2020 Benefits Overview - September | 2019 - Connect
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
September | 2019
2020 Benefits Overview
Presented by
Samuella Pratt
Aetna is the brand name used for products and services
provided by one or more of the Aetna group of subsidiary
companies, including Aetna Life Insurance Company and its
affiliates (Aetna).
©2019 Aetna Inc.
95.35.111.1 A (9/18) 1
OUR MISSION
Building
a healthier
world
Creating better health Better health comes
person by person from being forward-thinking,
and community by finding the right
community approach, and then
making it happen
Building support
systems for
personal health
Advancing the health
of the whole person
Moving people toward
better health every day
2
Today’s agenda:
• What’s New For 2020
• The Aetna Provider Networks
- CPOS II - Broad Network
- APCN - Narrow Network
Your Medical Plan Options
- $400 Deductible Plan
- $900 Deductible Plan
- $1,500 Deductible Plan
- $2,850 Deductible Plan
• Clinical Programs
• Transition Of Care
• Preventive Care
©2018 Aetna Inc. • Tools and Resources 3
What’s New For 2020
• Effective 7/1/2019:
- Applied Behavioral Analysis (ABA) for Autism Spectrum Disorder
• Effective 1/1/2020:
- Aetna Narrow Network: Aetna Premier Care Network (APCN)
- Centers of Excellence: Institute Of Quality for Musculoskeletal
4
Effective 7/1/2019: Applied Behavioral Analysis (ABA)
• Your behavioral health plan covers treatment of applied behavioral analysis
for individuals who have been diagnosed with autism spectrum disorder.
• Applied behavior analysis (ABA) requires precertification by Aetna.
• The network provider is responsible for obtaining precertification.
• You are responsible for obtaining precertification if you are using an
out-of-network provider.
• For additional information, contact the Aetna Health Concierge
at 1-866-210-7858.
5
Effective 1/1/2020: Aetna Narrow Network: Premier Care Network (APCN)
• MMC colleagues can elect the Aetna Narrow Network (APCN) where available
(as determined by home zip code)
• APCN is a network strategy focused on available performance networks to
provide the best network possible
• APCN networks utilize doctors and facilities chosen for cost and quality
standards
• To search for health care providers in the Narrow Network, select 2020 Aetna
Premier Care Network (APCN) Choice POSII
• Get quality care and lower out-of-pocket costs, by simply staying in-network
6
How to search for the new Aetna Narrow Network (APCN)
Your network has doctors and facilities that are chosen specifically
based on a series of quality, efficiency and access standards.
See if your doctor is in the narrow network
• Go to Aetna.com.
• Click on “Find a Doctor”
• Not a member yet? Click on
“Plan from an employer”
• Enter your home location
• Select the “2020 Aetna
Premier Care Network (APCN)-
Choice POSII” option
• Search for your provider 7
Current Provider Network: Broad Network
Aetna Choice POS II (Open Access)
• All plans are built on Aetna’s Broad Network - Aetna Choice POS II
(Open Access)
• To search for health care providers in the Broad Network, select Aetna
Choice POS II (Open Access)
• Using in-network doctors saves you time and money
8
Effective 1/1/2020: Centers of Excellence – IOQ for Musculoskeletal (Orthopedic)
• Access to a special network of hospitals and other facilities known as Institutes of
Quality (IOQ).
• IOQ’s are facilities that have met Aetna’s quality requirements.
• IOQ’s perform many procedures and have shown clear clinical results.
These facilities specialize in certain procedures such as:
• Orthopedic (for the joints and spine)
• Spine surgery
• Knee replacement
• Hip replacement
9
Centers of Excellence – IOQ for Musculoskeletal (Orthopedic) Benefit
Find a list of Institutes of Quality facilities and specialists by visiting Aetna.com
• Search “orthopedic health.”
• Select “Aetna Institutes of Quality Orthopedic Care Facilities — For
Members” from the list of links.
• Select “Find IOQs and specialists with privileges.”
• Select “Search a public directory.”
10Medical plans available effective January 1, 2020
• Aetna Broad Network - Aetna Choice POS II (Open Access)
• $400 Deductible Plan
• $900 Deductible Plan
• $1,500 Deductible Plan*
• $2,850 Deductible Plan*
• Aetna Narrow Network - Aetna Premier Care Network (APCN)
Choice POS II
• $400 Deductible Plan
• $900 Deductible Plan
• $1,500 Deductible Plan*
• $2,850 Deductible Plan*
11
*HSA Compatible High Deductible PlansMedical Plan Comparison – Broad and Narrow Networks
Plan feature $400 Deductible Plan $900 Deductible Plan
In-network Out-of-network In-network Out-of-network
Deductible $400/$800 (applies $2,500/$5,000 $900/$1,800 $3,000/$6,000
(individual/family) to medical only) (applies to medical (applies to medical (applies to medical
only) only) only)
Office visits $20 PCP copay / $40 40% after deductible 20% after deductible 40% after deductible
specialist copay
Coinsurance* 20% after deductible 40% after deductible 20% after deductible 40% after deductible
Out-of-pocket $2,200/$4,400 $4,400/$8,800 $3,000/$6,000 $6,000/$12,000
maximum – (includes medical / (includes medical / (includes medical / (includes medical /
includes deductible prescription drug prescription drug prescription drug prescription drug
(individual/family) copays and coinsurance) coinsurance) coinsurance)
coinsurance )
Preventive care Covered at 100% 40% after deductible Covered at 100% 40% after deductible
Emergency room $150 copay then 20% $150 copay then 20% 20% after deductible
after deductible after deductible
Teladoc® cost share $20 PCP copay 20% after deductible
*Please note: coinsurance percentages represent the portion of the costs you are responsible for.
12Medical Plan Comparison – Broad and Narrow Network
Plan feature $1,500 Deductible Plan $2,850 Deductible Plan
In-network Out-of-network In-network Out-of-network
Deductible $1,500/$3,000 $3,000/$6,000 $2,850/$5,700 $5,700/$11,400
(individual/family) (applies to medical (applies to medical (applies to medical (applies to medical
and prescription and prescription and prescription and prescription
drug) drug) drug) drug)
Coinsurance* 20% after 40% after deductible 30% after deductible 50% after deductible
deductible
Out-of-pocket $3,000/$6,000 $6,000/$12,000 $5,500/$11,000 $11,000/$22,000
maximum – includes (includes medical (includes medical (includes medical (includes medical
deductible and prescription and prescription and prescription and prescription
(individual/family) drug coinsurance) drug coinsurance) drug coinsurance) drug coinsurance)
Preventive care Covered at 100% 40% after deductible Covered at 100% 50% after deductible
Teladoc cost share 20% after deductible 30% after deductible
*Please note: coinsurance percentages represent the portion of the costs you are responsible for.
13How a deductible works
The deductible is the amount you pay for covered services before your health
plan begins to pay.
Remember
• Preventive care is covered 100 percent in network under your medical plan, and you do
not need to meet your deductible first.
• The $1,500 and $2,850 deductible plans includes prescription drug costs in the
deductible.
Know your type of deductible
• The $400 and $900 deductible plans includes an individual deductible that is embedded into
the family limit (Not “True” Family). No one person would have to satisfy more than the
individual deductible amount.
• The $1,500 deductible plan does not have an individual deductible limit for the family plan
(“True” Family). The deductible for family coverage is the dollar amount that the family, in the
aggregate, must pay out of pocket before the plan pays benefits for any family member. This
family deductible can be met by one or any combination of family members.
• The $2,850 deductible plan includes an individual deductible that is embedded into the family
limit (Not “True” Family). No one person would have to satisfy more than the individual
deductible amount.
14How coinsurance works
This is the percentage you pay for medical services after your
deductible has been met if you are enrolled in the $900 Deductible Plan.
For example:
Matt has already paid his $900 yearly deductible.
He sees the doctor and is charged $80 for the in-network visit.
Matt’s coinsurance is 20 percent.
This means:
1. Aetna pays 80 percent of the remaining bill: $64
2. Matt will get a bill for the remaining 20 percent: $16
If Matt went to a doctor out of network, he would be responsible for the
higher deductible and 40 percent of his bill.
Also, Matt's bill will likely be higher out of network.
Matt would also be responsible for any amounts above the reasonable and
customary charges for this service.
15How an out-of-pocket maximum works
This is the limit on the total costs you pay for covered services in a year.
Includes prescription drugs.
Once you have paid the maximum amount, your plan covers 100 percent of all remaining
eligible expenses*.
Know your type of out-of-pocket maximum
• The $400 and $900 deductible plans includes an individual out-of-pocket limit that is embedded into
the family limit (Not “True” Family). No one person would have to satisfy more than the individual out
of pocket limit.
• The $1,500 deductible plan does not have an individual out of pocket limit for the family plan. The
out of pocket for family coverage is the dollar amount that the family, in the aggregate, must pay out
of pocket before the plan pays benefits for any family member (“True” Family). The family out of
pocket limit can be met by one or any combination of family members.
• The $2,850 deductible plan includes an individual out-of-pocket limit that is embedded into the
family limit (Not “True” Family). No one person would have to satisfy more than the individual out of
pocket limit.
*Out of network – you are still responsible for the amounts above the reasonable and customary
charges.
16Clinical Programs: Care Management
Engaging colleagues with personalized care
• Offers high-touch/high-tech care
delivered through the innovative Care
Management Program
• Delivers customized approach to care
management
• Provides excellent service with our
concierge-style, single point of contact
service model
• Connects members to nurse and or
vendor partners as appropriate
17Aetna Maternity Program – Maternity Support Center
Digital hub helps members throughout pregnancy
A comprehensive, digital set of resources curated for all
maternity members – at no extra cost.
We aim to:
Empower – Guide members through the process of
managing their journey and care with new online
resources
Personalize benefit information – what’s covered and
what’s the anticipated cost based on the member’s plan
Organize and compartmentalize - resources by stages
of the journey
Provide multi-media resources in plain language –
includes videos, check-lists and tools from trusted
resources
18The right support for every stage of
becoming a parent
Planning for baby
Getting pregnant
Having trouble getting
pregnant
Pregnancy
Getting ready for baby
Staying healthy
Members log in
Delivering baby
through
Baby’s arrival
aetna.com
Feeding your baby account and
Bringing baby home select “Stay
The first year Healthy“
Baby at home
Taking care of yourself
Mental health check in
Planning ahead
19
19Aetna Cancer Support Center
20Aetna Cancer Support Center
21Telemedicine program: Teladoc®
When can I use Teladoc?
• When you need care now
• If your doctor is unavailable
• If you’re considering the emergency room or urgent care center for a
nonemergency issue
• On vacation, on a business trip, or away from home
• For short-term prescription refills
• Teladoc gives you 24/7/365 access to a doctor through the convenience of phone
or video consults
• It's an affordable option for quality medical care
• Members can speak with a Behavioral Health provider via an online
video consultation
• Consultations are available seven days a week, 7am to 9pm local
time
Teladoc doctors can treat many medical conditions, including:
• Cold & flu symptoms
• Allergies Contact Teladoc via:
• Bronchitis • 1-855-Teladoc (835-2362)
• Skin problems • Teladoc.com/aetna
• Teladoc.com/mobile
• Respiratory infection
22How does Teladoc work?
Teladoc.com/aetna
Step 1 Step 2 Step 3 Step 4 Step 5 Step 6
Complete Request Talk with a Resolve Continuity Reconcile
medical history consult physician the issue of care account
23Take advantage of the Informed Health® Line
• A 24-hour information line for all your health questions
• Toll-free access to registered nurses for health information 24/7
at 1-800-556-1555
• Learn about health conditions
• Find out more about a medical test or procedure
• Get help preparing for a doctor visit
• Receive emails with videos that relate to the question or topic
• Access to online health information via: www.aetna.com
24Transition of Care
• This is a form of temporary coverage that allows for in-network benefits to be paid if
you are in an active course of treatment with a doctor who is not in the Aetna network
(applicable to both Broad and Narrow networks).
• To qualify you must have begun a treatment program of planed services with your
doctor to correct or treat a diagnosed condition.
• The request for transition of care benefits must be received within 90 days from the
date of your enrollment.
• Contact an Aetna Health Concierge at 1-866-210-7858 to request a Transition of Care
request form that can be reviewed upon enrollment in the plan.
Examples:
• Members enrolled after 20 weeks of pregnancy
• Member is in an ongoing treatment plan such as chemotherapy or radiation therapy
• Members who have recently had surgery
• Members who are receiving outpatient treatment for mental illness or substance abuse
• Members who may need or have had an organ or bone marrow transplant
25Preventive Care: Covered preventive services for Adults
Screenings for: Immunizations:
• Abdominal aortic aneurysm (one-time screening for men of Doses, recommended ages and recommended
specified ages who have ever smoked) populations vary
• Alcohol misuse • Diphtheria, pertussis, tetanus (DPT)
• Blood pressure • Hepatitis A and B
• Cholesterol (for adults of certain ages or at higher risk) • Herpes zoster
• Colorectal cancer (for adults over age 50) • Human papillomavirus (HPV)
• Depression • Influenza
• Type 2 diabetes (for adults with high blood pressure) • Measles, mumps, rubella (MMR)
• Human immunodeficiency virus (HIV) • Meningococcal (meningitis)
• Obesity • Pneumococcal (pneumonia)
• Tobacco use • Varicella (chickenpox)
• Lung cancer (for adults age 55 and over with history
of smoking), effective January 1, 2015
• Syphilis (for all adults at higher risk) Please note: Coverage includes regular checkups, and
routine gynecological and well-child exams. Aetna follows
Counseling for:
the recommendations of national medical societies about
• Alcohol misuse how often children, men and women need these services.
• Diet (for adults with hyperlipidemia and other known risk Be sure to talk with your doctor about which services are
factors for cardiovascular and diet-related chronic disease) right for your age, gender and health status.
• Obesity
• Sexually transmitted infection (STI) prevention (for adults at
higher risk)
• Tobacco use (including programs to help you stop
using tobacco)
26Preventive Care: Covered preventive services for Children
Screenings and assessments for: Counseling for:
• Alcohol and drug use (for adolescents) • Obesity
• Sexually transmitted infection (STI) prevention
• Autism (for children at 18 and 24 months)
(for adolescents at higher risk)
• Behavioral issues
• Cervical dysplasia (for sexually active females) Immunizations:
• Congenital hypothyroidism (for newborns) From birth to age 18 — doses, recommended ages
• Developmental screening (for children under age 3, and recommended populations vary
• Diphtheria, pertussis, tetanus (DPT)
and surveillance throughout childhood)
• Haemophilus influenzae type b
• Hearing (for all newborns) • Hepatitis A and B
• Height, weight and body mass index measurements • Human papillomavirus
• Lipid disorders (dyslipidemia screening for children at • Inactivated poliovirus
higher risk) • Influenza
• Measles, mumps, rubella (MMR)
• Hematocrit or hemoglobin
• Meningococcal (meningitis)
• Hemoglobinopathies or sickle cell (for newborns) • Pneumococcal (pneumonia)
• HIV (for adolescents at higher risk) • Rotavirus
• Lead (for children at risk of exposure) • Varicella (chickenpox)
• Medical history
• Obesity Please note: Coverage includes regular checkups,
• Oral health (risk assessment for young children) and routine gynecological and well-child exams. Aetna
• Phenylketonuria (PKU) (for newborns) follows the recommendations of national medical
• Tuberculin testing (for children at higher risk of tuberculosis) societies about how often children, men and women
• Vision need these services. Be sure to talk with your doctor
about which services are right for your age, gender
and health status.
27Improved Digital Platform – New Mobile App
Aetna Health
Aetna Health
A member app and website that are
intuitive and easy to use. With the real
time personalized information, tools,
and guidance our members need to
understand benefits and manage their
health through their entire health
journey.
28App screens are a composite of real situations.
All names and other identifying information are
fictional.
29Aetna Aetna Health Single digital front door with
personalized real time information,
tools, and guidance helping our
is on a is delivering on this mission members manage their health
where, when, and how they want
mission
to help our
members
achieve their
personal health
ambitions on
their terms
We are focused on
making health care
easy to understand and
navigate, leading to a
great experience,
improved health and
lower costs
30• Real-time out-of-pocket estimates* for the most common medical,
non-emergency health care services, including those that may offer
Cost Estimator the biggest opportunity to save on health care expenses and allow
comparison shopping.
• Lets members compare costs for physician office visits, surgical
procedures, and diagnostic test and procedures before they receive
care.
• Allow members to compare up to ten in-network providers or
facilities at one time.
650+ medical • Estimates based on members actual benefits plan (including
deductible, coinsurance, copayments, plan limits, Aexcel benefits,
services to Aetna Performance Network benefits, HRA dollars).
choose from • Provides estimates for “service bundles”.
• Helps members understand the money they can save, without
compromising quality of care.
*Estimated costs not available in all markets. The tool provides an estimate of what
would be owed for a particular service based on the plan at that very point in time.
Actual costs may differ from an estimate if, for example, claims for other services
are processed after the estimate is provided but before the claim for this service is
submitted. Or, if the doctor or facility performs a different service at the time of the
visit. HMO members can only look up estimated costs for doctor and outpatient
facility services.
31All you need to manage your health
Aetna discount programs:
• Enjoy discounts on eye exams and
eyewear, hearing aids, vitamins and
supplements, weight-loss programs
and more.
• Simply show your Aetna ID card to
participating vendors.
• The discounts are not insurance—the
member is responsible for the entire
cost of the service they receive.
• Learn more on your secure member
site Aetna Health.
URL: www.aetna.com
32Connect with Aetna — when and how it’s best for you
By phone at 1-866-210-7858, online at www.aetna.com and by email, — even on the
go
• Mobile web is optimized for over 5,000 devices
• Mobile applications provide a more enhanced
experience and are available for use with
iPad®, iPhone® and iPod touch® mobile digital
devices,
the AndroidTM mobile technology platform and
the BlackBerry® CurveTM* smartphone
We know what you need on the go
• DocFind®
• Claim search
• Urgent care finder
• Member ID card information
• Personal Health Record
• Contact Us capabilities
• User name and password recovery
• Registration
Standard text messaging and other rates from your wireless carrier may apply.
Apple, the Apple logo, iPad®, iPod®, iPod touch® and iPhone® are trademarks of Apple Inc., registered in the U.S. and other countries.
Android and Google Play are trademarks of Google Inc.
Blackberry Curve is the trademark or registered trademark of Blackberry Limited, the exclusive rights to which are expressly reserved. Aetna is not affiliated with, endorsed, sponsored,
or otherwise authorized by Blackberry Limited.
3334
What You Need to Know About
Your 2020 Prescription Drug Benefit
Administered by Express Scripts
35
© 2019 Express Scripts Holding Company. All Rights Reserved.Reminder during today’s webcast
For privacy purposes, please refrain from asking
questions that are specific to medications that you
or a family member may be taking.
36
© 2019 Express Scripts Holding Company. All Rights Reserved.Agenda
About Your Prescription Drug Benefit Administered by Express Scripts
The Features of Your Prescription Drug Benefit
Information You Need to Know About Your Plan’s Prescription
Drug Coverage
Making the Best Use of Your Benefit
We’re Here to Help Answer Your Questions and Address Your
Concerns
37
© 2019 Express Scripts Holding Company. All Rights Reserved.About Your Prescription Drug
Benefit Administered by Express
Scripts
38
© 2019 Express Scripts Holding Company. All Rights Reserved.About Your Prescription Drug Benefit
Your prescription drug benefit is administered by Express Scripts*
2020 new enrollees will receive a Welcome Package containing plan
summary information and a prescription ID card.
In the event you do not have your ID cards
• Call Member Services at (800) 987-8360 to request an ID card or
• Register at www.Express-Scripts.com to print a temporary ID card
or
• Download the Express Scripts™ Mobile App to display a virtual
ID card to your local pharmacist.
*if you are enrolled in an Aetna, Anthem BCS or UnitedHealthcare $400, $900, $1,500 or $2,850 Deductible Plan
39
© 2019 Express Scripts Holding Company. All Rights Reserved.About Your Prescription Drug Benefit
You automatically receive prescription drug coverage from Express Scripts when you elect medical
coverage under one of the following plans:
• $400 Deductible Plan
• $900 Deductible Plan
• $1,500 Deductible Plan
• $2,850 Deductible Plan
Coverage includes the option to purchase short term medications from a retail pharmacy and
maintenance medications from the Express Scripts® mail-order service.
New for 2020: In addition to mail order, you will be able to fill a 90-day supply of your
maintenance medications at a Walgreens retail pharmacy, at the same cost as you would
through the mail order program.
Please Note: For all maintenance medications, if you choose to fill a 30-day prescription at a retail
pharmacy other than Walgreens, after the first three fills, you will pay 100% of the cost for all
subsequent fills.
Your prescription drug costs will vary based on whether the medication is a Generic (Tier 1),
Formulary Brand (Tier 2), or Non-Formulary Brand (Tier 3).
If you have questions or need further information to better understand your prescription drug plan:
• Call Member Services at (800) 987-8360, 24 hours a day, 7 days a week except Thanksgiving
and Christmas or
• Log on to the member website at www.Express-Scripts.com
40
© 2019 Express Scripts Holding Company. All Rights Reserved.The Features of Your
Prescription Drug Benefit
41
© 2019 Express Scripts Holding Company. All Rights Reserved.Your Plan’s Drug Coverage
Your plan covers a broad range of medications that fall into three categories:
Tier 1 – Generics
Equivalent to brand-name drugs that have exactly the same dosage, intended use, routes of
administration and strength as the brand drug. Generic drugs most often cost significantly less than
Formulary Brand and Non-Formulary Brand medications.
Tier 2 – Formulary Brands
A broad list of preferred brand-name drugs. Drugs on this list may cost you less than Non-Formulary
Brand medications.
Tier 3 – Non-Formulary Brands
Brand drugs that are not included on the preferred list of covered medications. You may pay more for
these drugs.
Your plan encourages you to choose generic and formulary brand medications. Unless your physician specifically prescribes
a brand-name medication without substitution, prescriptions will be filled with the generic equivalent when allowed by
state law.
If you or your physician requests the brand-name drug when a generic equivalent is available, and there is no medical
reason for the brand-name drug, you will pay your share of the cost for the generic drug in addition to the difference in cost
between the brand and generic drugs .
Please note, that some drugs may not be covered under your prescription benefit when there are similar safe and effective
alternatives.
42
© 2019 Express Scripts Holding Company. All Rights Reserved.How much you will pay toward your prescriptions under the $400 or $900
Deductible Plans*:
Participating Retail Pharmacies
Generic Formulary Brand Non-Formulary Brand
up to a 30-day supply
$400 Deductible Plan $10 $30 $60
30% 30% 45%
$900 Deductible Plan
($10 min / $20 max) ($25 min / $50 max) ($40 min / $80 max)
Express Scripts Mail Order Pharmacy
Generic Formulary Brand Non-Formulary Brand
up to a 90-day supply
$400 Deductible Plan $25 $75 $150
30% 30% 45%
$900 Deductible Plan
($25 min / $50 max) ($62.50 min / $125 max) ($100 min / $200 max)
Note: For all maintenance medications, after the first three fills at a retail pharmacy, if you choose to continue to fill the
prescription at a retail pharmacy, you will pay 100% of the cost for all subsequent fills. Beginning 1/1/2020 you will have the
option to get a 90-day supply of your maintenance medications via Mail Order or at Walgreens. Mandatory Mail has been
expanded to include all Walgreens Pharmacies for maintenance medications dispensed for a days’ supply of greater than
30-days.
*The deductible does not apply to prescriptions for the $400 and $900 plans.
Under the Affordable Care Act (ACA) certain preventive medications will be covered at 100% and are not subject to a deductible or
copayment. Please note that over the counter (OTC) drugs under ACA require a prescription to be covered at 100%.
43
© 2019 Express Scripts Holding Company. All Rights Reserved.Maximum Out-of-Pocket
The $400 and $900 Deductible Plans have a yearly Maximum Out-of-
Pocket (MOOP) that is combined with your medical carrier.
Express Scripts will share claims with your medical carrier and track
yearly spending – this will reset every year on January 1st.
Once the maximum out-of-pocket is met, your copay will be $0 for
prescriptions (excluding applicable penalties).
PLAN IN NETWORK OUT OF NETWORK
Single - $2,200 Single - $4,400
$400 Deductible Plan
Family - $4,400 Family - $8,800
Single - $3,000 Single - $6,000
$900 Deductible Plan
Family - $6,000 Family - $12,000
44
© 2019 Express Scripts Holding Company. All Rights Reserved.High Deductible Health Plan (HDHP) Options
($1,500 and $2,850 Deductible Plans*):
The HDHP is a combined medical and prescription drug benefit. You may make pre-tax
contributions to your HSA and use the funds to help pay for medical and prescription
drug expenses.
You pay 100% of your medical and prescription drug expenses until you meet your
annual deductible.
• Preventive medications are not subject to a deductible but you will still be responsible for the
applicable coinsurance. To find out if your medication is considered preventive – price your
medication on www.express-scripts.com or the Express Scripts™ Mobile App.
Once you have met your deductible, you pay the applicable coinsurance amounts until
you reach your maximum out-of-pocket.
Once you have reached your maximum out-of-pocket, including your deductible, the
plan pays 100% of eligible medical and prescription drug expenses for the remainder of
the benefit year.
Under the Affordable Care Act (ACA) select preventive medications will be covered at
100% and are not subject to a deductible or coinsurance. Please note that over the
counter (OTC) drugs under ACA require a prescription to be covered at 100%.
*The Health Savings Account is a tax-advantaged account available to employees who elect the $1,500 Deductible Plan or the $2,850
Deductible Plan.
45
© 2019 Express Scripts Holding Company. All Rights Reserved.How much you will pay for your prescription medications under the
$1,500 and $2,850 High Deductible Health Plans:
Participating Retail Pharmacies
up to a 30-day supply
Generic Formulary Brand Non-Formulary Brand
Express Scripts Mail Order Pharmacy
up to a 90- day supply
20%, 20%, 20%,
$1,500 Deductible Plan
after deductible after deductible after deductible
30%, 30%, 30%,
$2,850 Deductible Plan
after deductible after deductible after deductible
Participating Retail Pharmacies
up to a 30-day supply IN NETWORK OUT OF NETWORK IN NETWORK OUT OF NETWORK
Express Scripts Mail Order Pharmacy Deductible Deductible Out-Of-Pocket Out-Of-Pocket
up to a 90- day supply
Single - $1,500 Single - $3,000 Single - $3,000 Single - $6,000
$1,500 Deductible Plan
Family - $3,000 Family - $6,000 Family - $6,000 Family - $12,000
Single - $2,850 Single - $5,700 Single - $5,500 Single - $11,000
$2,850 Deductible Plan
Family - $5,700 Family - $11,400 Family - $11,000 Family - $22,000
Note: For all maintenance medications, after the first three fills at a retail pharmacy, if you choose to continue to fill the
prescription at a retail pharmacy, you will pay 100% of the cost for all subsequent fills. Beginning 1/1/2020 you will have the
option to get a 90-day supply of your maintenance medications at Walgreens. Mandatory Mail has been expanded to include
all Walgreens Pharmacies for maintenance medications dispensed for a days’ supply of greater than 30-days.
46
© 2019 Express Scripts Holding Company. All Rights Reserved.Information You Need to Know
About Your Plan’s Prescription
Drug Coverage
47
© 2019 Express Scripts Holding Company. All Rights Reserved.Information You Need to Know About Your Plan’s
Prescription Drug Coverage
Your plan covers a broad range of medications. You may be subject to several different types of drug management
programs. These include quantity management, prior authorization and step therapy.
Some medications may not be covered by your plan unless you receive approval through a coverage review (e.g.
prior authorization).
• This review helps ensure a particular drug is being prescribed appropriately and in accordance with your plan’s
coverage.
• The review uses plan rules that are based on FDA-approved prescribing and safety information, clinical
guidelines, and uses that are considered reasonable, safe, and effective.
• Some covered medications may also have quantity limits and/or prior authorization requirements (for
example, only for a certain amount or for certain uses) unless you receive approval through a coverage review.
As changes in the marketplace occur, such as when new drugs become available or new indications are approved for
existing drugs, the list of drugs that require a coverage review may be modified. To obtain prior authorization for
coverage, ask your doctor to call Express Scripts at 1 800-753-2851. After Express Scripts receives the necessary
information, you and your doctor will be notified confirming whether or not coverage has been approved.
Specialty medications must be filled through Accredo. Accredo is the Express Scripts specialty pharmacy, and is
your plan’s preferred source for direct delivery of specialty medications. Specialty medications are drugs that are
used to treat complex conditions, such as cancer, growth hormone deficiency, hemophilia, hepatitis C, immune
deficiency, multiple sclerosis and rheumatoid arthritis.
You may be required to try a preferred drug(s) before a non preferred drug. Any changes will be communicated to
impacted members via a mailing.
Fertility drugs will continued to be covered, subject to a $15,000 lifetime maximum.
48
© 2019 Express Scripts Holding Company. All Rights Reserved.Making the Best Use
of Your Benefit
49
© 2019 Express Scripts Holding Company. All Rights Reserved.Using Your Prescription ID Card at a Participating
Retail Pharmacy
This is a separate ID card in addition to your medical plan’s ID card
A retail pharmacy is a perfect choice for medications to treat an acute or temporary
condition, such as antibiotics for an infection.
Express Scripts includes more than 68,000 retail pharmacies in the Broad National
Network associated with this Plan. The Plan generally pays higher benefits if you use
an in-network retail pharmacy.
If you use a non-participating pharmacy, in addition to your coinsurance/copayment,
you will be responsible for the cost above the Plan’s discounted price.
To locate a participating retail pharmacy:
• Go to www.Express-Scripts.com and select “Locate a Pharmacy” or
• Check on the Express Scripts™ Mobile App or
• Call Member Services at (800) 987-8360.
Temporary ID cards can be printed from the Express Scripts member website or via the
Express Scripts mobile app.
50
© 2019 Express Scripts Holding Company. All Rights Reserved.Using the Express Scripts Mail Order Pharmacy
A convenient, safe, and less costly way to have medications delivered
to you
You can receive up to a 90-day supply of your maintenance
medications
The perfect choice for medications you take on an ongoing basis,
such as those used to treat:
• High Blood Pressure
• High Cholesterol
• Diabetes
To learn more about how to get started:
• Go to www.Express-Scripts.com or
• Call Member Services at (800) 987-8360.
51
© 2019 Express Scripts Holding Company. All Rights Reserved.Getting Started with the Express Scripts Pharmacy
Ask your doctor to fax or submit your
prescription electronically. Prescriptions are
processed and delivered within 5 to 8 calendar days
(after receipt of your prescription).
Mail in your prescription
• Print a mail-order form
• Mail prescription and completed order form to the
Express Scripts Pharmacy
• First-time orders will usually be delivered within 8
to 11 calendar days after
we receive your order
It’s easy to get started with mail service
ePrescribe Web/Mobile App Member Services
Physicians can ePrescribe Savings opportunities called out on Member services can transfer
prescriptions directly to the the dashboard an existing prescription
Express Scripts Pharmacy
Patients can request prescription Mail in your prescription
transfers with a click of a button
52
© 2019 Express Scripts Holding Company. All Rights Reserved.Refilling Prescriptions at the Express Scripts
Pharmacy
When you have a 14-day supply of your medication
remaining, you can order refills:
• Online at www.Express-Scripts.com
Refills for long-term prescriptions filled at
• Call us toll-free at (800) 987-8360 retail can be transferred to the Express
Scripts Pharmacy at
• Mail in your refill slip (included with your last prescription www.Express-Scripts.com
order)
• Express Scripts™ Mobile App
Have some of your prescriptions refilled and sent
automatically - sign up for automatic refills
Refills are processed and delivered within 3 to 5 calendar
days (online or phone orders) or 6 to 9 calendar days
(mailed-in orders) after receipt of your order
Beginning 1/1/2020 you will have the option to get a 90-
day supply of your maintenance medications at
Walgreens. Mandatory Mail has been expanded to
include all Walgreens Pharmacies for maintenance
medications dispensed for a days’ supply of greater
than 30-days.
53
© 2019 Express Scripts Holding Company. All Rights Reserved.Have a question about a medication?
Call to speak to a pharmacist
You can call one of our Each Express Scripts
You can call
pharmacists for general Specialist Pharmacist has
an Express Scripts
counseling — or an had specialized training in
Specialist Pharmacist
Express Scripts Specialist the medications used to
24/7 to ask
Pharmacist for complex treat a specific condition,
questions about:
concerns. such as:
High Cholesterol Drug interactions
High Blood Pressure Side effects
Depression Risks and benefits of your
Diabetes medication
Asthma The challenges of taking
Osteoporosis your medication as
prescribed — one of the
Cancer
best ways to help maintain
or improve your health
To speak to a pharmacist, call Member Services at
1-800-987-8360
54
© 2019 Express Scripts Holding Company. All Rights Reserved.Generic Medications
When you receive a prescription from your doctor, or if
you are taking brand-name drug today, ask:
If a generic version of the medication is available.
If generic medications are right for you.
If there are any risks if you change from a brand-name
drug to a generic drug.
Eight out of 10 prescriptions filled in the United States
are for generic drugs.
FDA-approved generic drugs are as safe and effective
as their brand-name
Generics cost less. On average, the cost of a generic
drug is 80% to 85% lower than the brand-name product.
55
© 2019 Express Scripts Holding Company. All Rights Reserved.Registering with Express Scripts
Online access to savings and convenience
Manage your medicines anywhere, any time on the member
website at www.express-scripts.com and the Express
Scripts™ Mobile App
Register now so you can experience:
More savings
Compare prices of medicines at multiple pharmacies. Get free standard
shipping* from the Express Scripts PharmacySM.
More convenience
Get up to 90-day supplies of your long-term medicine sent to your home.
Order refills, check order status, and track shipments. Print forms and ID
cards, if needed.
More confidence
Talk with a pharmacist from the privacy of your home any time, from
anywhere. Find the latest information on your medicine, including
possible side effects and interactions.
More flexibility
Download the Express Scripts mobile app to manage your medicines,
find nearby pharmacies and get directions, and use your virtual ID card
while on the go.
* Standard shipping costs are included as part of your prescription plan benefit.
56
© 2019 Express Scripts Holding Company. All Rights Reserved.Pharmacy That Goes Farther
Get Started Today!
Registering is safe and simple. Your information is secure and confidential. Please have your member ID number or
SSN available
Go to express-scripts.com, select Register Now or download the Express Scripts™ Mobile App for free from your
mobile device’s app store and select Register Now
Complete the information requested, including personal information and member ID number or Social Security
Number (SSN), create your user name and password, along with security information in case you ever forget your
password
Click Register now and you’re registered!
On the final page, you can set preferences** now, or later in My Account on www.express-scripts.com
Click Continue
Members who have Apple’s touch ID authentication on their iPhone or iPad
devices can enable it to login to their Express Scripts account on the mobile
app, if desired.
** Preferences include the option to share your prescription information with other adult members of your household (aged
18+) covered under your prescription drug plan.
All covered adults (aged 18+) in the household need to register separately.
When you grant permission to share your prescription information with other registered household members, they can
view your information, place orders on your behalf and more.
The Express Scripts™ Mobile App is available for iPhone®, Android, Windows Phone®, Amazon, and Blackberry® mobile
devices.
57
© 2019 Express Scripts Holding Company. All Rights Reserved.An app that drives better decisions and healthier
outcomes for members on the go
Convenience Peace of Mind
• Easy-order refills and • Reminders and a
up-to-the-minute drug interaction
order status lets checker help keep
members avoid trips members traveling on
to their local the road to good
pharmacy health
Simplicity Versatility
• One swipe of the • Flexibility that fits
finger is all it takes to members’ lives,
stay on track with delivering personalized
medications prescription information –
whenever & wherever
they need it
58
© 2019 Express Scripts Holding Company. All Rights Reserved.We’re here to help answer your questions
and address your concerns
Visit www.Express-Scripts.com
• Information that you will need to complete registration can be found on
your prescription drug ID card.
• To get the most from your online account, you’ll also need a recent
prescription number to view your personalized information.*
Call Express Scripts Member Services at (800) 987-8360, 24 hours
a day, 7 days a week except Thanksgiving and Christmas.
Visit www.Express-Scripts.com/MMC during annual enrollment, to
compare drug prices within the different plans as well as see
details of each plan.
*A prescription number is not required to register on this site.
59
© 2019 Express Scripts Holding Company. All Rights Reserved.Questions
and Answers
For privacy purposes, please refrain from asking
questions that are specific to medications that you
or a family member may be taking.
60
© 2019 Express Scripts Holding Company. All Rights Reserved.61 © 2019 Express Scripts Holding Company. All Rights Reserved.
You can also read
