

Discover more Helpful programs, services, and resources are available to you, over the phone and online, to help you and your family stay healthy. NurseHelp 24/7 To talk with registered nurses any time, day or night, and get answers to your health-related questions, or go online to have a one-on-one personal chat with a registered nurse anytime. The NurseHelp 24/7 SM phone number is conveniently located on the back of your Access+ HMO member ID card. Prenatal Program This program guides expectant parents from the first trimester to postnatal care and offers practical advice and useful information. Some materials are also available in Spanish. As an Access+ HMO member, you can enroll by logging in to blueshieldca.com or calling (877) 371-1511. Condition management programs The Access+ HMO plan is complemented by a wide range of helpful programs. These programs provide our members with chronic conditions with educational resources and strategies to help them manage their condition and feel better. Programs include the Asthma Program, Diabetes Program, Coronary Artery Disease (CAD) Program, Heart Failure Program, and the Chronic Obstructive Pulmonary Disease (COPD) Program. Members can apply to the programs by logging in to blueshieldca.com or calling (866) 954-4567. 6 Blue Shield of California

Wellness discount program Your wellness is important to us. To make it easier for you to take better care of yourself, Blue Shield offers participants a variety of discounts on popular programs 1 that can help you save money and get healthier. Weight Watchers Get discounts on three- and 12-month subscriptions, monthly passes, and at-home kits. 24 Hour Fitness Enjoy waived enrollment fees and discounts on monthly membership dues. ClubSport and Renaissance ClubSport 2 Get a 60% discount on enrollments when joining with a month-to-month agreement. Enrollment fees are waived when joining with a 12-month agreement. (There is a one-time $25 processing fee when you enroll.) Drugstore.com Save on health and wellness products. Alternative care discount program 2 Save at least 25% on acupuncture, massage therapy, and chiropractic services, plus get discounts on health and wellness products. Vision services Get 20% off the published retail prices when you use a participating provider 3 in the Discount Vision Program network for exams, frames, lenses, and more. QualSight LASIK Members in California receive a 20% discount off providers usual and customary fees on traditional and custom LASIK surgery. TLCVision LASIK 4 Get 15% off providers usual and customary fees for LASIK and PRK correction surgery through a TLCVision or NVision network provider in California. Members who live outside California get a 10% discount off providers usual and customary fees from TLCVision providers. * Text4baby is a service mark of the National Healthy Mothers, Healthy Babies Coalition (text4baby.org). The National Healthy Mothers, Healthy Babies Coalition has an agreement with most carriers to waive applicable text charges. The networks of practitioners and facilities in the discount programs are managed by the external program administrators identified below, including any screening and credentialing of providers. Blue Shield does not review the services provided by discount program providers for medical necessity or efficacy. Nor does Blue Shield make any recommendations, representations, claims, or guarantees regarding the practitioners, their availability, fees, services, or products. Some services offered through the discount program may already be included as part of the Blue Shield plan covered benefits. Members should access those covered services prior to using the discount program. Members who are not satisfied with products or services received from the discount program may use Blue Shield s grievance process described in the Grievance Process section of the Evidence of Coverage. Blue Shield reserves the right to terminate this program at any time without notice. Discount programs administered by or arranged through the following independent companies: Alternative care discount program American Specialty Health Systems Inc. (ASH Networks) Discount Vision Program MESVision Weight control Weight Watchers North America Fitness facilities 24 Hour Fitness, ClubSport, and Renaissance ClubSport Health products (excluding prescription drugs) drugstore.com inc. LASIK Laser Eye Care of California, LLC, QualSight Inc., and TLCVision Corporation Note: No genetic information, including family medical history, is gathered, shared, or used from these programs. 1 These discount program services are not a covered benefit of Blue Shield health plans, and none of the terms or conditions of Blue Shield health plans apply. Discount program services are available to all members with a Blue Shield medical, dental, vision, or life insurance plan. 2 24 Hour Fitness, ClubSport/Renaissance ClubSport, and alternative care discount program are not available in all states. Members should contact their local 24 Hour Fitness or ClubSport gym, or American Specialty Health Systems (ASH) provider to determine whether a Blue Shield of California discount applies. To find an ASH provider, call (877) 335-2746 or go to blueshieldca.com/ findaprovider. 3 For Discount Vision Program providers in California, go to blueshieldca.com and search for Routine Care Discount Vision Program. For providers outside California, go to ecndiscount.com. 4 TLC Centers are not available in all states. To find a TLC Center near you, call (877) TLC-2020. Life insurance plans are underwritten by Blue Shield of California Life & Health Insurance Company. blueshieldca.com/sisc 7

Schools Helping Schools SISC III SELF-INSURED SCHOOLS OF CALIFORNIA SISC sisc.kern.org/hw (661) 636-4410 Health Smarts is SISC s health improvement program for members and their families. By providing customized resources and information in the areas of nutrition, fitness, preventive care, and condition management, Health Smarts helps you take charge of your health and well-being. Through Health Smarts, you and your family have access to tools and resources designed to provide the incentives and support needed to keep you in good health. These include: Onsite health screening* Health assessment* Digital health coaching* Condition management *If available in your District Blue Shield is here to help Member Services...(800) 642-6155 7 a.m. to 7 p.m., Monday through Friday. BlueCard Program... (800) 810-BLUE NurseHelp 24/7...(877) 304-0504 Prenatal Program... (877) 371-1511 Condition management programs...(866) 954-4567 Blue Shield of California Privacy Office...(888) 266-8080 Visit blueshieldca.com/sisc to access information on your plan benefits and health resources. An independent member of the Blue Shield Association A44288-SISC-HMO (6/12)