Download EASTERN MICHIGAN UNIVERSITY 2014 HEALTH CARE OPTIONS

EASTERN MICHIGAN
UNIVERSITY
2014 HEALTH CARE OPTIONS
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Introduction
Who you are
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About Your Medical Coverage
• 100% Preventive Care Benefits
- Based on age & gender
- No deductibles or copays apply if rendered innetwork and doctor codes as preventive (annual
physical or annual screening)
- Not covered out of network; exceptions for
mammograms and colonoscopy
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Available Options
• Community Blue PPO – Option 5
• Simply Blue HSA
• Blue Care Network Healthy Blue Living
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ACA Mandated Benefits
The following are applicable to all Large groups:
• Coverage of routine care for participants in certain clinical trials
• Preventive drug coverage with no cost share that includes (all must be prescribed
by a physician):
– Coverage for select smoking cessation drugs
– Aspirin for women ages 55 to 79 years when the potential benefit of a reduction in ischemic
strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage
– Aspirin for men ages 45 to 79 years when the potential benefit due to a reduction in myocardial
infarctions outweighs the potential harm due to an increase in gastrointestinal hemorrhage
– Folic acid for women planning or capable of pregnancy take a daily supplement containing 0.4 to
0.8 mg (400 to 800 µg)
– Oral fluoride supplementation at currently recommended doses to preschool children older than
age 6 months whose primary water source is deficient in fluoride
– Routine iron supplementation for asymptomatic children ages 6 to 12 months who are at
increased risk for iron deficiency anemia
– Over the counter female contraceptive medications only when prescribed by a physician
Deductible, Copays & Maximums
Benefits
PPO Option 5
PPO HSA
HMO – Enhanced
(Standard)
Deductible
$250 – employee
$500 – 2-person
$750 – family
$1,250 – employee
$2,500 – 2 or more
$500 – employee/(1,500)
$1,000 – 2 or more /($3,000)
Fixed-dollar copays
$20 for office visit*
(*$15 - chiropractic)
$50 emergency room
None
(chiropractic coverage
is excluded)
$5 allergy injections ($5)
$20 office & urgent care ($35
office/$50 urgent)
$100 emergency room ($100)
Percent coinsurance
(approved amounts
after deductible)
10%
20% other services
20% or 50% (35% or 70%)
depending on service; includes
lab, x-rays, inpatient and
outpatient hospital
Annual out-of-pocket
maximum
$1,000 – employee
$2,000 – 2 or more
(includes
coinsurance)
$6,350 – employee
$12,700 – 2 or more
(includes deductibles,
fixed dollar medical
and Rs copays and
coinsurance)
$2,500 – employee
$5,000 – 2 or more
(includes deductible,
fixed-dollar medical
and Rx co-pays and
coinsurance)
$1,000 – employee
$2,000 – 2 or more
(includes deductible, fixeddollar medical co-pays and
coinsurance)
$6,350 – employee
$12,700 – 2 or more
Separate out-of-pocket
maximum will apply for Rx copays
Refer to the Enrollment Guide posted online for more detailed info, including out-ofnetwork coverage
Community Blue PPO/HSA Option
• Who is eligible?
- Must be enrolled in a qualifying High Deductible Health Plan
(HDHP)
- Deductibles at least $1,250 individual/$2,500 family
- Not covered under any other health insurance (unless it is
another HDHP)
- Not enrolled in Medicare
- Not receiving any VA benefit
- Subscriber cannot be eligible to be claimed as a dependent on
another person’s tax return and must be over 18 years old
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What is an HSA?
• Similar to checking account for health expenses
- You own your HSA funds that are deposited into your “Health
Equity” account
- Debit card to pay for qualified medical expenses
- HSA funds can be used for:
- Deductibles, copays and coinsurance for medical, Rx,
vision and dental plans
- COBRA premiums
- Health insurance premiums while receiving unemployment
- Medicare Part A and B premiums
- Qualified long term care
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Who is Health Equity?
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A FDIC full-service financial institution
Leader in
HSA, HRA and FSA administration
Free investment options through Charles Schwab
24/7 customer service available
HSA Tax Advantages
• All contributions are pre-tax
• All funds grow tax free in bank account
• Funds are not taxed when you use money to pay for a
qualified medical expense – there is a 20% penalty if
money is spent on a non-qualified expense prior to
age 65
SAVE YOUR RECEIPTS
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Blue Care Network – Healthy Blue Living
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Health Maintenance Organization (HMO)
High performance network that encourages a health lifestyle
Comprehensive network of providers
Two levels of benefits
- Enhanced
- Standard
• Must select a primary care physician (PCP) from the Focus
Network
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Enhanced and Standard Benefits
• HMO participants are eligible for 2 benefit levels with cost
sharing options
- Enhanced – has lower deductible and copayments
- Standard – has higher deductible and copayments
• You are automatically enrolled in the enhanced benefit for the
first 90 days of coverage at the initial enrollment
• To qualify to remain in the enhanced plan you and your enrolled
spouse must do the following:
- Complete an online Health Risk Assessment (HRA)
- Receive a physical exam and have your physician complete a
qualification form
- There are 6 Wellness Targets that will be measured
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Wellness Targets for Enhanced Benefit
Level
Health
Measure
Wellness Target
If I do not meet the target – how can I
qualify for the enhanced benefit?
Tobacco
Non-tobacco user
Enroll in Quit the Nic tobacco cessation program
Actively participate until you quit using tobacco
Weight
Body mass index below 30
Participate in Weight Watchers or WalkingSpree
program until BMI falls below 30
Blood Pressure
Below 140/90
Commit to and follow doctor’s treatment plan
Cholesterol
LDL below target based on risk
factors: <100, <130 and <160
Commit to and follow doctor’s treatment plan
Blood sugar
At or below target (Fasting Blood
Sugar or A1C)
Commit to and follow doctor’s treatment plan
Depression
Any depression in full remission
Commit to and follow doctor’s treatment plan
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Selecting a PCP in the HMO
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-
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Employees residing in one of the 7 identified southeast counties
must select a PCP from the PCP Focus Network:
Macomb
Washtenaw
Oakland
Monroe
Saint Clair
Wayne
Livingston
Members residing outside of these 7 counties will select a PCP
from BCN’s existing network
Network includes all BCN contracted hospitals and specialists
Members that do not select a PCP upon enrollment will be
assigned to a Focus PCP
Visit www.mibcn.com to view network providers
About the BCBSM Pharmacy Cost
Control Measures for PPO and
PPO/HSA
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Cost Savings Programs for Pharmacy Benefits
• EMU/Snow Pharmacy Discount Program
- Lower Generic Copay @ Snow Pharmacy
- $3 copay for 30 day generic
- $7 copay for 90 day generic
• BCBSM Pharmacy Cost Savings Programs
- Mandatory Maximum Allowable Cost (MMAC)
- Pharmacy Initiatives
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About Your RX Coverage
Benefits
PPO Option 5
PPO & HSA
HMO – Enhanced (Standard)
Retail Copays*
Tier 1
Snow Health Center Pharmacy Discount Program
$3 for 30-day supply of generic medication ($5 at other retail pharmacies)
$7 for a 90-day supply of generic medication (not available at other retail)
Tier 2
$25
$25
$25 ($40)
Tier 3
$50
$50
$50 ($80)
90-day Retail / Mail Order Copays*
90-day retail only at
Snow
2x retail only at Snow
2x retail copay up to 90 day
supply at Snow and Medco
2.5x copay at Medco Mail Order
Refer to the Enrollment Guide for more detailed info about your RX benefits.
*The PPO Option 5 and PPO/HSA Plan includes certain drug initiatives that require you to use generic or pay higher
out-of-pocket charges unless you receive approval from BCBSM to use generic when there is a brand equivalent.
Read more online by clicking this link: 2014 RX Coverage Under New Health Plan Options.
Mandatory Maximum Allowable Cost (MMAC)
* When a generic equivalent is available for a brand-name drug and
the brand-name drug is purchased, the member is responsible
for the difference in cost between the brand-name drug and the
MAC price, in addition to the applicable brand-name copayment,
regardless of whether the doctor indicates DAW or not
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How MMAC Works
Mandatory MAC
(aka Mandatory Generic)
Physician requests brand
(DAW)
Member pays cost difference
between
brand and generic PLUS
applicable brand copay
Additional cost
may be waived with approved
Medical Necessity
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Member requests brand
Member pays cost difference
between
brand and generic PLUS
applicable brand copay
BCBSM Pharmacy Initiatives
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Dose Optimization
Brand-to-Alternate Generic Interchange
Generic Copay Waiver
Quantity Limits
Off Label/High-Cost Specialty Review
Preferred Therapy
Details posted on the EMU Benefits website under
Prescription Drugs
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