Valley View School District 365-U January 1, 2020 Employee Benefits - - PowerPoint PPT Presentation
Valley View School District 365-U January 1, 2020 Employee Benefits Open Enrollment Presentation 2020 Open Enrollment Presentation 2020 Program Overview Open Enrollment Special Enrollment Rights Medical Plan Overview
BCBS of IL PPO Plan
BCBS of IL PPO Plan
PayFlex Flexible Spending Account PayFlex Dependent Care Account
EyeMed PPO Plan
Liberty Mutual Life AD&D Plan
Liberty Mutual Long Term Disability Plan
Network Name PPO Network Level In Network / Out of Network Claim Payment Basis In Network: Contracted Fee; Out of Network:100% of Medicare; No Balance Billing Balance Billing Applies Deductible Individual Family Maximum $250 / $500 $500 / $1,500 General Coinsurance Health Plan: 90% / 60% Plan Member: 10% / 40% Medical Out of Pocket Maximum Individual Family Maximum Current: $1,250 / $3,500 $2,500 / $7,500 New: $1,500 / $3,750 $3,000 / $8,025 Out of Pocket Eligible Expenses Deductible, Coinsurance, Office Visit & ER Copays The deductible and out of pocket maximums accumulate on a calendar year basis (January 1st – December 31st) and therefore reset every January 1st. Any portion of your in network deductible that is satisfied in the fourth quarter of the year (October, November and December) is automatically credited as satisfied deductible for your next calendar year in network deductible.
Network Level In Network / Out Network Inpatient Hospital 90% after Deductible / 60% after Deductible Outpatient Surgery 90% no Deductible / 60% after Deductible Office Visit - Primary Care Physician & Specialist Consult $30 Copay / 60% after Deductible Outpatient Diagnostic / Lab Work / Tests 90% after Deductible / 60% after Deductible Hearing Aid Benefit Exam Aid/Instrument New: 90% after Deductible / 60% after Deductible 1 Per Ear Per 36 Months 1 Per Ear Per 36 Months Adult: $2,500 Per Ear / Child(ren): No Maximum Emergency Room (Copay Waived if Admitted to Inpatient) Current: $150 Copay then 90% after Deductible New: $250 Copay then 90% after Deductible Preventive Screenings 100% no Deductible / 100% no Deductible
PREVENTIVE
mandated benefit
stay healthy by checking for disease before you feel sick
deductible DIAGNOSTIC
disease when you have symptoms or because of a known health issue
a health issue
copays, deductibles & coinsurance
Annual physicals Well woman exams & mammograms Child approved immunizations Adult approved immunizations Visit healthcare.gov for complete list Sick office visits Mammogram due to a lump Travel immunizations Blood pressure medicine Full body scans Other health issues
Chiropractic & Osteopathic Manipulation 30 Visits Physical Therapy Services 110 Visits Occupational Therapy Services 28 Visits Speech Therapy Services 19 Visits Additional Speech Therapy Benefits for Treatment of Pervasive Developmental Disorders 20 Visits
In Network Retail Pharmacy (30 Day) Generic Preferred Brand * Non-Preferred Brand * Current: Up to a $10 Copay Current: Up to a $30 Copay Current: Up to a $50 Copay New: $0 Copay New: Up to a $40 Copay New: Up to a $60 Copay Mail Order (90 Day) Mandatory as of 4th Refill Generic Preferred Brand * Non-Preferred Brand * Current: Up to a $20 Copay Current: Up to a $60 Copay Current: Up to a $100 Copay New: $0 Copay New: Up to a $80 Copay New: Up to a $120 Copay Out of Pocket Maximum Individual Family $1,500 $3,000 Out of Network Retail Pharmacy (30 Day) * Mail Order Out of Pocket Maximum Appropriate In Network Copay + 25% Cost of Drug & Balance Billing Not Covered No Maximum * If a brand name drug is filled and a generic equivalent is available, in addition to the appropriate brand copay, the plan member is responsible for the cost difference between the brand and generic drug.
the cost of the drug and you are subject to balance billing.
submit prior authorization paperwork. The paperwork is required to substantiate medical necessity and to cross check for potential drug interactions.
submission of supporting medical records.
full cost of the drug.
BCBS will mail impacted plan members a letter advising if they are currently filling a script that will be subject to the Prior Authorization Program effective 01/01/20. Effective 01/01/20 BCBS will require the prescribing physician to provide prior authorization paperwork. Drugs subject to the Prior Authorization Program are published on the BCBS website. BCBS customer service, network providers and network pharmacies can also confirm if a script is subject to the Prior Authorization Program.
“first line” (typically a generic equivalent or alternative drug) when the script is filled by the retail pharmacy or mail order.
Written on the script.
physician can provide medical documentation and request the member be allowed fill the original prescription drug aka “step up” to the brand name drug.
BCBS will grandfather plan members currently taking a step therapy drug and they will not be subject to the step therapy program for those script(s) effective 01/01/20. BCBS will implement the program going forward for any plan members taking a step therapy drug on or after 01/01/20. Pharmacists will automatically substitute the brand name drug with the generic equivalent or alternative drug. Drugs subject to the Step Therapy Program are published on the BCBS website. BCBS customer service, network providers and network pharmacies can also confirm if a script is subject to the Step Therapy Program.
categories and will be expanded to include all brand name categories.
responsible for paying the appropriate prescription drug copay plus the difference of the cost between the brand name drug and the generic equivalent.
will not apply to the member’s out of pocket maximum.
be required to pay the difference regardless of if the prescribing physician indicates dispense as written on the script.
Example 1: Preferred brand name drug cost is $142 and the generic equivalent cost is $65. Member responsibility is the $40 preferred brand copay + cost difference between $142-$65 = $77 Member total responsibility: $117. Example 2: Preferred brand name drug cost is $45 and the generic equivalent cost is $17. Member responsibility is the $40 preferred brand copay + cost difference between $45-$17 = $28 Member total responsibility: $45 as $68 exceeds the cost of the drug.
subject to the Member Pay the Difference program effective 01/01/20.
1) Paying the cost difference if filling a brand name drug if a generic equivalent is available. 2) Requesting the pharmacy to fill the generic equivalent instead which is subject to the $0 copay.
The following drugs will be excluded from coverage on the BCBS prescription drug plan:
Non FDA approved Lack of evidence based efficacy and safety concerns
Generics are available Abundance of over the counter availability
Abundance of over the counter availability
Lack of evidence based efficacy and safety concerns
excluded from coverage effective 01/01/20.
1) Paying the full cost if filling a brand name drug as it is excluded from coverage. 2) Requesting the pharmacy to fill a generic instead which is subject to the $0 copay.
will not be an eligible for coverage under the BCBS health plan and the member will pay the full cost of the drug.
Advantage Pharmacy Network Transfer scripts from CVS pharmacy to in network pharmacy. Specialty Pharmacy Requirement Transfer scripts from retail specialty pharmacy to AllianceRX Walgreens Prime. Prior Authorization Program Discuss your current and newly prescribed drugs 01/01/20 or after with your physician. Step Therapy Program Current drugs are grandfathered. Discuss any newly prescribed drugs 01/01/20 or after with your physician. Member Pay the Difference Program Discuss your current and newly prescribed drugs 01/01/20 or after with your physician. Consider generic equivalents. Prescription Drug Exclusions Discuss your current and newly prescribed drugs 01/01/20 or after with your physician. Consider generic proton pump Inhibitors. Check for FSA coverage eligibility.
BCBS of IL PPO Medical Providers BCBS of IL offers you access to their PPO network of providers, facilities and hospitals. Members that enroll in the PPO plan will have the freedom to seek care from providers regardless of their network relation. Choosing care from a provider in the BCBS of IL PPO network affords you and your dependents an in network level of benefit which can mean lower deductibles and out of pocket expenses, as well as discounted services and no balance billing. To search the BCBS of IL PPO network please use the following internet search instructions:
1.Go to www.bcbsil.com. 2.On the top right side of the screen, click on the box labeled “Find a Doctor or Hospital”. You can login as a member to search or you may continue to search as a guest. 3.If searching as a guest, you will answer a few questions about how you obtain your coverage. 4.You will select the type of provider you are looking for and your network. You will be asked to enter additional information to narrow down your search. You may click on “More Search Options” to further narrow your search. For your Medical network:
a.For the PPO network, select “Participating Provider Organization [PPO]”
Deductible (Waived for Preventive) Individual Family $25 $75 Annual Maximum Per Individual $2,000 In Network Versus Out of Network
In Network: Maximum Allowance Out Network: Usual and Customary
Preventive Services 100% Basic Services 80% Major Services 50% Orthodontia Services (Children to Age 23) Not Covered Deductible Per Individual Not Covered Lifetime Maximum Per Individual Not Covered *If you are an Administrative or Secretarial classed employee, your plan will differ slightly. Please see the Insurance Department with any questions.
BCBS of IL PPO Dental Providers BCBS of IL offers you access to their PPO network of providers. Members that enroll in the PPO plan will have the freedom to seek care from providers regardless of their network relation. Choosing care from a provider in the BCBS of IL PPO Dental network affords you and your dependents an in network level of benefit which can mean lower out of pocket expenses, as well as discounted services and no balance billing. To search the BCBS of IL PPO Dental network please use the following internet search instructions:
1.Go to www.bcbsil.com. 2.On the top right side of the screen, click on the box labeled “Find a Doctor or Hospital”. You can login as a member to search or you may continue to search as a guest. 3.If searching as a guest, you will answer a few questions about how you obtain your coverage. 4.You will select the type of provider you are looking for and your network. You will be asked to enter additional information to narrow down your search. You may click on “More Search Options” to further narrow your search. For your Dental network, select “BlueCare Dental PPO”
Eye Exam $10 Copay Up to $45 Allowance Frames Up to $130 Allowance; 20% off Balance Up to $70 Allowance Single Vision Lenses Bifocal Vision Lenses Trifocal Vision Lenses Lenticular Vision Lenses $25 Copay $25 Copay $25 Copay $25 Copay Up to $30 Allowance Up to $50 Allowance Up to $65 Allowance Up to $100 Allowance Standard Contact Lenses Fitting Up to $55 Copay Not Covered Specialty Contact Lenses Fitting 10% off Retail Price Not Covered Conventional Contact Lenses $130 Allowance; 15% off Balance Up to $105 Allowance Disposable Contact Lenses $130 Allowance Up to $105 Allowance Lasik Vision Care Discounts Available Not Covered Exam Frequency Lenses Frequency Frames Frequency Once Every 12 Months Once Every 12 Months Once Every 24 Months
EyeMed PPO Vision Providers EyeMed Vision offers you access to their network of providers. Members that enroll in the Vision plan will have the freedom to seek care from providers regardless of their network relation. Choosing care from a provider in the EyeMed Insight network affords you and your dependents an in network level of benefit which can mean lower out of pocket expenses, as well as discounted
services and can submit the claim for reimbursements. To search the EyeMed Vision network please use the following internet search instructions:
1.Go to www.eyemed.com. 2.On the top right side of the screen, click “Find an eye doctor”. 3.Next, enter the zip code in which you wish to search. From the “Choose Network” dropdown menu, choose “Insight”. 4.As an option step, you may choose important search factors listed under the “What else is important?” dropdown
(Unless with script from a provider)