Membership Benefit Overview Plan Year 2014-2015

Transcription

Ease of Access
Performance Based
Healthcare
Employee Engagement
HITECH Data Analytics
HITECH/Go Green
Communication
Membership Benefit
Overview
Plan Year 2014-2015
IEBP
Champions the Integrity of the
Healthcare Dollar by Optimized
Efficient Performance Based
Outcome
Personal Touch
1
Dedicated to Service for Over 30 Years
Board of Trustees: 2014-2015 Plan Year
Trustees at Large
Appointed by Chair
Bill Storey
Dr. Lew White
Mike Slye
Glen Metcalf
Richard Browning
Larry Fields
Michael Smith
City of
Margaret Burkett
Jacksboro
City of The Colony
Eddie Edwards
City of Borger
Gayle Sims
City of Waxahachie
Chairman
David Riley
City of Idalou
Brenda Samford
City of Carthage
Connie Standridge
City of Corsicana
Dru Gravens
City of Crane
Ex-officio Trustees
Bennett Sandlin
Terry Henley
Andres Garza
Dr. Joseph Arisco
City of Groves
Glen Johnson Mayor of Port Neches
October 2014
Initial Meeting Sept 2014
Vice Chairman
James Stokes
City of Deer Park
Stephen Haynes
City of Brownwood
Joe Cardenas
City of Uvalde
Vic Barnett
City of Caldwell
Joe Hermes
City of Edna
Jorge Arcaute
City of Alton
2
Rerate Letter
PATIENT PROTECTION AFFORDABLE CARE ACT (PPACA) BENEFIT DISTRIBUTION TIMELINE REQUIREMENT:
• Benefit Distribution thirty (30) days prior to new coverage year
• Must distribute SBCs to plans within seven (7) business days after negotiations are finished and policies set
• Special Enrollees must receive information within ninety (90) days of enrollment
DEDICATED TO SERVICE
and Managing the Integrity of the Healthcare Dollar by
Optimized Efficient Performance Based Outcome
MEMORANDUM
TO:
DATE:
RE:
TML MultiState IEBP Pool/Mini-Pool Members
May 2014
2014-2015 Plan Year Renewal
Investment Earnings, Rate Increase, and Equity Offset
Membership Equity Return
Reserve booked adjustment
Investment Income
Net Income from prior plan year
Average Rate Increase
Projected Claim Utilization
Administrative Cost
Administrative Cost with fees
Medical Trend
Prescription Trend
Stop Loss Trend
PPACA Administrative Fee
*Budgeted
2014-2015
$806,891
$2,000,000.00
$2,235,939*
$806,891
6.8%
$146,241,899.54
10.65%
16.74%
6%
8%
30%
1.4% plus Federal Liaison: $175,000
2013-2014
$5,288,203
$2,066,042
$3,183,804
$1,245,429
4.5%
$134,028,025.18
10.41%
16.89%
7%
9%
30%
1.88% plus Federal Liaison: $175,000
3
2012-2013
$3,055,684
$2,247,466
$2,974,554
4.7%
$120,872,471
10.52%
17.28%
7%
10%
30%
Rerate Letter
High Dollar Claim Review - 2013-2014: 10.2%
$ Amount (in Millions)
Number of Potential Covered Individuals
2.0
1
2.25 $2.5
1
2
$2.75
1
$3.0
1
$3.5
1
$4.5
$4.7
1
$5.5
1
Pool Membership Rate Overview
TML MultiState IEBP understands the impact of today’s economy and the challenges confronting our Members.
2014-2015
TML MultiState IEBP Equity
Return $806,891 | Average
Rate Increase 6.8%
2% of Member did NOT get
a rate increase
7% of Members received a
decrease in rates
38% of Member had an
increase
under 5%
28% of Members had an
increase between 5-10%
increase
between 11-15%
increase over 15%
2013-2014
TML MultiState IEBP Equity
Return $5,288,203 | Average
Rate Increase 4.5%
2012-2013
2011-2012
3.4 million TML MultiState IEBP 797 Political Subdivisions depend
investment income offset the cost on TML MultiState IEBP to provide
YOUR healthcare | Average Rate
value based employee benefits
Increase 4.7%
and rate stability.
a rate increase
a rate increase
a rate increase
decrease in rates
decrease in rates
decrease in rates
19% of Member had an increase 16% of Member had an increase
26% of Member had an increase
under 5%
under 5%
under 5%
9% of Members had an increase
between 5-10%
between 11-15%
between 5-10%
between 11-15%
increase over 15%
over 15%
4
between 5-10%
between 5-15%
Employee Ease to Healthcare Transparency
 Electronic Friendly Benefit Management Resources









MyBenefits on Demand
Electronic EOB
MyMobileMe
Electronic claim information interface
IEBP Website
Timeliness and accuracy of annual eligibility audit
Prescription RePortal
Teach & Learn Library
Mobile Applications
5
MyBenefits on Demand Order Form
6
Employee Sensitivity to Out of Pocket Management

Minimize Out of Pocket Spend for Covered Individual

Provider
 Medicare Secondary Payer
 Clinical Protocol
 Electronic Fund Transfers
 ACH
 Virtual Card
 Enhancement of Electronic Payment Solutions


 Provider Coding Guidelines
Privacy Practices
Supplemental Benefits
 EAP
 Face to Face
 Tele-counseling
 Supplemental Benefits
 Cancer
 Critical Care
 Accident
 Access to Online Enrollment Navigators
7
Provider Pricing Transparency

Compass: Jim Landers [email protected]
 Healthcare Economics Knee Surgery
 Hospital, Surgeon, Anesthesiologist: For each knee the bill came to roughly $32,000.
Michael Toomey, president of Compass Care Engineering in Dallas states for Dallas average
is between $42,000 and $43,000.
 Government Accountability Office report covering a small sample of hospitals found that
one knew replacement was $5,200 while another paid $9,500 for the same device. Prices
seem to run between $2,000 and $16,000 for the device.
 Compass uses the fair health repricing table.
 IEBP strongly believes in repricing transparency.
 We engaged with Optum and will offer the membership a transparency tool attached
to a professional health coach 10.1.14.
 Provider Transparency
 21 Care Paths and 52 procedures
 Pricing transparency is key, but performance based outcome is the deliverable.
 Due to co-morbidities, personal preferences and performance based outcome
steerage the IEBP professional health coaches will work with your employees within
twenty-once care paths.
 On the above care path, the IEBP data per the UnitedHealthcare Choice Plus network
states for total knew replacement the facility fees range from $7,466 to $42,319.
Baylor fees are $18,952.
8
Care Path Variances in Pricing
Market
Austin
Care Path Name
Service Name
Total Hip Replacement Major Joint Replacement
Total HIp Replacement (THR)
Physical Therapy Visit Charge
No. of
Providers/Facilities
14
50
30
Minimum Median
$10,792 $15,850
$1,127
$2,327
$280
$1,720
Dallas
61
110
79
$7,466
$1,446
$260
$25,576 $40,099
$1,735 $2,331
$1,640 $2,250
$42,319
$3,634
$3,650
Houston
Physical Therapy
42
82
55
$9,796
$1,169
$138
$20,654 $27,868
$1,408 $2,042
$630
$1,698
$49,878
$3,263
$1,890
San Antonio Total Hip Replacement Major Joint Replacement
20
35
23
$9,740
$1,123
$310
$19,931 $21,799
$1,504 $2,821
$1,280 $2,050
$25,280
$3,750
$2,230
West Texas Total Hip Replacement Major Joint Replacement
8
12
14
$16,580
$1,955
$600
$21,864 $23,131
$2,000 $2,140
$1,040 $2,060
$23,131
$2,666
$2,550
East Texas
11
29
24
$6,400
$1,333
$290
$15,582 $30,612
$2,408 $3,171
$1,140 $2,220
$98,319
$3,171
$3,990
9
90th
Percentile Maximum
$22,819 $22,819
$2,779
$2,779
$2,220
$3,700
Market
Austin
Dallas
Houston
Care Path Name Service Name
'Back Pain - Lumbar Spinal Fusion - Except Cervical Spine
Laminectomy
Fusion of two vertebrae in the lumbar spine
Anesthesia for extensive spine and spinal cord surgery
Lumbar Laminectomy; removal of bone or bone spurs
in lower back
Wiring of Vertebrae to Support Spine
No. of
Providers/
90th
Facilities Minimum Median Percentile Maximum
10
$15,699 $30,423 $32,111 $32,111
35
3
30
7
$1,524
$2,067
$252
$1,239
$2,226
$2,179
$1,548
$1,406
$2,889
$2,292
$1,998
$1,572
$3,078
$2,292
$3,330
$1,572
38
$734
$1,090 $1,373
$1,463
Laminectomy
in lower back
43
$23,770
$47,855 $93,641
$106,302
20
86
79
11
$1,370
$1,605
$234
$1,211
$2,362
$1,925
$1,476
$1,440
$3,494
$4,026
$2,025
$2,760
$6,765
$4,756
$3,285
$3,018
93
$739
$927
$2,409
$2,409
Laminectomy
in lower back
19
$7,317
$35,374 $46,954
$47,490
17
55
69
12
$1,485
$1,114
$225
$817
$1,931
$1,552
$1,332
$1,014
$2,626
$2,420
$2,556
$1,693
$2,940
$4,372
$3,312
$1,693
37
$564
$755
$1,124
$1,127
10
Market
Care Path Name Service Name
San Antonio 'Back Pain - Lumbar Spinal Fusion - Except Cervical Spine
Laminectomy
in lower back
No. of
Providers/
90th
9
$36,645 $52,069 $52,069 $52,069
27
3
6
$1,229
$1,623
$1,042
$1,767 $2,197
$1,706 $1,729
$1,275 $1,605
$2,984
$1,729
$1,605
23
34
$279
$612
$1,152 $1,845
$856 $1,109
$2,007
$1,109
West Texas 'Back Pain - Lumbar Spinal Fusion - Except Cervical Spine
Laminectomy
in lower back
5
$33,424
$42,222 $43,099
$43,099
10
3
3
$1,229
$1,707
$1,521
$2,075 $3,050
$1,714 $1,928
$1,521 $1,521
$3,304
$1,928
$1,521
11
$1,051
$1,283 $1,378
$1,674
East Texas
5
$8,274
$30,487 $54,700
$54,700
11
3
$1,460
$1,930
$2,685 $2,920
$1,930 $1,930
$2,920
$1,930
16
24
$739
$261
$1,378 $1,498
$1,026 $1,998
$1,498
$3,591
Laminectomy
in lower back
11
Market
Austin
Care Path Name
'Knee Arthroscopy With
Meniscectomy
No. of
Providers/
90th
31
$1,600
$2,746 $7,424
$7,424
Service Name
Operating Room Services
Knee Arthroscopy with Meniscus Repair 88
Dallas
Meniscectomy
93
Houston
Meniscectomy
63
San
Antonio
Meniscectomy
20
West Texas 'Knee Arthroscopy With
Meniscectomy
8
East Texas 'Knee Arthroscopy With
Meniscectomy
12
12
$494
$871
$1,054
$1,156
$1,345
$4,456 $6,464
$9,238
$332
$725
$1,378
$1,313
$4,633 $6,500
$8,823
$509
$606
$1,410
$1,288
$4,221 $5,245
$9,310
$457
$649
$1,219
$1,500
$2,415
$4,200 $7,387
$7,387
$586
$866
$1,173
$1,747
$3,067 $5,131
$15,302
$833
$1,071 $1,377
$1,377
$974
$897
$1,173
Market
Austin, Tx
Dallas, Tx
Houston, Tx
San Antonio, Tx
Western Tx
Eastern Tx
Austin, Tx
Dallas, Tx
Houston, Tx
Care Path Name
MRI Scan - Lower Spine
CT Scan - Abdomen and
Pelvis
Pelvis
Pelvis
San Antonio, Tx CT Scan - Abdomen and
Pelvis
Western Tx
Eastern Tx
Pelvis
Pelvis
No. of
Providers/
Facilities
40
135
129
42
20
36
28
90th
Minimum Median Percentile
$311
$817
$1,780
$299
$881
$1,881
$337
$715
$1,656
$430
$724
$1,564
$432
$1,264 $2,677
$430
$965
$2,533
$738
$1,038 $6,308
Maximum
$2,055
$2,823
$3,139
$2,372
$4,404
$4,161
$7,422
CT scan of the abdomen and pelvis
with contrast
CT scan - General Classification
12
$320
$367
$1,030
80
$271
$1,443 $1,730
$6,520
with contrast
36
$284
$357
$1,570
53
$406
$1,327 $2,154
$5,028
with contrast
52
$268
$364
$606
$2,439
28
$604
$907
$2,654
$4,837
with contrast
66
$320
$465
$465
$757
9
$849
$1,204 $5,721
$5,721
with contrast
3
$517
$736
$1,174
$1,174
21
$544
$901
$3,835
$5,026
with contrast
9
$355
$537
$844
$844
Service Name
MRI - Spine
MRI - Spine
MRI - Spine
MRI - Spine
MRI - Spine
MRI - Spine
13
$736
$778
Market
Austin, Tx
Dallas, Tx
Houston, Tx
San Antonio, Tx
Western Tx
Eastern Tx
Care Path Name
CT Scan - Chest
CT Scan - Chest
CT Scan - Chest
CT Scan - Chest
CT Scan - Chest
CT Scan - Chest
Service Name
CT Scan - General Classification
No. of
Providers/
Facilities
Minimum Median
25
$663
$948
90th
Percentile Maximum
$1,742
$3,650
CT scan of the chest with contrast
13
$252
$325
$680
$707
73
$296
$1,245
$1,608
$3,403
35
$260
$325
$680
$1,710
49
$403
$1,084
$1,504
$2,290
42
$220
$358
$680
$1,113
20
$562
$751
$1,791
$2,436
62
$293
$388
$390
$565
9
$575
$1,216
$2,776
$2,776
5
$433
$509
$1,216
$1,216
20
$475
$833
$2,214
$2,336
8
$325
$581
$698
$698
14
Medical Benefit Updates
 Benefit Update
 Benefit Changes
 Medical | Dental | Vision
 Consumer Centered Eligible Benefits
 The Trustees voted to Opt Out of the Title I of the Health
Insurance Portability and Accountability Act of 1996 (HIPAA)
 Mental Health Parity
 Network
 Choice Plus: Premium Doctors Identified by Tiers: Performance
Based Outcome Focus
• Plan Year 2011-2012: 59.63%
• Choice Plus Plan Year 2012-2013: 60.63%
• Choice Plus Plan Year Oct 2013 - Feb 2014: 60.12%
 OptumInsight/UnitedHealthcare Centers of Excellence/Designated
Centers of Treatment in conjunction with UnitedHealthcare Choice
Plus Network Providers
 Emergency Providers negotiations at network facilities is ongoing
15
Administrative Services Improvements
 Health Information Technology Update
 Conversion to ICD 9 to ICD 10
 Second Delay from Federal Government until October 2015
 Electronic Services




Internet Upgrade
Customer Care Upgrade
Electronic Eligibility Audit
Online Enrollment
 MyMobile Me
 Electronic Explanation of Benefits
 Electronic Claim Information
 Prescription RePortal
 MyBenefits on Demand
 Employer Custom Benefit Information
 Electronic Fund Transfers
 Electronic Explanation of Payment
 Medical Intelligence VITAL Upgrade
 Provider Transparency
 MyTeach and Learn Tutorials Webcast Library
16
 Health Information Technology Update
 QicLink Claim Adjudication System
 QicLink Front End Preprocessing (QL FEPPS) Upgrade
• Member identification
• Prompt Pay
 Out of Network Repricing
 System Down Time
 Current Turnaround Time
Claims
2013-14
Oct
8.35
Nov
6.69
Dec
6.43*
17
Jan
9.12
Feb
8.81**
Mar
13.37
April
10.09
 Health Information Technology Update (HITECH)
 QicLink Claim Adjudication System Conversion
 Latency Issues
 Log In Issues
 Claim Adjustments
 Bill Processing
 Out of Network Repricing
 Network Contract Code
 Accumulator Carry Over Amounts
 Loss of Functionality
 TML MultiState IEBP Recalibration for HITECH
Workflow Management
18
Patient Protection Affordable Care Act
 Minimum Essential Benefits
• Minimum Essential Benefit Compliance delayed the effective date until 2015
(along with the delay of the employer penalty provision.) The first required
reports will occur in early 2016 based on 2015 information.
• Ambulatory patient services, Emergency services, Hospitalization, Maternity and
Newborn Care, Rehabilitative/Habilitative Services and Devices, Pediatric
Services including Oral and Vision Services (Pediatric defined child to attained 19
years of age), Laboratory Services, Preventive and Wellness, Chronic Care
Management, Mental Health and Substance Use Disorder services (including
Behavioral Health ),
• Mental Health and Substance Abuse Disorder Parity mandate (substantially 2/3
of benefits) and predominately (1/2 of benefits) to medical and surgical care for
all Levels of Care Plan Years July 2014 thereafter.
• Six classifications: network inpatient and outpatient, out of network inpatient
and outpatient, emergency room and prescription including medical necessity
decisions.
• Preventive Services mentions: alcohol screening and counseling, depression
counseling and tobacco-use screening.
• EAP parity excluded unless greater than ten visits.
• Participants must not be required to exhaust benefits under the EAP (e.g., a
gatekeeper EAP) before an individual is eligible for benefits under the medical
health plan.
19
 Minimum Essential Benefits
• Prescription drugs (Use of US Pharmacopeia’s (USP)
Model Guidelines as a common organizational tool for
plans to report drug coverage.
• Plan must offer one drug for each USP category and class
or the number of drugs in the EHB benchmark Plan),
• Prior Authorization can be used as long as it is not
discriminatory Health Plans have two options:
• Cover at least the greater of: One drug in every category.
Same number of drugs in each category and class as the
benchmark plan.
• Covered benefits and limitations of coverage must
remain substantially equal to the benefits in the State’s
Essential Health Benefits benchmark plan.
20

Minimum Essential Coverage Benefit Reporting Requirements
 The 6055 reporting requirement is to provide information regarding MEC (minimum
essential coverage) as an aid in enforcing the individual mandate provision of the
Affordable Care Act. The following entities are responsible for filing the section 6055
return with respect to MEC provided under a group health plan:
 Health insurance issuer with respect to fully insured coverage
 In the case of a self-insured single employer/group health plan, the “plan sponsor”
 In the case of a self-insured multiemployer plan, the association, committee, joint board
of trustees or other similar group of representatives of the parties who establish or
maintain the plan
 The employee organization (i.e., union) in the case of a self-insured plan maintained
solely by the employee organization
 In the case of a self-insured governmental group health plan, the governmental employer
may enter into a written agreement with another governmental unit to make the
required reporting.
 Participating employers in a MEWA
 If not otherwise indicated, plan sponsor, plan administrator or entity that maintains the
plan
 The 6055 return is required to be filed with the IRS no later than February 28 if filing nonelectronically, March 31 if filing electronically.
 The IRS requires 6055 returns to be filed electronically unless the aggregate of all returns
(w-2’s 6055 returns) the reporting entity is required to file less than 250.
21
Medical and SBC Summary of Benefit Plan Changes PY14-15
Changes are in red
 Contact Table
Resource
TML MultiState Intergovernmental Employee Benefits Pool
1821 Rutherford Lane, Suite 300 | Austin, Texas 78754
Customer Care Helpline:
Secured Customer Care E-mail:
TML MultiState IEBP Internet Website:
Medical Notifications:
Prescription Authorizations:
Professional Health Coaches:
Contact Information
Accessible Hours
(800) 282-5385
Visit www.tmlmultistateiebp.org | click on the
“Login” button | click on “Online Customer Care”
under the “My Tools” menu
www.tmlmultistateiebp.org
(800) 847-1213
(888) 871-4002
(800) 818-2822
8:30 AM - 5:00 PM Central
Twenty-four (24) hours
8:30 AM - 6:00 PM Central or
Scheduled Appointment
Spanish Line:
Where to Mail Paper Medical Claims:
(800) 385-9952
TML MultiState IEBP
PO Box 149190 | Austin, Texas 78714-9190
Restat | Patient Reimbursement
Where to Mail Paper Prescription Claims:
11900 W. Lake Park Drive | Milwaukee, WI 53224
1-800-Teladoc | Teladoc.com
Telemedicine:
Call 911 or immediately go to the emergency
After Hours and/or Weekend Medical and Mental Healthcare Emergencies:
department.
Visit www.tmlmultistateiebp.org/ | click on the
Cultural Sensitive Counties: Summary of Benefits and Coverage (SBC) and benefit declinations can be
“Login” button | click on “Online Customer Care”
requested in Spanish in the following counties. County list may be updated midyear.
under the “My Tools” menu
Counties
Year
Andrews | Atascosa | Bailey | Bexar | Brooks | Cameron | Camp
2013
Castro | Cochran | Collingsworth | Concho | Crane | Crockett
Crosby | Culberson | Dallam | Dallas | Dawson | Deaf Smith
Dimmit | Duval | Ector | El Paso | Floyd | Frio | Gaines
Garza | Gonzales | Hale | Hall | Hansford | Harris | Hemphill
Hidalgo | Howard | Hudspeth | Jim Hogg | Jim Wells | Karnes
Kinney | Kleberg | Lamb | La Salle | Limestone | Lipscomb | Lynn
Maverick | Midland | Moore | Navarro | Nueces | Ochiltree
Parmer | Pecos | Potter | Presidio | Reagan | Reeves
San Patricio | Sherman | Starr | Sterling | Sutton | Tarrant
Terry | Titus | Travis | Upton | Uvalde | Val Verde | Ward
Webb | Willacy | Winkler | Yoakum | Zapata | Zavala
22
Changes are in red

Notice to Plan Participants - Pg. 3
 Following a covered mastectomy, the Plan will pay for the initial
reconstructive treatment episode of both the affected and the unaffected
breast to restore symmetry. Reconstructive surgery includes tissue
expanders, breast implants, nipple reconstruction and nipple tattooing and
removal of initial prosthetics due to complications.
 For coverage ending prior to December 31, 2014, HIPAA requires the Plan to
provide covered employees and dependents with a “certificate of creditable
coverage” when they cease to be covered by the Plan. There is no
exemption from this requirement. The certificate provides evidence that
you were covered under this Plan, because if you can establish your prior
coverage, you may be entitled to certain rights to reduce or eliminate a preexisting condition exclusion if you join another employer’s health plan, or if
you wish to purchase an individual health insurance policy. Employees and
dependents may request a certificate of creditable coverage at any time for
coverage ending before December 31, 2014 by calling IEBP’s Customer Care
staff at (800) 282-5385. (The creditable coverage letter will not be required
after December 31, 2014 due to the prohibition of the pre-existing
limitation for plan year January 1, 2014 thereafter and extended plan
years.)
23
Medical and SBC Summary of Benefit Plan Changes
PY14-15 Changes are in red
 Medical Intelligence Care Management Features
 Notification does not constitute verification of
eligibility for benefits.
 Notification Requirements
SERVICE
Inpatient Admissions
Scheduled Specialty Admissions
 Orthopedic/Spine Surgeries (spinal surgeries, total knee replacements, and total hip
replacements)
 Transplants: At least ten (10) working days prior to any pre-transplant evaluation, the
Covered Individual or a family member must provide Notification to Medical Intelligence
Care Management; failure to do so will result in a Late Notification Penalty of $400 or a
reduction in benefits.
 Reconstructive/Potentially Cosmetic procedures
 Bariatric Surgery: after the approved six (6) consecutive months (within the most recent
twelve (12) months) physician supervised weight management treatment plan
 Congenital Heart Disease
Other Inpatient Admissions
 Skilled Nursing Facility
 Mental Health/Substance Use Disorder Inpatient
 Mental Health/Substance Use Disorder Residential Treatment
 Acute Care Hospital/Facility
 Long Term Acute Care Facility
 Acute Rehabilitation Facility
 Scheduled Cesarean Section Delivery
NOTIFICATION
LATE NOTIFICATION PENALTY
Facility: twenty-four (24)
hours after actual admission
or by 5 pm the next business
day for weekend/holiday
admissions
$400
Three (3) working days prior to $400
services
Facility: twenty-four (24)
hours after emergency
admission or by 5 pm the next
business day for
weekend/holiday admissions
24
SERVICE
Inpatient Admissions
Inpatient Pregnancy/Maternity (Delivery Admission)
 Vaginal Delivery admission in excess of forty-eight (48) hours
 Cesarean delivery admission in excess of ninety-six (96) hours
 Inpatient antepartum care or other undelivered admissions
 Newborns who remain in the hospital after mother is discharged
Pregnancy/Maternity
 Sonogram/Ultrasound in excess of three (3)
 Amniocentesis
 Home Health (uterine monitoring)
 All High Risk obstetrical services
 Multiple birth diagnosis
Scheduled Outpatient/Office Surgical Procedures
 Blepharoplasty (eyelid surgery)
 Breast Surgery (excludes Breast Biopsies)
 Carpal Tunnel Release (nerve decompression)
 Jaw Surgery (including mandibular joint)
 Joint Surgery (excluding fingers & toes)
 Laparoscopy (except sterilization)
 Myringotomy or Myringoplasty (tympanic/ear drum surgery)
 Nasal Surgery
 Tonsillectomy and/or Adenoidectomy
 Uvulopalatoplasty (roof of mouth surgery)
 Reconstructive Surgery
 Spinal Surgery
 Cochlear Device and/or Implantation
 Stereotactic Radiosurgery
 Bariatric Surgery: after the approved six (6) consecutive months (within the
most recent twelve (12) months) physician supervised weight management
treatment plan
Outpatient/Office Infusion Therapy
 For Pain Management
 Oncological Chemotherapy
25
NOTIFICATION
Facility: twenty-four (24) hours after actual
admission or by 5 pm the next business day for
weekend/holiday admissions
$400
Three (3) working days prior to commencement for $200
office, outpatient and Home Health procedures,
within forty-eight (48) hours of multiple birth
diagnosis or high risk pregnancy
Three (3) working days prior to procedures
$200
Prior to commencement
$200
SERVICE
Miscellaneous
 Mental Health/Substance Use Disorder Day Treatment
 Hospice
 Home Health Care
 Physician Home Visit
 Cardiac Rehabilitation
 Pulmonary Rehabilitation
 Positron Emission Tomography (PET) scans
 Computerized Axial Tomography (CAT) scans
 Computerized Tomographic Angiography (CTA) scans
 Magnetic Resonance Imaging (MRI) scans
 Magnetic Resonance Angiography (MRA) scans
 Single Photon Emission Computed Tomography (SPECT)
 Dental Injury (inpatient and outpatient)
 Dialysis for Kidney/Renal Failure
 Hyperbaric Oxygen Therapy
 Radiation Therapy
 Medically Necessary Evidence-Based Genetic Testing to direct treatment (after
diagnosis has been established)
 Durable Medical Equipment
NOTIFICATION
Three (3) working days prior to procedures
$200
Three (3) working days prior to dispensing/delivery of $200
durable medical equipment for charges in excess of
$1,000 per base piece of durable medical equipment
prior to purchase, lease, or rental
26
Role of Benefits | Wellness and Prevention Programs
% of
Attraction/Retention
Employees
28%
38%
61%
34%
Important reason in
deciding to work for a
company
Selected Wellness and Preventive Health Benefits
Offered by Employers, 2009-2013
Program
2013
2012
2011
2010
2009
Wellness
64%
61%
60%
59%
59%
24-hour Nurse Hotline
55%
54%
53%
56%
50%
Health Screening
50%
45%
42%
43%
38%
Health and Lifestyle Coaching
48%
45%
37%
33%
33%
Customizable package
increases employee
loyalty
Smoking Cessation
44%
39%
36%
39%
39%
Rewards for Health/
Wellness Completion
43%
35%
31%
28%
23%
Paying a larger share
of benefits decreases
employee loyalty
Prevention for Chronic
Conditions
42%
36%
33%
33%
30%
Weight Loss
37%
32%
30%
30%
30%
Important reason to
continue working for a
company
Source: MetLife, Inc. 2013
Source: Society for Human Resource Management
27
Changes are in red
 Eligible Benefits
 Well Woman/Contraceptive Benefits
Benefit
Medical Plan
Prescription Plan
X
IUD Device (no cost share)
Implant Device (no cost share)
X
X
X**
X**
Permanent Implantable Contraceptive Coil (subject to the appropriate deductible and benefit
percentages)
X
Insertion and/or Removal of Devices (no cost share)
Sonogram to Detect Placement of Device (no cost share)
X
X
Injectable Contraceptives/Align Network (no cost share)
Injectable Administration Fee (no cost share)
X
X
Oral Contraceptives generic/Align Network (no cost share)
Diaphragm, Hormone Vaginal Ring, Hormone Patch, Cervical Cap, Spermicides, Sponges (no
cost share)
Diaphragm Instruction and Fitting Fee (no cost share)
Contraceptive Management (no cost share)
Female Condoms
X
X
X
X
X
Medications for risk reduction of breast cancer in women who are at increased risk for
breast cancer and at low risk for adverse medication effects. Tamoxifen or raloxifene:
Tamoxifen is generic and fairly inexpensive - $20; Rx Raloxifene (Evista) is not generic yet
28
X
Changes are in red
 Preventive/Routine Care Benefit (Calendar Year)
 The following will be processed for network
reimbursement at 100% of network allowable.
 Non-network provider eligible billings will be subject to
usual and reasonable charges and are subject to the nonnetwork deductible and benefit percentage.
 To be considered as an eligible preventive/routine care
benefit, the provider’s bill must designate or outline a
routine diagnosis code.
 These measures represent important areas for quality
improvement by assessing the use of services that are
recommendations from the U.S. Preventive Services Task
Force (USPSTF) and other national organizations.
29
Changes are in red
Age & Gender Biometric Screenings
Health Power Assessment
Questionnaire
Preventive Office Visit
Lipid Panel
Comprehensive Metabolic Blood
Panel
TSH
Female Female Female Female Female Female Female Male Male
18 thru 30 thru 36 thru 40 thru 50 51 thru 74+
18
40
29
35
39
49
73
thru 3 thru
9
50
Male
71+
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
PSA
X
Fecal Occult (including colonoscopy and sigmoidoscopy as a
qualifier)
Mammogram
* 1 per CY for females age 40 thru 49
** 1 every 2 CY for females age 50 thru 73
PAP
every 3 CY for females age 30 thru
50
Male
51
thru
70
X
X
X
X
X
X*
X**
X**
X
X
30
X
X
X
X
Changes are in red
 Preventive/routine care benefits also includes:

General Health
Panel
Screening for Visual
Acuity
TB test

PAP Smear



Rubella Screening


Well Baby Care/Well Child Care


Hearing Screening


Mammograms


Urinalysis


Prostate Specific Antigen (PSA)
TSH
Bone Density
Screening
Basic
Metabolic Test
Venipuncture

Women's
Reproductive Health
Annual Examination

Autism Screening – eighteen (18) and twenty-four (24) months of age

31
Skin Cancer
Counseling
Changes are in red


Preferred Lab must be routine diagnosis for 100% payment for High Deductible
H.S.A. Plans if deductible has not been met
Population Health Engagement/Chronic Care Management





Healthy Initiative Biometric Screenings
Health Power Assessment
Personal Health Record
Personal Health Profile
Spreadsheet to Employer regarding Healthy Initiative Participation if implementing
a cost share program for lack of covered individual participation
 Self Assessment Tools and Healthy Living Resources
 There are self assessment tools located on the IEBP website including the Health Power
Assessment and Wheel of Life. Healthy Living Resources include: Healthy Living Guides,
Healthy Living Fact Sheets, and helpful website links.
 Professional Health Information Line
 Professional Health Coaches will answer basic health and medication questions and assist
covered individuals with the Healthy Initiatives Incentive Program.
 The Personal Health Engagement Program includes:
 Opt In: Enrollment method by which covered individuals call the professional health
coaching line and request a professional healthcare coach or agree to professional health
coaching upon receipt of an outreach call or letter. Covered individuals may enroll by
calling (888) 818-2822.
32
Health Engagement Resources
Topic
PHASE I - ASTHMA
Asthma
Healthy
Health Fact
Living Guides Sheets
Status
Status
Webcast
Status
Bi-annual
Update
Consider for
2015
Yes
Self Mgm't Self Mgm't Gaps in Care
Assessment Tools on Web Letters
Modules of Care
No
Yes-3nd
Quarter
2014
Yes-Fall
Phase I- Completion of Health Power Assessment
Phase II- Completion of Wheel of Life and review of results
of HPA & WOL
Phase III- Introduction- Overview, Risk Factors, Signs and
Symptoms, and Diagnosis
Phase IV- Tools of the Trade
Phase V- Medication Treatments and Healthy Lifestyle
Choices
Phase VI- Triggers (irritants, allergens, infections, acid reflux
or GERD, weather, physical activity, and emotions) and How
to Avoid Them
Phase VII- Action Plans
Coaching Use Only: Asthma Medication Table, Symptoms of
Asthma Flares
PHASE II - CARDIOVASCULAR
CV-Hypertension
Bi-annual
Update
Bi-annual
Update
Consider for
2015
No
Yes-3nd
Quarter
2014
33
Yes- Feb
Managing High Blood Pressure
of HPA & WOL
Phase III- Introduction
Phase IV- Medications Used to Lower Blood Pressure
Phase V- Lifestyle Changes to help manage high blood
pressure
Phase VI- Setting Health Goal and Resources
Healthy
Health Fact
Living Guides Sheets
Status
Status
CV-Hyperlipidemia Bi-annual
No
Update
Webcast
Status
Consider for
2015
CV-CAD/Ischemic
Vascular Disease
In
No
developmen
t
Bi-annual
Yes
Update
Bi-annual
Update
see HTN,
Lipids
Topic
COPD
CAD
Heart Disease
Modules of Care
No
Yes-3nd
Quarter
2014
Yes- Feb
Consider for
2015
No
No
Yes- Feb
Consider for
2015
No
No
Yes- Fall
No
No
No
No
Yes- Feb
Yes
Consider for
2015
No
No
Yes- Feb
34
of HPA & WOL
Phase III- Introduction to Series
Phase IV- What is Cholesterol?
Phase V- Heart Disease Risk Factors
Phase VI- What is Your Heart Disease Risk?
Phase VII- Cholesterol Management Plan Overview-Making
it All Work
Phase VIII- TLC Diet Overview
Phase IX- Eating Out Tips/ Holiday and Special Occasion Tips
Phase X- Fiber and Other Dietary Factors
Phase XI- Food Labels
Phase XII- Exercise Safety and Physical Activity
Phase XIII- Cholesterol Lowering Medications
of HPA & WOL
Phase III- Introduction to COPD
Phase IV- COPD and Treatment
Phase V- COPD and Daily Life
Phase VI- COPD and Nutrition
Phase VII- COPD and Activity
Healthy
Living
Topic
Guides
Status
PHASE III - DIABETES
Diabetes
Bi-annual
Update
Health
Fact Sheets
Status
Yes
Webcast
Status
Self
Self
Mgm't Gaps
Mgm't
Tools on in Care
Assessment Web
Letters Modules of Care
Yes-3nd
Quarter
2014
YesNov
No
No
Yes
No
YesMarch
2014
No
No
No
No
No
Yes-3nd
Quarter
2014
No
Webcast
No
planned for
Nov 2014
PHASE IV - HEPATITIS INFECTION
Hepatitis
No
No
no
No
Infection
PHASE V - MENTAL HEALTH/SUBSTANCE USE DISORDER
Depression
Bi-annual Needs
Planned for No
Update
development Mar 2014
Mental Health Bi-annual
Update
Managing
Bi-annual
Stress
Update
Avoiding Risky Bi-annual
Drinking
Update
Needs
No
development
Bi-annual
Deer Oaks
Update
No
No
Phase II- Completion of Wheel of Life and review of results of HPA & WOL
Phase IV- Diet-General Information
Phase V- Diet- Heart Healthy
Phase VI- Physical Activity
Phase VII- Meds
Phase VIII- Monitoring
Phase IX- Highs and Lows
Phase X- Neuropathy
Phase XI- Dental
Phase XII- Depression
Phase XIII- Eyes
Consider development in 2014
No
Risk of Alcohol Use
Phase II- Completion of Wheel of Life and review of results of HPA & WOL
Phase III- Risks of Alcohol Use, "Standard Drink" size, "Low-Risk" Drinking
Phase IV- "At Risk" Drinking, Symptoms of Alcohol Use Disorder
Phase V- Reduce Risks, Pattern of Alcohol Use: Low Risk or Moderate/High Risk?
Phase VI- Alcohol Healthy Change Plan, Resources and Tools
35
Topic
Behavioral Health Practice
Guideline
Behavioral Health Practice
Guideline-for children
Healthy Living
Guides
Status
Consider
development in
2015
Consider
development in
2015
Health Fact
Sheets
Status
No
Webcast
Status
No
Modules of Care
No
No
No
No
No
No
No
No
Bi-annual Update No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Consider for
3rd Quarter
2014
No
No
No
No
Bi-annual
Update
Needs
development
No
Consider in
2015
Planned for
April 2014
No
No
No
No
No
No
No
Yes-April
2014
No
No
No
No
No
No
No
Yes-prev
health-June
Np
No
No
No
No
Cancer- Cervical
Bi-annual
Update
No
Bi-annual
Update
Bi-annual Update Bi-annual
Update
No
No
No
No
No
Cancer-Colon
None
No
No
No
Yes-prev
health-June
Yes-prev
health-June
PHASE VI - BALANCED LIVING
Financial Health
Sleep
Sleep Apnea
Suicide Prevention
Grieving
Bi-annual Update
Bi-annual Update
Bi-annual Update
Needs
development
Managing the Season in
Yes-Stress
Emotional and Physical Health Management
Physical Activity
Needs
development
Chronic Fatigue Syndrome
Bi-annual Update
PHASE VII - CANCER
Cancer-Breast
No
Cancer-Prostate
Cancer-Skin
Annual
Update
36
No
No
No
No
No
Healthy Living Health Fact
Guides
Sheets
Status
Status
PHASE VIII - WEIGHT MANAGEMENT/NUTRITION
Weight
Bi-annual
Needs
Management
Update
development
Topic
Healthy Eating
Bi-annual
Update
Bariatric Surgery
Bi-annual
Update
Healthy Weight
Bi-annual
(BMI) Maintenance Update
Eat Right and
No
Exercise
PHASE IX - MUSCULOSKELETAL
Back Pain
Bi-annual
Update
Osteoarthritis
Bi-annual
Update
Osteoporosis
Bi-annual
Update
Rheumatoid
Bi-annual
Arthritis
Update
Webcast
Status
Offered
1/23/14
Needs
Consider for
development 2015
No
No
Modules of Care
No
Yes
No
No
No
No
No
No
No
Needs
development
Bi-annual
Update
Offered
1/23/14
Consider for
2015
No
Yes
No
No
No
No
No
No
No
No
No
Consider for
2015
No
No
No
No
No
No
No
No
No
No
No
No
No
No
37
Weight Loss
of HPA & WOL
Phase III- Assessment and Setting Weight Loss Goal
Phase IV- Methods of Dieting
Phase V- Food Labels
Phase VI- Meal Planning and Grocery Shopping
Phase VII- Support Networks
Phase VIII- How to Get Through Weight Loss Plateaus
Phase IX- How to Maintain Weight and Cope with Diet
Relapses
Phase X- Eating Out Tips
Phase XI- Emotional Eating and Food Triggers
Phase XII- Physical Activity Safety
Phase XIII- Physical Activity
Healthy Living
Guides
Status
PHASE X - PREVENTIVE
Smoking Cessation Bi-annual
Update
Health Fact
Sheets
Status
Webcast
Status
Bi-annual
Update
Consider for
2015
No
No
No
Preventive Health
Consider
Guidelines-Perinatal development
in 2015
No
No
No
No
No
Preventive Health
Consider
Guidelines-children development
to 24 mos.
in 2015
No
No
No
No
No
Preventive Health
Consider
Guidelines-children development
2-19
in 2015
No
No
No
No
No
Preventive Health
Guidelines-Adults20-64
Consider
development
in 2015
No
No
No
No
No
Preventive Health
Guidelines-Adults
65>
Consider
development
in 2015
No
No
No
No
No
Dental Health
No
No
No
No
No
Eye Health
Bi-annual
Update
Bi-annual
Update
Bi-annual
Update
No
No
No
Yes-*
Topic
Modules of Care
38
Tobacco Cessation
of HPA & WOL
Phase III A- Person Just Quit Tobacco
Phase IV- Preparing to Quit
Phase V- Support Immediately Following Quitting,
Phase V A- Relapse
Phase VI A- Maintenance
Phase VI B- Maintenance
Topic
Healthy Living
Guides
Status
Health Fact
Sheets
Status
Vaccinations for Adults
No
Bi-annual
Update
No
No
No
No
Childhood Immunizations
No
Needs
development
No
No
No
No
Healthy Pregnancy
Bi-annual Update
No
No
No
No
No
Men's Health
Bi-annual Update
Bi-annual
Update
Planned for
June 2014
No
No
No
Women's Health
Needs development Needs
development
Planned for
June 2014
No
No
No
Celiac Disease
Bi-annual Update
No
No
No
No
No
Gout
Bi-annual Update
No
No
No
No
No
Irritable Bowel Syndrome
Bi-annual Update
No
No
No
No
No
Migraine Headache
Bi-annual Update
No
No
No
No
No
Multiple Sclerosis
Bi-annual Update
No
No
No
No
No
Neuropathy
Bi-annual Update
No
No
No
No
No
Webcast
Status
Modules of Care
OTHER
39
Changes are in red
 Intensive Care Management
 Internal Medical Consultant
 External Clinical Specialty Review for Evidence Based
Medicine
 Medically Justified Review
 Independent Review Organizations
40
Changes are in red




Hospice Care Benefit Home Hospice will be paid at the network facility benefit
percentage.
Transplant Benefit
The transplant services must be performed at an OptumHealth Centers of
Excellence Centers. A list of OptumHealth Transplant Centers of Excellence may be
obtained from Medical Intelligence Care Management.
This benefit will cover charges resulting from organ transplantation for:
1. travel (if more than two hundred (200) miles one way to hospital or facility from
place of employment);
a. Private vehicle use will be reimbursed at the maximum allowable amount
determined by the Internal Revenue Service and reimbursement is limited to travel
between home and the Transplant Center. Airfare will be reimbursed at cost.
b. The Plan provides for ground or air transportation of the Covered Individual to and
from the pre-transplant evaluation, organ transplantation and any other Eligible
Benefit or follow-up appointment.
c. The Plan provides for ground or air transportation of each eligible companion to and
from the pre-transplant evaluation, organ transplantation and any other eligible
provider services or follow-up appointment.
d. Receipts will be required for reimbursement and submitted on an Expense Activity
Report.
41
Changes are in red

Transplant Benefit
2.
3.
4.
5.
6.
organ transportation;
donor medical benefits not covered under the donor’s plan of benefits;
locating and preserving the tissue for the transplant procedure;
fees for maintenance on an organ transplant waiting list;
food for the Covered Individual and eligible companion to a maximum of
thirty-five dollars ($35) each per day (if more than two hundred (200) miles
one way to the designated transplant facility from place of employment);
and
a. The Plan will pay for the Covered Individual and eligible companion’s
(age eighteen years of age or older) food during transplant-related
outpatient treatment that is an Eligible Benefit and the eligible
companion’s food during transplant-related inpatient.
b. Maximum food reimbursement rate of thirty-five dollars ($35) each per
day.
c. Receipts will be required for reimbursement and submitted on an
Expense Activity Report.
42
Changes are in red
 Transplant Benefit
7. lodging (if more than two hundred (200) miles one way to
the designated transplant facility from place of
employment).
a. The Plan will pay for the covered individual’s and the
eligible companion’s eligible lodging when the patient is
not confined to eligible facility.
b. The Plan will pay for the eligible companion’s lodging
when the patient is confined to an eligible facility.
c. Receipts will be required for reimbursement.
 The maximum travel, food and lodging benefit for the Covered
Individual is $10,000 and $5,000 for an eligible companion (per the
medical network Summary of Benefits and Coverage percentage).
Eligible companion is a person of the Covered Individual's choice.
43
Changes are in red

Morbid Obesity Benefit
 Bariatric Surgery: Morbid Obesity Services (after the approved six (6)
consecutive months [within the most recent twelve (12) month] physician
supervised weight management treatment plan).
 Morbid Obesity is defined as a condition for which a Covered Individual,
eighteen (18) years of age or older, is 200% over ideal weight or 100 pounds
overweight with a Body Mass Index (BMI) of greater than 40. A Notification
Review is required to review the eligibility for the medically evidence-based
surgical procedure. This review requires documentation of six (6)
consecutive months (within the most recent twelve (12) months) physiciansupervised weight management program that may include but is not
limited to nutritional education and a physical activity program. The
Covered Individual, treating physician or family member must provide
information for the Medical Intelligence Care Management notification
review. Failure to do so will result in no benefit coverage for morbid obesity
services. Medically evidence-based morbid obesity treatment will be an
eligible benefit subject to the lifetime maximum morbid obesity benefit
limitation.
44
Changes are in red

Morbid Obesity Benefit
 Morbid Obesity treatment will not be eligible for individuals with a substance
use disorder who do not have Physician-documented six (6) consecutive months
(within the most recent twelve (12) months) of recovery. Morbid Obesity
treatment procedures will not be paid if the procedure is an Unproven Medical
Procedure as defined in this booklet.
 Under this provision, Morbid Obesity includes the pre-treatment evaluation,
medical and surgical treatment for post treatment care including but not limited
to evidence-based medicine device adjustments, device removal, and/or body
sculpting services. The Morbid Obesity surgical treatment must be performed at
a Designated Centers of Excellence Morbid Obesity Treatment Center by an
American Bariatric Surgery accredited Network Provider, unless services are
deemed emergent or immediate. The Metabolic and Bariatric Surgery
Accreditation and Quality Improvement Program (MBSAQIP) designates the
facilities that have been accredited. The Centers and physicians must also
participate in the UnitedHealthcare Choice Plus Network for IEBP Plan to
consider them as a designated provider.
 Non-Designated Morbid Obesity Center
 A non accredited, non-network UnitedHealthcare Choice Plus, and nondesignated Center of Excellence facility will not be eligible for benefit plan
eligibility.
45
Changes are in red
 General Exclusions or Limitations
6.
for treatment of any injury, illness or disability, resulting from
or sustained as a result of being engaged in a felonious act as
defined by Texas law regardless of whether arrested,
indicted or convicted. This exclusion will apply when the
felonious act is proven by a preponderance of the evidence;
38. for services rendered by any of the following relatives:
a.
b.
c.
d.
e.
f.
g.
h.
spouse;
parent(s), step-parent(s) or parent(s)-in-law;
child(ren) or child(ren)-in-law;
brother(s) or brother(s)-in-law;
sister(s) or sister(s)-in-law;
grandparent(s) or grandparent(s)-in-law;
grandchild(ren) or grandchild)ren)-in-law;
aunt(s) or uncle(s) or aunt(s)- or uncle(s)-in-law;
46
Medical Benefits
Changes are in red

Telemedicine $40.00 by Plan Year 9.1.14 thereafter




High Deductible Plan Impact
Teladoc ID Card
Teladoc not Tela-prescription
Level of Care
 Telemedicine
• Does Not replace primary care provider for chronic illness








Primary care visit
Urgent Care Clinic
Emergency Room
Outpatient Surgery
Intensive Outpatient Services
Inpatient Surgery
Intensive Care Unit
Cataract Surgery (Lenses: initial contact lenses or glasses required following
cataract surgery, $200 network maximum allowable)
47
Medication Therapy Management Program (MTMP)
Changes are in red
 RePortal
 Smartphone
 Droid Phone
 Capsules vs. tablets
 Generic for Nexium is in the June 2014 pipeline for release
 Prescription Gaps in Care
 Updated Best Brand Medication (formulary)
 New form for Diplomat
 Updated specialty prescription list from Catamaran
 Updated align pharmacy list
 Texas
 Oklahoma
 Updated Catamaran High Deductible Wellness Drug List
48
Price Differences for Specialty Drugs
Outpatient Hospital
300%
Physician Office
267%
250%
227%
200%
150%
128%
107%
100%
50%
0%
Generic Oncology
All Other Drugs
Source: Artemetrx Specialty Drug Solutions, 2014
49
SBC Prescription Summary of Benefit Plan Changes PY14-15
Changes are in red
 If you need drugs to treat your illness or condition
Over the Counter/Behind the Counter
Prescribed Over the Counter Alternates:
Doctor Ordered: Non-Sedating Antihistamines (Claritin®, Claritin-D®,
Alavert®, Allegra®, Allegra-D®, Zyrtec®, Zyrtec-D®); per prescription
Stomach and Ulcer (Prilosec®, Prevacid®, Zegerid®); per prescription
Smoking Cessation - (Nicorette Gum) Quantity Limit – three (3) boxes
per plan year
Doctor Ordered: Aspirin, Folic Acid, Fluoride Chemoprevention
Supplements, Iron Deficiency Supplements, and Vitamin D
supplementation to prevent falls in community-dwelling adults age
65 years and older who are at an increased risk for falls; per
prescription
50
Cost Share Copay Drugs
Changes are in red
IEBP has implemented a clinical evidence-based approach to its prescription plan for groups
adopting 2014-2015 Plan Year benefits. As such, IEBP will impose a higher patient copayment
for drugs for which there is no clinical evidence to show that non-preferred “Cost Share Drugs”
perform any better than therapeutic doses of less costly preferred “Alternative Drugs”.
ADHD/CNS Stimulants
•Impacts utilization on: Immediate Release Amphetamine Products: Adderall®, Dexedrine®, Dextrostat®;
Immediate Release Methylphenidate Products: Ritalin® (brand only), Focalin®; Extended Release
Amphetamine Products: Adderall XR®, Amphetamine ER, Dexedrine Spansules®; Extended Release
Methylphenidate Products: Concerta®, Daytrana®, Focalin XR®, Metadate CD®, methylphenidate ER, Ritalin
LA®, Intuniv®, Kapvay®, Nuvigil®, Provigil® (brand only); Alternate Drugs: Generic: methylphenidate®,
amphetamine, guanfacine immediate release (for Intuniv®), clonidine (for Kapvay®), modafinil (for Provigil®,
Nuvigil®); Brand: Strattera®, Vyvanse®
Analgesics/Anti-Inflammatory/Pain Agents
•Impacts utilization on: Lazanda®, Subsys®; Alternative Drugs: Generic: fentanyl patch, fentanyl lozenge
•Impacts utilization on: Celebrex®, Naprelan®, diclofenac ER, Flector patch®, Solaraze®, Pennsaid®, Zipsor®;
Alternative Drugs: Generic: naproxen, diclofenac
•Impacts utilization on: Conzip®, Rybix®, Ryzolt®, tramadol ER, Ultracet®, Ultram®, Ultram ER®; Alternative
Drug: Generic: tramadol
51
Changes are in red
Antibiotics: Anti-Infective Agents
•Impacts utilization on: Adoxa®, Doryx®, Dynacin®, Monodox®, Periostat®, Solodyn®, Oraxyl®, Oracea®;
Alternative Drugs: Generic: capsule minocycline (for Dynacin®, Solodyn®), doxycycline (for Adoxa®, Doryx®,
Monodox®, Periostat®, Oracea®, Oraxyl®)
Anticonvulsants
•Impacts utilization on: Gralise®, Lamictal XR®, lamotrigine ER, Lyrica®, Neurontin®; Alternative Drugs:
Generic: gabapentin (for Gralise®, Lyrica®, Neurontin®), lamotrigine (for Lamictal XR®, lamotrigine ER)
Antidepressants/Fibromyalgia
•Impacts utilization on: Cymbalta®, duloxetine, Effexor XR, Pristiq, Savella®, Viibryd®; Alternate Drugs:
Generic (Multiple): bupropion, citalopram, escitalopram, fluoxetine, paroxetine, sertraline, venlafaxine,
venlafaxine ER (capsules only) buproprion
Antihypertensive Agents
•Impacts utilization on: Dutoprol®, Amturnide®, Atacand®/Atacand HCT®, Avapro®/Avalide®, Azor®,
Benicar®/Benicar HCT®, Cozaar®/Hyzaar® (brand only), Diovan®/Diovan HCT® (brand only),
Edarbi®/Edarbyclor®, Exforge®/Exforge HCT® (brand only), Micardis®/Micardis HCT®, Tekamlo®,
Tekturna®/Tekturna HCT®, Teveten®/Teveten HCT®, Tribenzor®, Twynsta®, Valturna®; Alternate Drugs:
Generic: metroprolol-hydrochlorothiazide (for Dutoprol®), any generic ACE Inhibitor, losartan/losartan HCTZ
(for Cozaar®/Hyzaar®), irbesartan/irbesartan HCTZ (for Avapro®/Avalide®), eprosartan/eprosartan HCTZ (for
Teveten®/Teveten HCT®), valsartan/valsartan HCTZ (for Diovan®/Diovan HCT®)
52
Changes are in red
Central Nervous System: Sedative Hypnotics
•Impacts utilization on: Ambien®, Ambien CR®, Edluar®, Lunesta®, Rozerem®, Sonata®, zolpidem ER®,
Intermezzo®, Silenor®, Zolpimist®; Alternate Drugs: Generic: zolpidem immediate release (generic for
Ambien®), zaleplon (generic for Sonata®), doxepin (for Silenor®), zolpidem (for Intermezzo®, Zolpimist®)
Lipid-Lowering Agents (Statins)
•Impacts utilization on: Advicor®, Altocor®, Altoprev®, amlodipine/atorvastatin combination, Caduet®,
Crestor® (except 40mg strength), Lescol®, Lescol XL®, Lipitor®, Livalo®, Mevacor®, Pravachol®, Simcor®,
Vytorin®, Zocor®, Zetia®; Alternate Drugs: atorvastatin (generic for Lipitor®), lovastatin (generic for
Mevacor®), pravastatin (generic for Pravachol®), simvastatin (generic for Zocor®)
Lipid-Lowering Agents (Fibric Acid Derivatives)
•Impacts utilization on: Antara®, fenofibric acid, Fenoglide®, Fibricor®, Lipofen®, Lofibra®, Lopid®, Tricor®,
Triglide®, Trilipix®, fenofibrate 43, 130 and 145mg; Alternate Drugs: fenofibrate (generic for Tricor® and
various other brands), gemfibrozil (generic for Lopid®)
Migraine Headaches
•Impacts utilization on: Amerge®, Axert®, Frova®, Imitrex® (brand), Maxalt®, Relpax®, Treximet®, zolmitriptan,
Zomig®, Zomig ZMT®; Alternate Drugs: Generic: sumatriptan (for Imitrex®), naratriptan (for Amerge®),
rizatriptan (for Maxalt®)
53
Changes are in red
Nasal Steroids
•Impacts utilization on: Beconase AQ®, Dymista®, Flonase® (brand), Nasacort AQ®, Nasalide® (brand),
Nasarel®, Nasonex®, Omnaris®, Rhinocort AQ®, Veramyst®, QNASL®, triamcinolone, Zetonna®; Alternate
Drugs: Generic: fluticasone (for Flonase®), and flunisolide
Osteoporosis Drugs
•Impacts utilization on: Actonel®, Actonel® w/Calcium, Alendronate® (brand), Atelvia®, Binosto®, Boniva®,
Fosamax®, Fosamax-D®, ibandronate (generic for Boniva®); Alternate Drug: Generic: alendronate (for
Fosamax®)
Otic Products
•Impacts utilization on: Auralgan®; Alternate Drug: Generic: benzocaine-antipyrine
Overactive Bladder Drugs
•Impacts utilization on: Detrol®, Detrol LA®, Ditropan® (brand), Ditropan XL®, Gelnique®, Myrbetriq®,
Enablex®, oxybutynin ER®, Oxytrol® patches, Sanctura®, Sanctura XR®, tolterodine, Toviaz®, trospium CL,
Vesicare®; Alternate Drugs: Generic: oxybutynin immediate release
54
Changes are in red
Respiratory/Allergy/Asthma: Antihistamines
Impacts utilization on: Clarinex®, fexofenadine®, levocetirizine, Xyzal®; Alternate Drugs: Generic: loratidine
or cetirizine; OTC: Alavert®, Allegra®, Zyrtec®, Claritin® Over-the-Counter (OTC) versions of Allegra-D
(fexofenadine-D), Claritin-D (loratidine-D), and Zyrtec – D (cetirizine-D) are available at member’s out of
pocket cost.
Respiratory/Allergy/Asthma: Antihistamines – Decongestant
Impacts utilization on: fexofenadine-D®, Clarinex-D®; Alternate Drugs: Over-the-Counter (OTC) versions of
Allegra-D (fexofenadine-D), Claritin-D (loratidine-D), and Zyrtec – D (cetirizine-D) are available at member’s
out of pocket cost. Generic: loratidine-D or cetirizine-D; OTC: Allegra-D®, Zyrtec-D®, Claritin-D®
Skeletal Muscle Relaxants
•Impacts utilization on: Amrix®, Carisoprodol® 250mg (brand), cyclobenzaprine ER, Fexmid®, Flexeril®,
Lioresal® (brand only), Lorzone®, metaxalone (generic for Skelaxin®), Norflex® (including its generic
orphenadrine injection), Parafon Forte®, Robaxin®, Skelaxin®, Soma®, Soma® Compound, orphenadrine
(generic for Norflex®), orphenadrine compound (generic for Norgesic®), Soma® Compound w/Codeine,
Zanaflex®;
Alternate Drug: Generic: carisoprodol, chlorzoxazone, cyclobenzaprine, methocarbamol,
tizanidine
55
Changes are in red
Stomach Ulcer/Reflux Drugs/Gastrointestinal/Stomach: Proton Pump Inhibitors
•Impacts utilization on: Aciphex®, Dexilant®, Duexis®, lansoprazole, Nexium® (,prescription strength), Prevacid®
(prescription strength), Prilosec® (prescription strength), Protonix®, Vimovo®, Zegerid capsules (prescription strength –
including generic omeprazole/bicarbonate); brand and generic); Alternate Drugs: Generic: omeprazole, pantoprazole,
ibuprofen and famotidine separately (for Duexis®); Over-the CounterTC (OTC) versions of Nexium 24 HR (esomeprazole),
Priolosec®: (omeprazole), Prevacid® (lansoprazole),and Zegerid®, (omeprazole/sodium bicarbonate) are available at
member’s out of pocket cost. Prevacid®, Prilosec®, Zegerid®
Topical Antifungal Agents
•Impacts utilization on: Pedipirox-4®; Alternate Drug: Generic: ciclopirox
Cost Share Copays




Broad Network Retail Copay – up to 34 day supply - $120 or cost of drug (whichever is less)
Effective September 1, 2012: Please order mail service prescriptions from new vendor, MedVantx: (866) 744-0621.
Mail Order** Copay – 35 up to 90 days supply - $300 or cost of drug (whichever is less)
Alternative Drug Copays:
$0 copay - Align Network* Retail Over the Counter
$0 copay - Align Network non-cost share Generic retail up to 34 day supply
$9 copay - Align Network non-cost share Generic retail 35 up to 90 day supply
$10 copay - Broad Network non-cost share Generic retail up to 34 day supply
$25 copay - **Mail Order non-cost share Generic copay: 35 up to 90 day supply
56
Medication Therapy Management Program
Changes in Red
 Narcotic Utilization Management






Opioids
Amphetamines
Narcotic
Morphine
Antipsychotic
Anti-depressants
57
Value Tiered Align Network Pharmacies
At the time of this printing, the Value Tiered/Align Network Pharmacy Extension includes the following
pharmacies:
TEXAS
A&C Discount Pharmacy
A and P Pharmacy
Abeldt's Gaslight Phcy Inc
Ability Pharmacy Inc
Ackman Pharmacy
Acorn Pharmacy
Adcock's Medicine Chest
Agape Care Pharmacy
Alameda Thrifty Pharmacy
Alamo Drugs Ltd
Albertson's Pharmacy
Albrecht's Pharmacy
All Care Pharmacy
Alvarado Medicine Chest
Anderson Drug
Angleton Health Mart Pharmacy
APNS Pharmacy
Atkins Express Pharmacy
Atkin's Pharmacy Services
Aubrey Pharmacy
Autrey Pharmacy
Avita Drugs
Axtell Pharmacy Inc
B and B Pharmacy
Baggett Pharmacy
Bao Chau Pharmacy
Barnes and Williams Drug Ctr
Baylor Medical Plaza Phcy
Ben Franklin Apothecary
Berks Pharmacy, LLC
Berry Oaks Pharmacy
Best Value Hico Pharmacy
Best Value Medical Ctr Phcy
Elsa Pharmacy Services
Evercare Pharmacy LLC
Express Care Pharmacy
F Street Pharmacy
Family Pharmacy
Fleming Medicine Chest
Flower Mound Phy and Herbal Alts
Food City Pharmacy
Forty Acres Pharmacy
Freeport Pharmacy
Fritch Drug and Gift Shoppe
Galloway Pharmacy
Garcia's Pill Box
Garza Pharmacy
Genpharm Pharmacy
Gibson Pharmacy
Glen Rose Discount Drug
Goods Medicine Chest
Grace Pharmacy
Graham Pharmacy
Grand Pharmacy
Groveway Pharmacy
Guffey's Drugstore
Gulf Coast Pharmacy
Gus' Drug Store
Hall's Pharmacy
Hallsville Drug & Hardware LLC
Harrels Kingsville Pharmacy
Hazel's Compounding Rx Pharmacy
Healthcare Pharmacy LLC
Healthco Pharmacy
Heard Jones Healthmart
HEB Pharmacy
Markum Drive Pharmacy
Martin Tipton Pharmacy LLC
Maxwell Pharmacy Inc
MCA Pharmacy, LLC
McGaughey Medicine Chest
McKellar's Medicine Chest
McNease Drugs
Med-Aid Pharmacy
Med Care Pharmacy
Med Choice Pharmacy
Med Time Pharmacy
Med Valt Pharmacy LLC
Medcenter Pharmacy
Medi Drive Pharmacy
Medic Pharmacy and Gifts
Medical Arts Drug Company
Medical Ctr Medicine Chest
Medical Plaza Pharmacy
Medicine Chest
Medicine Shoppe Pharmacy
Medworld Pharmacy Inc
Memphis Drug
Mercury Drive Pharmacy
Meridian Pharmacy Group
Merkel Drug Co
Midcities Pharmacy
Mi Doctor Pharmacy
Miller's Pharmacy
Minyard Pharmacy
Mohrmann's Drug Store
MS Pharmacy
Murr's Medicine Chest
Myers Drug Inc
58
Rx Partners Pharmacy Dallas
Sam's Pharmacy
San Juan Pharmacy
San Martin Pharmacy
Save Mart Pharmacy
Savon Pharmacy
Senderra Rx
Sesame Pharmacy
Seton Central Outpatient Pharmacy
Seymour Pharmacy
Shannon Pharmacy
Shelby Pharmacy
Sherman Pharmacy
Sholars Medicine Chest
ShopRite Pharmacy
Slaton Pharmacy
SMA Pharmacy
Sonexus Health Pharmacy Services
Sonterra Rx
South Austin Pharmacy
South San Medical Pharmacy
Southpark Pharmacy
Steeplechase Pharmacy
Stone Oak Pharmacy
St Rose Pharmacy
Sun Drugs
Sunrise Pharmacy Inc
Super Mercado Pharmacy
Super S Pharmacy
Super Script Pharmacy
Super Value Pharmacy
Tanglewood Pharmacy
Target Pharmacy
At the time of this printing, the Value Tiered/Align Network Pharmacy Extension includes the
following pharmacies:
Best Value Waddy Pharmacy
Big State Drug
Boomtown Drug
Bowen's Health Mart Phcy
Bratton's Pharmacy
Braun Medicine Chest
Broadway Drug Store Inc
Brookhaven Apothecary & Surgical Shop
Brookshire Brothers Phcy
Browns Pharmacy
Bruce and Human Drug
Bryan Medicine Chest
Budget Chopper Pharmacy
Cantus Pharmacy
CareRx Pharmacy At Sherman
Carie Boyd's Rx Shop
Carter's Pharmacy
Carvajal Pharmacy
Cash Saver Cost Plus Pharmacy
Catching's Prescriptions Ltd
CCH Pharmacy
CDF Rx
Cedar Creek Pharmacy Inc
Cedar View Pharmacy
Celina Drug
Central Pharmacy
Champs Medical
Channelview Pharmacy
Chapel Hill Pharmacy Ltd
City Pharmacy
Cleveland Pharmacy
Clinic Pharmacy
Cody Drug
Hereford Health Mart Phcy
Heritage Parkway Pharmacy
Hico Pharmacy
Hilliard Drugs Inc
Hoast Pharmacy
Holmes Pharmacy
Hometown Pharmacy
Hoots Pharmacy
Hughes Pharmacy
Huntleigh Pharmacy
Interaction Pharmacy
Inventive Infusion Solutions
J and D Pharmacy Inc
J and J Pharmacy Inc
J & L Pharmacy
Jacinto Pharmacy Inc
Jacks Park Pharmacy
Jacobs Family Pharmacy
Jay's City Pharmacy
Jerry's Pharmacy
Johnson City Health Mart Phcy
Jones McCall Pharmacy
Junior's Pharmacy
Justin Family Pharmacy
K & K Pharmacy
Kearney Park Pharmacy
Keene Pharmacy
Kenjura Pharmacy
Kermit Pharmacy
Kerrville Drug Company
Key Medicine Chest
Keyes Pharmacy
Keystone Rx
Neel's Medicine Chest
Neese Medicine Chest
Neighborcare Eagles Trace
Neighborhood Pharmacy
Nelson's Medicine Chest
New Era Pharmacy
Normandy Rx Inc
North Central Pharmacy
Nuvision Pharmacy, Inc
Oak Hills Pharmacy
Oakdell Pharmacy
O K Pharmacy Inc
Ochoa's Pharmacy
Oswalt Pharmacy
Outpatient Phcy, Cancer Ctr
Overton Pharmacy
P and S Rexall Pharmacy Inc
Panhandle Drug Store
Parkway Pharmacy
Patrick Street Pharmacy
Pavilion Pharmacy
Pecan Discount Drug
Pelzel's Hometown Phcy
Penita's Family Pharmacy
Peoples Pharmacy
Pete's Pharmacy
Pfennigs Prescription Pharmacy
Pham Family Pharmacy Inc
Pharmacia
Pharmhouse Pharmacy
Pharr Family Pharmacy
Physician's Plaza Pharmacy
Pinecroft Pharmacy
59
Tarrytown Pharmacy
Terrell Pharmacy
Texas Professional Phcy-Magnolia
The Apothecary Shop
The Family Pharmacy
The Friendly Pharmacy
The Med Shop
The Medicine Shoppe
The Prescription Shop
Timberland Discount Phcy
Tom Thumb Pharmacy
Tomball Health Mart Phcy
Tower Medic Pharmacy Inc
Town and Country Drug
Trilogy Pharmacy
Trinity North Pharmacy
Trinity Rx
Troup Pharmacy
Twin Oaks Pharmacy
Tyson Pharmacy
U S Drug Mart
U and T Pharmacy
United Market Street Pharmacy
United Pharmacy
United Care Pharmacy
United Drugs Comp. Network
University Pharmacy Inc
Uptown Pharmacy
Valu Med Pharmacy Inc
Village Oaks Pharmacy
Village Pharmacy
Vina Pharmacy
Vista Pharmacy
Collingsworth Pharmacy
Comal Drug Healthmart
Community Pharmacy
Complete Care Pharmacy
Conoly Drug Healthmart
Corner Drug Store
Country Drug Store
Courtyard Pharmacy
Crawford Pharmacy
Cyfair Pharmacy
Cypress Pharmacy
Circle Drug
City Drug Store
Conquest Plaza Pharmacy
Dad's Pharmacy
Danny's Drug
Davis City Pharmacy Inc
Deleon's Pharmacy Inc
Denton Prescription Shop
Diamond Pharmacy
Doc's Drugstore
Doc's Drugstore of Early Inc
Doctor's Pharmacy
Donna Family Pharmacy
D R Pharmacy
D US Pharmacy
Deliverit Pharmacy Inc
DLS Pharmacy
Dyer Drug Store
Eagle Lake Drug Store
Economy Drug
Eco Pharmacy of Willowbrook, LLC
Edgewood Legend Drug
Edinburg Family Pharmacy
Elgin Medicine Chest
Kings Daughters Pharmacy
Kings Pharmacy
Kingsland Pharmacy
Kmart Pharmacy
Kroger Pharmacy
KVN Pharmacy
Lake Area Pharmacy
Lakeside Pharmacy
La Plaza Pharmacy
Laredo Downtown Phcy Inc
Larson's Pharmacy
Las Colinas Pharmacy
Laura's Pharmacy
Lawrence Bros Pharmacy
Liberty Drug
Liberty Medicine Chest
Lifechek Drug (excluding Del Rio)
Lifewatch Pharmacy
Lino's Pharmacy
Live Oak Pharmacy
Livingston Pharmacy
Lock Drug Store
Lonestar Rx
Longhorn Health Solutions
Loper's Family Pharmacy
Lopez Pharmacy
Lovoi and Sons Pharmacies
Luna's Friendly Pharmacy
Lynn's Pharmacy
Lyons Pharmacy
Mabank Family Pharmacy
Main Medical Plaza Pharmacy
Main St. Pharmacy
Maloney Prescription Phcy
Market Street Pharmacy #553
Plaza Pharmacy
Plaza Medical Pharmacy
Prescription Laboratory
Prescription Pharmacy
Prescription Shop
Preston Road Apothecary Inc
Preston Road Pharmacy
Pro Med Pharmacy
Pro Script Pharmacy Services
Procare Rx
Professional Pharmacy
Public Pharmacy
Q Pharmacy
QRC Healthmart Pharmacy
Quality Care Pharmacy & Compounding
Quality Pharmacy Inc
QVL Pharmacy
Randall's
Randol Mill Pharmacy
Rast Rx
Ray Pharmacy
RC Pharmacy
Red River Pharmacy of Atlanta
Rediger's Pharmacy
Remedies Pharmacy Inc
Rexco Pharmacy
Richard's Pharmacy
Rippetoe Pharmacy
Rite-Away Pharmacy
Roanoke Pharmacy
Roger's Pharmacy
Rosebud Pharmacy
Royse City Pharmacy
Rushing Gonzalez Legend Drug
Rx.com Pharmacy
60
Waldie's Pharmacy
Walker Pharmacy
Wal-mart Pharmacy
Walter's Pharmacy, Inc.
Webster Pharmacy
Wedgwood Pharmacy
Wellness Plus Pharmacy Inc
Westgate Pharmacy
Westside Drug
Westview Pharmacy
Whisenhunt's City Phcy
White Cross Pharmacy
Whitehouse Pharmacy
Winn Dixie Pharmacy
Woody Weaver Pharmacy
Wynnewood Village Pharmacy
Your New Waverly Pharmacy LLC
Zalcon Pharmacy
OKLAHOMA
ADA Dollar Saver Pharmacy
Advanced Rx Pharmacy 023
Brookhaven Pharmacy &
Compounding Center
Cherokee Hills Pharmacy
Corner Drug of Durant
Country Mart Pharmacy
Crest Pharmacy
D and D Pharmacy
Dennis Express Pharmacy
East Central Oklahoma Family Health
Center, Inc. Pharmacy
Express Rx of Bartlesville
Express Rx of Miami
Fikes Pharmacy
Greens Prescription Center
61
Homeland Pharmacy Pyramid Pharmacy
K mart Pharmacy
Sam's Pharmacy
Medic Pharmacy
Sullins Drugs
Medicine Shoppe
Nichols Dollar Saver
OneSource
OptionOne, LLC
Target Pharmacy
United Pharmacy
Variety Care Pharmacy
Wal-mart Pharmacy
Wellston Clinic
Pharmacy
Western Drug #5
Hospitals have Higher Drug Administration Costs than
Physician Offices
Hospital outpatient costs compared to physician office costs
Source: IMS Institute for Healthcare Informatics, Innovation in Cancer Care and Implications for Health Systems: Global Oncology Trend Report, released May 2014. Visit
www.theimsinstitute.org .
62
Changes in Red
 Narcotic Utilization Management






Opioids
Amphetamines
Narcotic
Morphine
Antipsychotic
Anti-depressants
63
At the time of this printing, the Value Tiered/Align Network Pharmacy Extension includes the following
pharmacies:
TEXAS
A&C Discount Pharmacy
A and P Pharmacy
Abeldt's Gaslight Phcy Inc
Ability Pharmacy Inc
Ackman Pharmacy
Acorn Pharmacy
Adcock's Medicine Chest
Agape Care Pharmacy
Alameda Thrifty Pharmacy
Alamo Drugs Ltd
Albertson's Pharmacy
Albrecht's Pharmacy
All Care Pharmacy
Alvarado Medicine Chest
Anderson Drug
Angleton Health Mart Pharmacy
APNS Pharmacy
Atkins Express Pharmacy
Atkin's Pharmacy Services
Aubrey Pharmacy
Autrey Pharmacy
Avita Drugs
Axtell Pharmacy Inc
B and B Pharmacy
Baggett Pharmacy
Bao Chau Pharmacy
Barnes and Williams Drug Ctr
Baylor Medical Plaza Phcy
Ben Franklin Apothecary
Berks Pharmacy, LLC
Berry Oaks Pharmacy
Best Value Hico Pharmacy
Best Value Medical Ctr Phcy
Elsa Pharmacy Services
Evercare Pharmacy LLC
Express Care Pharmacy
F Street Pharmacy
Family Pharmacy
Fleming Medicine Chest
Flower Mound Phy and Herbal Alts
Food City Pharmacy
Forty Acres Pharmacy
Freeport Pharmacy
Fritch Drug and Gift Shoppe
Galloway Pharmacy
Garcia's Pill Box
Garza Pharmacy
Genpharm Pharmacy
Gibson Pharmacy
Glen Rose Discount Drug
Goods Medicine Chest
Grace Pharmacy
Graham Pharmacy
Grand Pharmacy
Groveway Pharmacy
Guffey's Drugstore
Gulf Coast Pharmacy
Gus' Drug Store
Hall's Pharmacy
Hallsville Drug & Hardware LLC
Harrels Kingsville Pharmacy
Hazel's Compounding Rx Pharmacy
Healthcare Pharmacy LLC
Healthco Pharmacy
Heard Jones Healthmart
HEB Pharmacy
Markum Drive Pharmacy
Martin Tipton Pharmacy LLC
Maxwell Pharmacy Inc
MCA Pharmacy, LLC
McGaughey Medicine Chest
McKellar's Medicine Chest
McNease Drugs
Med-Aid Pharmacy
Med Care Pharmacy
Med Choice Pharmacy
Med Time Pharmacy
Med Valt Pharmacy LLC
Medcenter Pharmacy
Medi Drive Pharmacy
Medic Pharmacy and Gifts
Medical Arts Drug Company
Medical Ctr Medicine Chest
Medical Plaza Pharmacy
Medicine Chest
Medicine Shoppe Pharmacy
Medworld Pharmacy Inc
Memphis Drug
Mercury Drive Pharmacy
Meridian Pharmacy Group
Merkel Drug Co
Midcities Pharmacy
Mi Doctor Pharmacy
Miller's Pharmacy
Minyard Pharmacy
Mohrmann's Drug Store
MS Pharmacy
Murr's Medicine Chest
Myers Drug Inc
64
Rx Partners Pharmacy Dallas
Sam's Pharmacy
San Juan Pharmacy
San Martin Pharmacy
Save Mart Pharmacy
Savon Pharmacy
Senderra Rx
Sesame Pharmacy
Seton Central Outpatient Pharmacy
Seymour Pharmacy
Shannon Pharmacy
Shelby Pharmacy
Sherman Pharmacy
Sholars Medicine Chest
ShopRite Pharmacy
Slaton Pharmacy
SMA Pharmacy
Sonexus Health Pharmacy Services
Sonterra Rx
South Austin Pharmacy
South San Medical Pharmacy
Southpark Pharmacy
Steeplechase Pharmacy
Stone Oak Pharmacy
St Rose Pharmacy
Sun Drugs
Sunrise Pharmacy Inc
Super Mercado Pharmacy
Super S Pharmacy
Super Script Pharmacy
Super Value Pharmacy
Tanglewood Pharmacy
Target Pharmacy
Best Value Waddy Pharmacy
Big State Drug
Boomtown Drug
Bowen's Health Mart Phcy
Bratton's Pharmacy
Braun Medicine Chest
Broadway Drug Store Inc
Brookhaven Apothecary & Surgical Shop
Brookshire Brothers Phcy
Browns Pharmacy
Bruce and Human Drug
Bryan Medicine Chest
Budget Chopper Pharmacy
Cantus Pharmacy
CareRx Pharmacy At Sherman
Carie Boyd's Rx Shop
Carter's Pharmacy
Carvajal Pharmacy
Cash Saver Cost Plus Pharmacy
Catching's Prescriptions Ltd
CCH Pharmacy
CDF Rx
Cedar Creek Pharmacy Inc
Cedar View Pharmacy
Celina Drug
Central Pharmacy
Champs Medical
Channelview Pharmacy
Chapel Hill Pharmacy Ltd
City Pharmacy
Cleveland Pharmacy
Clinic Pharmacy
Cody Drug
Hereford Health Mart Phcy
Heritage Parkway Pharmacy
Hico Pharmacy
Hilliard Drugs Inc
Hoast Pharmacy
Holmes Pharmacy
Hometown Pharmacy
Hoots Pharmacy
Hughes Pharmacy
Huntleigh Pharmacy
Interaction Pharmacy
Inventive Infusion Solutions
J and D Pharmacy Inc
J and J Pharmacy Inc
J & L Pharmacy
Jacinto Pharmacy Inc
Jacks Park Pharmacy
Jacobs Family Pharmacy
Jay's City Pharmacy
Jerry's Pharmacy
Johnson City Health Mart Phcy
Jones McCall Pharmacy
Junior's Pharmacy
Justin Family Pharmacy
K & K Pharmacy
Kearney Park Pharmacy
Keene Pharmacy
Kenjura Pharmacy
Kermit Pharmacy
Kerrville Drug Company
Key Medicine Chest
Keyes Pharmacy
Keystone Rx
Neel's Medicine Chest
Neese Medicine Chest
Neighborcare Eagles Trace
Neighborhood Pharmacy
Nelson's Medicine Chest
New Era Pharmacy
Normandy Rx Inc
North Central Pharmacy
Nuvision Pharmacy, Inc
Oak Hills Pharmacy
Oakdell Pharmacy
O K Pharmacy Inc
Ochoa's Pharmacy
Oswalt Pharmacy
Outpatient Phcy, Cancer Ctr
Overton Pharmacy
P and S Rexall Pharmacy Inc
Panhandle Drug Store
Parkway Pharmacy
Patrick Street Pharmacy
Pavilion Pharmacy
Pecan Discount Drug
Pelzel's Hometown Phcy
Penita's Family Pharmacy
Peoples Pharmacy
Pete's Pharmacy
Pfennigs Prescription Pharmacy
Pham Family Pharmacy Inc
Pharmacia
Pharmhouse Pharmacy
Pharr Family Pharmacy
Physician's Plaza Pharmacy
Pinecroft Pharmacy
65
Tarrytown Pharmacy
Terrell Pharmacy
Texas Professional Phcy-Magnolia
The Apothecary Shop
The Family Pharmacy
The Friendly Pharmacy
The Med Shop
The Medicine Shoppe
The Prescription Shop
Timberland Discount Phcy
Tom Thumb Pharmacy
Tomball Health Mart Phcy
Tower Medic Pharmacy Inc
Town and Country Drug
Trilogy Pharmacy
Trinity North Pharmacy
Trinity Rx
Troup Pharmacy
Twin Oaks Pharmacy
Tyson Pharmacy
U S Drug Mart
U and T Pharmacy
United Market Street Pharmacy
United Pharmacy
United Care Pharmacy
United Drugs Comp. Network
University Pharmacy Inc
Uptown Pharmacy
Valu Med Pharmacy Inc
Village Oaks Pharmacy
Village Pharmacy
Vina Pharmacy
Vista Pharmacy
Collingsworth Pharmacy
Comal Drug Healthmart
Community Pharmacy
Complete Care Pharmacy
Conoly Drug Healthmart
Corner Drug Store
Country Drug Store
Courtyard Pharmacy
Crawford Pharmacy
Cyfair Pharmacy
Cypress Pharmacy
Circle Drug
City Drug Store
Conquest Plaza Pharmacy
Dad's Pharmacy
Danny's Drug
Davis City Pharmacy Inc
Deleon's Pharmacy Inc
Denton Prescription Shop
Diamond Pharmacy
Doc's Drugstore
Doc's Drugstore of Early Inc
Doctor's Pharmacy
Donna Family Pharmacy
D R Pharmacy
D US Pharmacy
Deliverit Pharmacy Inc
DLS Pharmacy
Dyer Drug Store
Eagle Lake Drug Store
Economy Drug
Eco Pharmacy of Willowbrook, LLC
Edgewood Legend Drug
Edinburg Family Pharmacy
Elgin Medicine Chest
Kings Daughters Pharmacy
Kings Pharmacy
Kingsland Pharmacy
Kmart Pharmacy
Kroger Pharmacy
KVN Pharmacy
Lake Area Pharmacy
Lakeside Pharmacy
La Plaza Pharmacy
Laredo Downtown Phcy Inc
Larson's Pharmacy
Las Colinas Pharmacy
Laura's Pharmacy
Lawrence Bros Pharmacy
Liberty Drug
Liberty Medicine Chest
Lifechek Drug (excluding Del Rio)
Lifewatch Pharmacy
Lino's Pharmacy
Live Oak Pharmacy
Livingston Pharmacy
Lock Drug Store
Lonestar Rx
Longhorn Health Solutions
Loper's Family Pharmacy
Lopez Pharmacy
Lovoi and Sons Pharmacies
Luna's Friendly Pharmacy
Lynn's Pharmacy
Lyons Pharmacy
Mabank Family Pharmacy
Main Medical Plaza Pharmacy
Main St. Pharmacy
Maloney Prescription Phcy
Market Street Pharmacy #553
Plaza Pharmacy
Plaza Medical Pharmacy
Prescription Laboratory
Prescription Pharmacy
Prescription Shop
Preston Road Apothecary Inc
Preston Road Pharmacy
Pro Med Pharmacy
Pro Script Pharmacy Services
Procare Rx
Professional Pharmacy
Public Pharmacy
Q Pharmacy
QRC Healthmart Pharmacy
Quality Care Pharmacy & Compounding
Quality Pharmacy Inc
QVL Pharmacy
Randall's
Randol Mill Pharmacy
Rast Rx
Ray Pharmacy
RC Pharmacy
Red River Pharmacy of Atlanta
Rediger's Pharmacy
Remedies Pharmacy Inc
Rexco Pharmacy
Richard's Pharmacy
Rippetoe Pharmacy
Rite-Away Pharmacy
Roanoke Pharmacy
Roger's Pharmacy
Rosebud Pharmacy
Royse City Pharmacy
Rushing Gonzalez Legend Drug
Rx.com Pharmacy
66
Waldie's Pharmacy
Walker Pharmacy
Wal-mart Pharmacy
Walter's Pharmacy, Inc.
Webster Pharmacy
Wedgwood Pharmacy
Wellness Plus Pharmacy Inc
Westgate Pharmacy
Westside Drug
Westview Pharmacy
Whisenhunt's City Phcy
White Cross Pharmacy
Whitehouse Pharmacy
Winn Dixie Pharmacy
Woody Weaver Pharmacy
Wynnewood Village Pharmacy
Your New Waverly Pharmacy LLC
Zalcon Pharmacy
OKLAHOMA
ADA Dollar Saver Pharmacy
Advanced Rx Pharmacy 023
Brookhaven Pharmacy &
Compounding Center
Cherokee Hills Pharmacy
Corner Drug of Durant
Country Mart Pharmacy
Crest Pharmacy
D and D Pharmacy
Dennis Express Pharmacy
East Central Oklahoma Family Health
Center, Inc. Pharmacy
Express Rx of Bartlesville
Express Rx of Miami
Fikes Pharmacy
Greens Prescription Center
67
Homeland Pharmacy Pyramid Pharmacy
K mart Pharmacy
Sam's Pharmacy
Medic Pharmacy
Sullins Drugs
Medicine Shoppe
Nichols Dollar Saver
OneSource
OptionOne, LLC
Target Pharmacy
United Pharmacy
Variety Care Pharmacy
Wal-mart Pharmacy
Wellston Clinic
Pharmacy
Western Drug #5
High Deductible Health Savings Account Benefit Plans
Wellness Drug List
68
Wellness Drug List
69
Wellness Drug List
70
Wellness Drug List
71
Wellness Drug List
72
Changes are in red

Definitions

Active Employee
 Is an employee who works and is paid by the employer for at least twenty (20) hours per week or is
accessing vacation, sick, personal, paid time off, or paid/unpaid Family Medical Leave Act of 1993
(FMLA) and is receiving the same benefits as all other employees. Persons who are receiving long or
short term disability payments or workers’ compensation income benefits are not otherwise on the
payroll of the employer are not active employees, nor do those benefits accrue toward the twenty
hour requirement.
 In order for any form of leave that is not accrued on a weekly, monthly, annual or other periodic basis
to be considered as vacation, sick, personal, or paid time off leave under the previous paragraph,
Member’s leave policy must be (1) in writing, (2) on file with IEBP prior to the start of the employer’s
plan year, and (3) available uniformly to all employees. This non-accruing leave shall include but not be
limited to sick pool leave, catastrophic leave, disability leave, non-FMLA medical leave, workers
compensation injury leave, and emergency leave. In order for compensatory time to be considered as
actively at work hours, the Member’s compensatory policy must be (1) in writing, on file with IEBP
prior to the start of the employer’s plan year, (2) available uniformly to all employees, (3) clearly
documented on each payroll document, and (4) in compliance with U.S. Department of Labor
requirements. Employees that do not meet the definition of an employee in the benefit book are not
eligible for medical benefits.
 A Family Medical Leave Act (FMLA) certification shall extend the period of coverage for active
employee(s) when the FMLA documentation is provided in writing to IEBP within thirty (30) days of the
certification and one hundred and twenty (120) days of the beginning date of the FMLA leave.

Adolescent Dependent
 An individual thirteen (13) to attained age of eighteen (18) years of age whose disabilities of minority
have not been removed by marriage or judicial decree.
 Depression is identified as a serious mental illness for adolescents.
73
Changes are in red
 Definitions
 Deductible
 Eligible Benefits in a given calendar year, which are the responsibility
of the employee before benefits become payable by this Plan.
 If an individual is accessing a High Deductible Health Savings Account
Family Plan, the plan is required to ensure the minimum family
deductible $2,400 dollar amount is paid prior to benefit percentage
plan payments. The IEBP plan design for the minimum family
deductible regulations will require the covered family individual’s
dollars in excess of each family individual deductible to accumulate to
the minimum family deductible prior to benefit plan percentage
payment.
 IRS Health Savings Account Out of Pocket Minimum and Maximums
Maximum Annual H.S.A. Contribution
Minimum HDHP Deductible
Maximum HDHP OOP Expense
2013 Minimums and Maximums for High
Deductible H.S.A. Plans
Individual Coverage
Family Coverage
$3,250
$6,450
$1,250
$2,500
$6,250
$12,500
74
2014 Minimums and Maximums for High
Deductible H.S.A. Plans
Individual Coverage
Family Coverage
$3,300
$6,550
$1,250
$2,500
$6,350
$12,700
Changes are in red

Definitions
 United States Preventive Services Task Force (USPSTF)
 Quality Improvement preventive services task force that works with other
national organizations.
 PHS Act section 2713 and the interim final regulations require nongrandfathered group health plans in the individual or group benefits prohibit
the cost-sharing requirements with respect to, the following:
1. Evidence-based items or services that have in effect a rating of “A” or “B” in
the current recommendations of the United States Preventive Services Task
Force (USPSTF) with respect to the covered individual;
2. Immunizations for routine use in children, adolescents, and adults that have
in effect a recommendation from the Advisory Committee on Immunization
Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) with
respect to the covered individual;
3. With respect to infants, children, and adolescents, evidence-informed
preventive care and screenings provided for in the comprehensive guidelines
supported by the Health Resources and Services Administration (HRSA); and
4. With respect to women, evidence-informed preventive care and screening
provided for in comprehensive guidelines supported by HRSA, to the extent
not already included in certain recommendations of the USPSTF.
75
Changes are in red
 Member Rights and Responsibilities Guide
 Wellness Initial Notice/Breast Feeding Expanded
Benefits
Services
Provider Billing Tips*
Comments
PREVENTIVE SERVICES FOR WOMEN “WOMEN’S HEALTH”
Breast feeding support Breast Feeding Support and One pump per pregnancy. Medically necessary Home Services for confined bed rest for
and counseling and
Counseling: S9443, 99341 - counseling and DME equipment in excess of $1,000 must be notified. Breast pump manual and
access to breast feeding 99350
breast pump electric are eligible no cost share pumps. Hospital Grade breast pumps will
supplies for pregnant
Breast Pumps & Supplies
require medical necessity per notification approval if charges are in excess of the $1,000.00.
and nursing women
E0602 – E0604,
Lactation classes are paid at no cost share, if receive lactation classes in the home the
A4261 – A4286
services must be medically necessary per notification approval.
Breast feeding support, supplies and counseling services will require network providers
(sample: network DME providers include: Lucina Care, www.Lucinacare.com (888) 809-9750)
to access the no cost share benefit.
For a list of current network breast pump suppliers, go to www.tmlmultistateiebp.org/ and
login:
1.
Click the "Provider Search" link found in the Benefit Information menu on the top.
2.
Click on the "Search the Choice Plus Network" button under United Choice Plus
Network
3.
Click the "Nationally Contracted Facilities and Equipment Vendors" link under Facilities
Breast pump replacement non-disposable accessories are reimbursed at no cost share:
A4281 tubing for breast pumps, A4282 adaptor for breast pumps, A4283 cap for breast pump
bottle, A4284 breast shield and splash protector, A4285 polycarbonate bottle for use with
breast pump, A4286 locking ring
76
IEBP Guide Overview PY14-15
3. Fund Contact E-Friendly Resource Guide
1. Executed Agreements Guide
Required Annual Executed Agreement

Interlocal

MyHealth Web Portal

Annual Rerate Sheet

Online Health Power Assessment (HPA) English/Spanish

Health Reimbursement Arrangement (HRA)

Provider Network Information

Retirement Reimbursement Arrangement (RRA)

Online Customer Care Services

Health Savings Account (HSA) Employer Enrollment Form

Secure E-mail

Section 125 Flex: Premium Only Plan, Standard Plan, Grace Period (two

Accessing Your Electronic Bill and Remittance Slip

months and fifteen days), Carryover (maximum $500 unreimbursed
healthcare dollars)
Accessing Your FSA/DCA/HRA Accounts

COBRA Continuation of Coverage (COC)
Restat ReSource Smartphone and Droid Application Instructions


Annual Certification of Distribution of Benefit Books and Plan Information
MyHealth Mobile Application


Helpful Links and Phone Numbers


Healthcare Links not found on the IEBP Website

2. Employee E-Friendly Resource Guide

MyHealth
Web
Portal

Online Health Power Assessment (HPA) English/Spanish

Provider Network Information
4. Protected Health Information Guide

Online Customer Care Services
Privacy Reference Tools


Secure E-mail
Privacy and Protection Statement


Why do I need an Authorization Form


Restat ReSource Smartphone and Droid Application Instructions
Notice of Privacy Practices


Health Information Authorization Form


Helpful Links and Phone Numbers
Glossary of Terms


Healthcare Links not found on the IEBP Website


77




5. Summary of Benefit Changes 2014-2015 Plan Year
Medical

Dental

Vision

Administrative Updates










6. Forms Guide
Sample Member Supply Request Form


Sample ID Card and Request Form

Sample Explanation of Benefits (EOB)

Sample Explanation of Payment (EOP)

Consumer Centered Medical Enrollment Form

Consumer Centered Medical Change-Term Form

Consumer Centered HRA/HSA Enrollment Form

Consumer Centered Benefit Calculator

Medical Enrollment Form

Active Employee/Continuation of Coverage Participant and Dependent

Eligibility Checklist Form
Medical Change-Term Form

Other Insurance Form English

Other Insurance Form Spanish

Right of Recovery-Accident/Injury Form

Section 125 Enrollment Form

Section 125 Premium Only Plan Enrollment Form

Section 125 Change Form

Section 125 Claim Form

Section 125 Premium Only Plan Change Form

Section 125 Dependent Care Reimbursement Form

Section 125 Unreimbursed Healthcare Reimbursement Form

Section 125 Recurring Expense Service Form

Section 125 Direct Deposit Authorization Agreement







78
HRA Enrollment Form
HRA Change Form
HRA Claim Form
RRA Enrollment Form (If Post Deductible RRA for access
to Consumer Centered Plans)
RRA Change Form
RRA Claim Form
HSA Enrollment Form
HSA Change Form
HSA Bank Employer Sign-Up Form
HSA Bank IRS Form 1099-SA Instructions
HSA Bank IRS Form 5498-SA Instructions
COBRA Continuation of Coverage Enrollment Form
COBRA Continuation of Coverage Employer's
Termination Notice Form
Life Enrollment and Change Form
Six Steps to Understand Open Enrollment
Patient Advocacy Form and Criteria
Patient Satisfaction Survey
Certificate of Credible Coverage
Pre 65 Retiree and Dependent Eligibility Checklist Form
7.
Supplemental Benefits Option Guide
9.
The Standard Life Overview

The Standard Claim Procedures

The Standard MEDEX Travel Assist Brochure

Standard Life Enrollment-Change Form

The Standard Voluntary AD&D Coverage Form

The Standard Sample Life/LTD/STD Correspondence

Public Employee Benefits Alliance (PEBA) Supplemental Benefit Options: Employee

Assistance Program, Wellness, International Medicine, Security Audits, Medical
Home Model of Care, Accident Supplemental Benefits, Cancer Supplemental
Benefits, Pre/Post Sixty-five Benefits, Comprehensive Eligibility Audit
8.
Human Resources/Fund Contact Healthcare Benefits Information Resource Guide
Required Executed Agreement

Annual Enrollment Required Information


Annual Enrollment Support Service Options

Employer Benefit Options

Provider Network Options

Open Enrollment Procedures

IEBP Billing Procedures

Benefit Guides Resources

Healthy Living Guides

Healthy Living Fact Sheets

Healthy Initiatives Engagement Resources

Sample Documents: Business Associate Agreement, Ordinance/Resolution

Sample Supply Request FormSample ID Card Request Form (Online Form Only)

Annual Paper Provider Directory Order Form

Annual Benefit Reminder Poster


79
Member Rights and Responsibilities Guide
E-Friendly IEBP Healthcare Benefit Information Links

IEBP Member Rights and Responsibilities Statement

IEBP Employee Healthcare Benefit Reminder

Active Employee/COC Participant and Dependent Eligibility

Checklist Form
COBRA Continuation of Coverage Information

Initial Notices

»
Special Enrollment Notice
»
Initial Notice of Benefits for Wellness Services
 IEBP Health and Wellness Programs
»
Notice of Benefits for Mastectomy and Breast
Reconstruction
»
Notice of Medicaid and Children’s Health Insurance
Program (CHIP)


Sample Identification Card and Online Request Form

Sample of Explanation of Benefits (EOB)

Sample of Explanation of Payment (EOP)

Explanation of Benefits Remark Codes Overview

Claim Audit Tool

Appeal Guidelines

How to Obtain Assistance on a Bill or Claim

Patient Advocacy Audit, Review Criteria, and Form

Managed Care/Cost Efficiency Audits

Manage Out of Pocket Expenses

Healthcare Reform Definitions

Government Programs: Medicare, Medicaid

Notice of Insurance Marketplace

10. Comprehensive Eligibility Guide
13.
Enrollment Requirements

Active Employee

Termination of Benefits

Termination of Benefits due to Gross Misconduct

Incomplete Eligibility Form Correspondence: Fund Contact and Employee

Eligibility Checklist Form

Active Duty Reservists

Required New Hire Eligibility Documentation

How to Obtain Vital Record Documentation

Health Information Authorization Form (Execution Optional)

Other Insurance Information


FMLA Overview

11. Online Enrollment Conversion Guide
Benefit Plan Year Rerate Timeline

Enrollment Parameters/Conversion Questions

Online Enrollment Data Load Spreadsheet Explanation

Online enrollment Data Load Spreadsheet

Online Sandbox Test Tool

Medical Intelligence Health and Wellness Guide
Wellness Program that Works

»
Biometric Screenings
»
No Cost Share Wellness Benefits
»
Personal Health Record
»
»
Health Power Assessment Overview
Preventive/Routine Care Benefit

Population Health Engagement/Professional Health Coaches Chronic Care

Management
Self Assessment Tools: Health Power Assessment, Wheel of Life

Healthy Living Guides List

Healthy Living Fact Sheets List

Medical Intelligence Care Management Features

Notification Requirements

Continued Stay Review

Medical Intensive Care Management

Outcome Improvement Protocol

Centers of Excellence Providers

Integrated Medical Home Model of Care

Sample Care Management Correspondence

12. Medication Therapy Management Guide
Prescription Flowsheet

Step Therapy/RxResults

Prior Authorization/RxResults

SpecialtyRx/Biotech Prescriptions/Diplomat

Cost Share Prescriptions/Sample Cost Share Letter

Restat Reportal (user friendly for iPhone and Droid)


Covered and Non-Covered Drugs

High Deductible H.S.A Benefit Plans Wellness Drug List

TML MultiState IEBP Preferred Formulary

Mail Order

Biotech Services/Diplomat

80
14.
Provider Access Provider Information Tool Guide
IEBP Quality Improvement and Management Program

IEBP Member Rights and Responsibilities Statement

Clinical Protocol

Website Services for Providers

Provider Network Assistance: Primary, Secondary Networks, Centers of

Excellence
Identification of the Covered Individual: Sample Medical ID Card

Public/Private Alliance Provider Solution

UnitedHealthcare Choice Plus Provider Network Information


»
Restat Reportal (user friendly for iPhone and Droid)
»
Step Therapy
»
Clinical Prior Authorization
»
Cost Share Medications
»
SpecialtyRx/Biotech Prescriptions
»
High Deductible H.S.A. Benefit Plans Wellness Drug List, OTC, PPACA
No Cost Share Mandates
»
Transplant and Obesity Designated Centers of Excellence and Choice
Plus Network Providers
»
Provider Coding Guidelines
»
Prompt Pay Adjudication
Sample
Explanation of Benefits (EOB)

Electronic
Fund Transfer Information

Sample Explanation of Payment (EOP)

How Benefits are Paid

Non-Duplication of Benefits

Healthy Initiatives

Medical Intelligence

After Hours and/or Weekend Medical and Mental Health Care Services

Transplant/Obesity Network Centers of Excellence in conjunction with

Network Providers
Provider Clinical Practice Guideline Resources

15.















Stop Loss Guide
IEBP Stop Loss Services Contact List
Medical Benefit Plan Document
Summary of Benefits and Coverage (SBC)
Medication Therapy Management Guide
Medical Intelligence Interface
Designated Centers of Excellence: Transplant and Obesity
Healthy Initiatives Program
United Healthcare Choice Plus Provider Network Information
Early Notification Reporting
Stop Loss Administration
Trigger List
Healthcare Reform Appeal Timeline
Independent Review Organizations Interface




Provider Care Path Pricing Transparency Guide
Twenty-one Care Paths and Fifty-two Procedures by Geographic Area
Care Path Descriptions
Specialties Linked to Care Paths
Care Path Definitions
16.
81
17. Retiree Benefits Guide
Medicare Overview

IEBP Benefit Plan Options

Pre 65

»
Medical Plan Book
»
Dental
»
Vision
Post 65

»
Medicare Overview
»
Post 65 Supplemental Benefits
 Supplemental K Post 65 United Healthcare
 Either Prescription Option: If Supplemental and Advantage Pres Option
has to be the same Supplemental F Post 65 United Healthcare
 Either Prescription Option: If Supplemental and Advantage Pres Option
has to be the same Formulary H Full Coverage in Gap
 Formulary G Generic in Gap
 Advantage Plan
 Value add Dental and Vision Supplements
 Supplemental Plans and Stand-Alone Prescription Options
 Retiree Comprehensive Eligibility Guide
 Retiree Rx Creditable Coverage Letter
 Retiree Rx Non-Creditable Coverage Letter (for high deductible plans)
Retiree Member Correspondence

»
Sample Retiree Fund Contact Letter
»
Pre Sixty-five Sample Fund Contact Options Form
»
Post Sixty-five Sample Fund Contact Options Form
»
Sample Pre Sixty-five Retiree Letter
»
Pre Sixty-five Retiree Medical Enrollment Form
»
Pre Sixty-five Retiree Medical Change-Term Form
»
Sample Post Sixty-five Retiree Letter
»
Sample Post Sixty-five Retiree Enrollment Form
»
Sample Retiree Ordinance/Resolution
82
18.
Political Subdivision MemberCentric Guide
Extended Plan Year Benefit Impact

Overview of Consumer Plan Options

Section 125 Pre-Tax Eligible Benefits

IEBP Consumer Centered Pool Plan Options Replicating IRS Minimum

and Maximum Regulations
High Deductible H.S.A. Plan Overview

High Deductible H.S.A Health Plan Diagram

High Deductible H.S.A. Benefit Plans Wellness Drug List, OTC, PPACA No

Cost Share Mandates
Health Savings Account Contribution Matrix Limits

Health Savings Account Catch up Contributions

Online Defined Contribution and Employer Subsidy Worksheet


Benefits Debit Card Management Tips


IRS Form 1099 SA Instructions

IRS Form S498 SA Instructions

Alegeus WealthCare Debit Card Flyer

Provider Directory Letter: Choice
Date
FUND CONTACT
GROUP NAME
MAILING ADDRESS
CITY TX ZIP
RE: Provider Directory Order Form Region #
Dear Fund Contact:
The Provider Directory information is online at www.tmlmultistateiebp.org. Annually, TML MultiState IEBP requests that the members identify how
many printed directories they would like to have on hand for distribution to their employee and dependent population. Please remember, the printed
Provider Directories are updated annually and the website is updated daily. TML MultiState IEBP has less of a demand for the printed Provider
Directories due to the provider network information being outdated.
To search for the most current listing of network providers, go to www.tmlmultistateiebp.org and login to the myTML IEBP web portal. Next, under
“Benefit Information” click the “Provider Search” link. To search the UnitedHealthCare Choice Plus Network, select the desired search option and
follow the step-by-step instructions. Search results may be printed at any time.
If you are interested in receiving Paper Provider Directories, at no additional cost, please fill out this form and return it to Adam Martinez via fax at
(512) 719-6509.
Provider Directory Order Form
Name of UnitedHealthCare Choice Plus Network Directory: ###
Number of Directories Needed: __________
Order Deadline: May 2, 2014
Directories will be shipped on June 6, 2014
Signature/Title ___________________________________________________
Please contact me at (512) 719-6780 if you have any questions or other suggestions that can help to reduce waste.
Sincerely,
Susan L. Smith
Executive Director
83
Provider Directory Letter: Options
Date
FUND CONTACT
GROUP NAME
MAILING ADDRESS
CITY TX ZIP
RE: Provider Directory Order Form Region #
Dear Fund Contact:
The Provider Directory information is online at www.tmlmultistateiebp.org. Annually, TML MultiState IEBP requests that the members identify how
many printed directories they would like to have on hand for distribution to their employee and dependent population. Please remember, the printed
Provider Directories are updated annually and the website is updated daily. TML MultiState IEBP has less of a demand for the printed Provider
Directories due to the provider network information being outdated.
To search for the most current listing of network providers, go to www.tmlmultistateiebp.org and login to the myTML IEBP web portal. Next, under
“Benefit Information” click the “Provider Search” link. To search the UnitedHealthCare Options PPO Network, select the desired search option located
under “United Options PPO Network” and follow the step-by-step instructions. In addition to the UnitedHealthCare Options PPO Network, you also
have access to additional network providers through TML MultiState IEBP contracts. If you are unable to find a provider using the UnitedHealthCare
Options PPO provider directory search, you may search the TML MultiState IEBP Direct PPO Network by selecting the desired search option listed
under “TML MultiState IEBP Direct PPO Network”. Search results may be printed at any time.
If you are interested in receiving Paper Provider Directories, at no additional cost, please fill out this form and return it to Adam Martinez via fax at
(512) 719-6509.
Provider Directory Order Form
Name of Provider Directory: ###
Number of Directories Needed: __________
Order Deadline: May 2, 2014
Directories will be shipped on June 6, 2014
Signature/Title ___________________________________________________
Please contact me at (512) 719-6780 if you have any questions or other suggestions that can help to reduce waste.
Sincerely,
Susan L. Smith
Executive Director
84
Changes in Red
 Plan Year 2014-2015 Membership Dental Benefits
 Deletion of Late Entrant Limitation
 ADA codes are being updated.
Current 2013-2014 Rates
Active Dental Rates
Pre-65 Dental Rates
Actives
Dental II
Dental II
Rolling 12
EE
$7.52 EE
$10.16 81.38%
Comp
$13.26 Comp
$17.90
Spouse
$10.56 Spouse
$14.26
Child(ren)
$9.06 Child(ren)
$12.24
Family
$15.52 Family
$20.96
Dental II Voluntary
EE
$11.36
Comp
$19.14
Spouse
$15.26
Child(ren)
$13.08
Family
$22.40
Dental II Voluntary
EE
$13.72
Comp
$24.18
Spouse
$19.26
Child(ren)
$16.52
Family
$28.30
Dental III
EE
Comp
Spouse
Child(ren)
Family
$30.14
$47.30
$31.74
$34.92
$62.40
Dental III
EE
Comp
Spouse
Child(ren)
Family
Dental IV
EE
Comp
Spouse
Child(ren)
Family
$20.24
$33.42
$27.34
$23.28
$40.48
Dental IV
EE
Comp
Spouse
Child(ren)
Family
Dental IV Voluntary
EE
$27.32
Comp
$45.12
Spouse
$36.92
Child(ren)
$31.44
Family
$54.66
0%
0%
0%
0%
0%
New 2014-2015 Rates
Active Dental Rates
Retiree % Incr
Dental II
EE
$7.52
17%
Comp
$13.26
17%
Spouse
$10.56
17%
Child(ren)
$9.06
17%
Family
$15.52
17%
Pre-65 Dental Rates
Retirees
Dental II
Rolling 12
EE
$11.90 165.11%
Comp
$20.94
Spouse
$16.68
Child(ren)
$14.32
Family
$24.52
Active% Incr
PY
84.52%
73.01%
67.60%
0%
0%
0%
0%
0%
Dental II Voluntary
EE
$11.36
Comp
$19.14
Spouse
$15.26
Child(ren)
$13.08
Family
$22.40
17%
17%
17%
17%
17%
Dental II Voluntary
EE
$16.06
Comp
$28.30
Spouse
$22.54
Child(ren)
$19.34
Family
$33.12
$40.70
$63.86
$42.86
$47.14
$84.24
85.28%
86.12%
7%
7%
7%
7%
7%
Dental III
EE
Comp
Spouse
Child(ren)
Family
$32.26
$50.62
$33.96
$37.36
$66.78
2%
2%
2%
2%
2%
Dental III
EE
$41.52
Comp
$65.14
Spouse
$43.72
Child(ren)
$48.08
Family
$85.92
$27.32
$45.12
$36.92
$31.44
$54.66
98.56%
100.98%
17%
17%
17%
17%
17%
Dental IV
EE
Comp
Spouse
Child(ren)
Family
$23.70
$39.10
$32.00
$27.24
$47.36
2%
2%
2%
2%
2%
Dental IV
EE
$27.88
Comp
$46.02
Spouse
$37.66
Child(ren)
$32.08
Family
$55.76
87.91%
89.48%
7%
7%
7%
7%
7%
Dental IV Voluntary
EE
$29.24
Comp
$48.28
Spouse
$39.50
Child(ren)
$33.64
Family
$58.50
17%
17%
17%
17%
17%
Dental IV Voluntary
EE
$43.16
Comp
$71.28
Spouse
$58.32
Child(ren)
$49.66
Family
$86.36
Dental IV Voluntary
EE
$36.88
Comp
$60.92
Spouse
$49.84
Child(ren)
$42.44
Family
$73.80
85
PY
95.65%
238.83%
207.50%
58.48%
44.90%
23.85%
23.85%
139.46%
166.95%
Supplement Benefits
Changes in Red

Plan Year 2014-2015 Membership Vision Rate Increases
Current 2013-2014 Rates
New 2014-2015 Rates
2013-2014
2013-2014
Active Vision Rates
Pre-65 Vision Rates
Active Vision
Rates
Pre-65 Vision
Rates
Vision A
Vision A
Vision A
Vision A
EE
$6.76
Family
$13.50
Vision A Voluntary
EE
$9.38
Family
$18.76
EE
Family
Family
56.08%
$14.18
EE
$9.86 57.52%
Family
2014-2015
0% EE
0% Family
Vision A Voluntary
Vision B
EE
$7.10 54.25%
Active
% Incr
58.69%
$19.70
0% EE
0% Family
$18.00
Vision B Voluntary
EE
Family
2014-2015
$6.76
8%
EE
$13.50
8%
Family
Vision A Voluntary
Vision B
$9.00
Retiree
% Incr
62.69%
$18.90
0% Family
Vision B Voluntary
EE
$12.50
EE
$13.14 52.88%
Family
$25.00
Family
$26.26
0% EE
55.87%
$15.32
$9.38
8%
EE
$10.66 49.85%
$18.76
8%
Family
$21.28
0%
EE
$18.00
0%
Family
$9.46 58.17%
26.01%
$18.90
Vision B Voluntary
0% EE
$12.50
15% EE
$15.12 80.12%
0% Family
$25.00
15% Family
$30.20
86
61.25%
Vision B
$9.00
Vision B Voluntary
98.99%
Vision A Voluntary
Vision B
$9.46 61.21%
$7.68 84.01%
111.18%
Leveraging Purchasing
Power of Political Entities for
Cost Effective Employee
Benefits
87
Member Agreements Summary of Benefit Plan Changes PY14-15
Changes are in red
 Section 125
 Acid reducer – Medical expenses paid per Patient
Protection and Affordable Care Act (PPACA) 1.1.2011.
Pepcid AC, Zantax, Prilosec
 Acne medication – Medical expenses paid per Patient
Protection and Affordable Care Act (PPACA) 1.1.2011.
Clearasil, OXY
 Allergy medicine – Expenses to alleviate or treat
injuries or sickness with a prescription. Alavert,
Benadryl, Claritin, Sudafed
 Allergy pillows, mattress covers, air purifiers, filters,
etc. – Treat allergies diagnosed by physicians.
88
Changes are in red
 Section 125
 Anti-bacterial hand sanitizers – Purell, Nexcare, Germ-X personal use
component; but for test must be established
 Antibiotic products – Bacitracin, Neosporin, triple antibiotic ointment
 Anti-diarrhea medication – Medical expenses paid per Patient
Protection and Affordable Care Act (PPACA) 1.1.2011. Imodium,
Kaopectate
 AntiGas – Gas-X, Phazyme with physician order
 Antifungal (Foot) – Lamisil, Lotrimin
 Antiparasitic treatments – Nix, Rid, lice treatments
 Antiseptics & wound cleansers – Rubbing alcohol, peroxide, Epsom
salt, betadine, hibiclens
 Anti-itch lotion – Medical expenses paid per Patient Protection and
Affordable Care Act (PPACA) 1.1.2011. Caladryl, Lanacane, Sarna,
hydrocortisone
89
Changes are in red
 Section 125
 Baby diapers – Huggies, Pampers, Pullups to treat
juvenile incontinence or medical condition
 Baby formulas/nutritionals – Pediassure, Progestimila
specialty formulas/nutritionals are covered if medically
necessary and authorized by medical practitioner. Only
the excess cost between regular formula and the
specialized formula may be eligible under an employer’s
plan.
 Baby electrolytes and dehydration – Pedialyte, Enfalyte
baby electrolytes and dehydration
 Baby rash ointments & creams – Desitin, Aveeno Baby
includes petroleum jelly merchandized and marketed
for baby rash
90
Changes are in red
 Section 125
 Breast pump – Prescribed breast pump and breast feeding supplies
used for the convenience of the mother is reimbursable. Breast
Pump (cost or rental fee), Breast Pump Parts (pump valve,
replacement tubing piston unit, diaphragms, pump body, flange,
shield), Storage Bottles, Storage Bags, Gel Pads, Nursing Pads, Nipple
Shields, Conversion Kits, Areola Stimulator, Car Adapter
 Compression hosiery – Jobst, TED, Futuro including diabetic socks;
excess cost over regular hose and socks
 Cough, cold & flu dietary supplements – Airborne, hall’s Defense,
Germ Defense Alka Seltzer Immunity products that are merely
dietary supplements and marketed as such, including those claiming
to “support the immune system” (i.e. Airborne), are not covered
(dual). Cold preventative products which are “proven to lessen the
severity” or “reduce the duration” of colds or flu are covered. These
include homeopathic, natural products, some herbals and some
forms of zinc.
91
Changes are in red
 Section 125
 Diabetes nutritionals – Glucerna, boost glucose to
treat symptoms of diabetes when recommended by
physician
 Diabetes personal care & supplies – Include
diabetes skin care, cough & cold, support socks and
supplies. Personal care is generally not covered;
must test or treat a specific symptom or condition
of Diabetes.
 Diagnostic products – Cholesterol screening,
thermometers, blood pressure monitors, cholesterol
testing
92
Changes are in red
 Section 125
 Dietary supplements – Essential fatty acids (fish oil), soy,
enzymes, amino acids under narrow circumstances, they will
be eligible if used to treat a medical condition or at-risk for
illness diagnosed by physician, dietary supplement marketed in
pain relief, cough & cold and antacids/laxative categories do
not automatically qualify as a medical expense 9i.e, Azo
Cranberry, Airborne, Culturelle, etc)
 Digestive aids – Lactaid, Lactase, Beano with physician order
 Drug Testing Kits – First Check diagnostics of illegal activities
are typically not covered
 Ear Care – Un-medicated ear drops, syringes, and ear wax
removal
 Ear plugs – Mack’s, Flent to treat medical condition
(presence of middle/inner ear tubes) diagnosed by
physician
93
Changes are in red
 Section 125
 Elastics/Athletic Treatments – ACE, Futuro, eklastic bandages,
braces, hot/cold therapy, orthopedic supports & rib belts etc.
 Exercise equipment – To treat medical condition diagnosed by
physician, not for general health
 Feminine Moisturizing – Raplens, Rephresh to treat vaginal
dryness caused by medical condition
 Feminine Protection (Pads & Liners) - Kotex, Always, Stayfree
they are ordinarily considered as being used to maintain
general health and for personal care. They are dual if used
for post-surgery or child birth.
 First Aid Burn & Scar Treatments & Skin Protectants
(petroleum jelly) – Aloe, Mederma, Neosporin Scar
Solution, Vaseline Jelly prescribed by a physician for a
burn
94
Changes are in red
 Section 125
 Fluoride Treatments – Gel-Kam to treat medical
condition diagnosed by physician and not for general
oral care
 Food Thickeners – Thick-it for test must be established
 Foot Insoles and Cushioning – Insoles, Heel & Arch, Dr.
Scholl’s Air Pillo, Odor Eaters treatment vs general use
for comfort, must treat specific ailment to be covered
 Gloves (Rubber & Cotton) – Becton, Dickinson and Co
(BD)
 Hair growth product – Rogain to treat symptom of
medical condition diagnosed by physician
95
Changes are in red
 Section 125
 Hearing aids/Medical batteries – Medical expenses for a
hearing aid and batteries are reimbursable. The cost of hearing
aid repairs is a qualified medical expense.
 Homeopathic Remedies – Products that treat an illness or
condition that are eligible with a prescription
 Medical Nutritionals – Treats a specific condition and
prescribed by a physician
 Medicated bath products – Medical expenses; Medical
expenses paid per Patient Protection and Affordable Care Act
(PPACA) 1.1.2011 or to treat a specific condition diagnosed by a
physician.
 Minerals – Calcium Carbonate, Ferrous, Sulfate under narrow
circumstances, they will be eligible if used to treat medical
condition or at-risk for illness diagnosed by a physician.
96
Changes are in red
 Section 125
 Nasal Strips & Snore Relief – Breathe Right to treat sleep apena or
improper breathing diagnosed by physician
 Naturopathy – Non-traditional healing treatments to treat a medical
condition. Naturopathy expenses are not reimbursable unless used
to treat medical condition or at-risk for illness diagnosed by
physician.
 Reading glasses and maintenance accessories – Reading glasses are a
reimbursable expense. Chains, etc., are not covered.
 Skin Care – Therapeutic Hand & body – Eucerin, Acquaphonr,
Amlactin to treat or remedy a skin condition diagnosed by a
physician
 Sunburn relief and sunscreens – Sunscreen and sunburn relief are
over-the-counter products that prevent disease (such as skin cancer)
or alleviate injuries (such as sunburns) and therefore should be
reimbursable FSA expenses; Coppertone, Banana Boat SPF 15+ and
UVA/UVB protection; protection against skin cancer and premature
skin aging
97
Changes are in red
 Section 125
 Therapeutic Shampoo & Scalp Treatments (medicated) – Nizoral, Neutrogena T-Gel
to treat skin/scalp condition for short duration diagnosed by physician
 Vaccinations – Flu Shots, Pneumonia Vaccinations
 Vaporizers & humidifiers and Accessories – Vicks, Sunbeam, Kaz if used to treat
illness, not covered for normal household use
 Weight loss program – The cost of a weight loss program for general health is not
reimbursable even if a doctor prescribes the program. However, the cost of a weight
loss program may be reimbursable in two instances. First, if attendance at a weight
loss program is prescribed by a physician to treat a specific illness (e.g., heart
disease), the expense is reimbursable. The physician should substantiate the
necessity of this treatment. Second, obesity is now medically recognized by the IRS
as a disease in its own right, and weight loss programs to treat obesity are
reimbursable expenses. Apparently, weight loss programs to treat obesity do not
have to be prescribed by a physician, but obesity must be diagnosed. Also see
Special foods. A medical expense for weight loss can be reimbursed if the treatment
is for a specific disease diagnosed by a physician. Exercise equipment and exercise
programs are covered if prescribed by a physician. Alli, Slim Fast to treat obesity
diagnosed by a physician.
98
Changes are in red
 HRA Pool and ASO Plan
 Dependent Coverage
 Coverage for a Dependent cannot extend beyond the
date coverage for the active Employee ends, unless
required by Section 615.071 of Chapter 615 of the
Government Code for survivors of certain employees
described in Section 615.003 of the Chapter who are
killed in the line of duty. Section 615.075(c) requires
that the survivor must give the employer notice of
election to purchase coverage within 180 days of the
decedent’s death.
99
Changes are in red
 HRA Limited Post Deductible Pool Plan
 Dependent Coverage
 Coverage for a Dependent cannot extend beyond the
date coverage for the active Employee ends, unless
required by Section 615.071 of Chapter 615 of the
Government Code for survivors of certain employees
described in Section 615.003 of the Chapter who are
killed in the line of duty. Section 615.075(c) requires
that the survivor must give the employer notice of
election to purchase coverage within 180 days of the
decedent’s death.
100
Changes are in red
 COC Agreement
II. Employer Duties
1. The undersigned Employer will notify the Pool’s Billing/Eligibility
Representative assigned to the Employer via FAX or Telephone (with a
written follow up) within one (1) business day of a qualifying event, as
defined by the COBRA Continuation of Coverage statute and its
amendments, or a termination for gross misconduct of a Covered Employee
for which the Employer has knowledge. Examples of qualifying events
include termination; lump sum or severance settlement; resignation; death;
retirement if the employee does not enroll for retiree coverage when offered
under the Employer’s benefit plan; reduction in hours (including reduction to
zero hours), call to duty for military service and absence from work for an
injury or illness after all earned sick leave, vacation leave and FMLA has been
exhausted.
2. The undersigned Employer will distribute Attachment A, which advises each
Covered Individual of their rights and responsibilities under COBRA
Continuation of Coverage. The Employer will certify through a letter to the
Pool that Attachment A was distributed to all Covered Individuals as of the
date the Pool commenced COBRA Continuation of Coverage Administration.
101
Changes are in red
 COC Agreement
II. Employer Duties
3. The undersigned Employer will distribute Attachment A to all
employees who become covered by the Employer’s benefit plan after
the date the Pool commenced COBRA Continuation of Coverage
administration and include verification of the distribution with the
enrollment card when it is submitted to the Pool.
4. The undersigned Employer will notify the Pool via FAX or Telephone
(with a written follow-up) within one (1) business day of gaining
knowledge that a Covered Individual has legally separated, divorced or
is no longer eligible for coverage, e.g., the Covered employee or
dependent is voluntarily dropped from coverage.
5. The undersigned Employer will notify the Pool at least ten (10) business
days prior to any open enrollment period. The notice to the Pool will
include the dates of the open enrollment.
102
Changes are in red
 COC Agreement
II. Employer Duties
6. The undersigned Employer will immediately notify the Pool of any suspected
claim, demand or suit arising from the administration of COBRA Continuation
of Coverage.
7. To the extent allowed by law, the undersigned Employer will indemnify and
hold harmless the Pool and its officers, agents, employees and
representatives from all suits, actions, losses, damages (including punitive
damages), claims or liability of any type, including without limiting the
generality of the foregoing all expenses of litigation, court costs, and
attorney’s fees, resulting from the failure of the undersigned Employer to
give any notice required by this Agreement. The foregoing reimbursement
obligation shall specifically include any medical claim costs incurred by the
Pool because of the failure of the Employer to give any notice of an
employee termination or other qualifying event. The undersigned Employer
will fund this obligation out of current revenues in the year the obligation is
determined or will levy a tax to fund the obligation if current revenues are
insufficient.
103
Changes are in red
 COC Agreement
II. Employer Duties
8. Any decision of whether an Employee was
terminated because of gross misconduct will be
made by the Employer no later than the 45th day
following the termination or the date a COBRA
election notice is mailed to the Employee,
whichever is earlier. Any determination of gross
misconduct shall be based only on events prior to
the termination of employment.
Expanded Notice to COBRA Participant of Insurance
Marketplace Option
104
105
Sample
Category
Plan Documents/Agreement
(most recent 5 years)
Documents requiring
Risk or Non-Risk Interlocal Agreement
signature for Execution Annual Rerate Sheet/Online Instructions
maintain 5 years online Annual Health Reimbursement Arrangement (HRA)
Annual Retiree Reimbursement Arrangement (RRA)
Navigate to a Health Savings Account (H.S.A.)
Annual Health Savings Account (H.S.A.)
IRS Form 1099 and 5498 SA Instructions
H.S.A. Health Savings Account Employer Enrollment Form
Annual Section 125: Premium, Standard, Grace, Carryover
Annual COBRA Continuation of Coverage
Certification of Distribution of Benefit Books
Annual Paper Directory Request Form
MyBenefits on Demand Order form
Fund Contact
Helpful Resource Guides
Annual Benefit Reminder Poster
Fund Contact Guide
Fund Contact E-Friendly Guide
 Agreements Requiring Signature and Return to IEBP  myIEBP Website
 Annual Enrollment Required Information
 Online Health Power Assessment (HPA)
 MyBenefits on Demand Order Form
 Provider Network Information
 Annual Enrollment Support Service Options
 Online Customer Care
 Employer Benefit Options
 Secure E-mail
 Provider Network Options
 Accessing your Electronic Bill and
 Open Enrollment Procedures
Remittance Slip
 IEBP Billing Procedures
 Accessing your FSA/DCA/HRA Accounts
 Benefit Guides Overview
 Restat Resource Smartphone
 Healthy Living Guides
Application Instructions
 Healthy Living Fact Sheet
 Resource Android Application
 Sample Documents: Resolution, Ordinance, Business
Instructions
Associate Agreement
 Contract Information
 Sample ID Card
 Helpful Links and Phone Numbers
 Sample Benefit Reminder Poster
 Healthcare Links not found on the IEBP
 Sample Supply Request Form
Website
 Annual Provider Directory Order From
 Six Steps to Understand Open Enrollment
 Healthy Initiatives Engagement Resources
106
Sample
Category
Fund Contact
Online Enrollment Conversion Guide
 Plan Year Rerate Timeline
 Enrollment Parameter Worksheet
 Online Enrollment Data Load Spreadsheet Explanation
 Online Enrollment Data Load Spreadsheet
 Employer Defined Contribution Cost
 Online Sandbox Test tool
Forms Guide
 Sample Member Supply Request Form
 MyBenefits on Demand Form
 Sample Explanation of Benefits (EOB)
 Sample Explanation of Payment (EOP)
 Sample ID Card and Request Form
 Consumer Centered Medical Enrollment Form
 Consumer Centered Medical Change-Term Form
 Consumer Centered HRA/HSA Enrollment Form
 Consumer Centered Benefit Calculator
 Medical Enrollment Form
 Active Employee-COC Participant and Dependent Eligibility
Checklist Form
 Medical Change-Term Form
 Other Insurance Form English
 Other Insurance Form Spanish
 Right of Recovery-Accident/Injury Form
 Pre-X Routine Inquiry Form (Employee) template
 Pre-X Inquiry Form (Provider) template
 Section 125 Enrollment Form
 Section 125 Premium Only Plan Enrollment Form
 Section 125 Change Form
 Section 125 Premium Only Plan Change Form
 Section 125 Claim Form
 Section 125 Dependent Care Reimbursement Form
 Section 125 Unreimbursed Healthcare Reimbursement Form
 Section 125 Recurring Expense Service Form
 Section 125 Direct Deposit Authorization Agreement
107

















HRA Enrollment Form
HRA Change Form
HRA Claim Form
HRA Limited Post Deductible Enrollment Form
RRA Enrollment Form (If Post Deductible RRA for
access to Consumer Centered Plans)
RRA Change Form
RRA Claim Form
HSA Enrollment Form
HSA Change Form
COBRA Continuation of Coverage Employer’s
Patient Advocacy Form
Certificate of Creditable Coverage Request
Pre Sixty-five Eligibility Form
Sample
Category
Plan Documents/ Helpful Resource Guides
Agreement (most
recent 5 years)
Eligibility
Comprehensive Eligibility Guide
Requirements
 Enrollment Requirements
 Active Employee
 Termination of Benefits
 Termination of Benefits due to Gross Misconduct
 Incomplete Eligibility Form Correspondence; Fund Contact and Employee
 Eligibility Checklist Form
 Active Duty Reservists (Out of Medical Book)
Member Rights
Employee E-Friendly Resource Guide
and
 IEBP Website
Responsibilitie
 Online Health Power Assessment (English/Spanish)
s
 Provider Network Information
 Online Customer Care Services
 Secure E-Mail
 Definition of Active Employee
Member Rights and Responsibilities Guide
 Members Rights and Responsibilities Statement
 Employee Benefit Reminder Notice
 Active Employee/COC Participant and Dependent Eligibility Checklist Form
 Healthcare Reform Definitions
 Initial Notices
Special Enrollment Notice
Initial Notice of Benefits for Wellness Services
Notice of Benefits for Mastectomy and Breast Reconstruction
Notice of Medicaid and Children’s Health Insurance Program (CHIP)
Pre-existing Notice of Limitations
 Notice of Privacy Practices
 Sample ID Card Request Form
 Sample EOB
 Sample EOP
 COBRA Continuation of Coverage
 Sample Identification Card and Online Request Form
 Explanation of Benefits Remark Code Overview
 Claim Audit Tool
 Appeal Guidelines
108






How to Obtain Vital Record Documentation
Protected Health Information Authorization Form (Execution Optional)
Other Insurance Information
Steps to Develop a Health Organizer
FMLA Overview



















Restat Smartphone/Droid Application
E-Friendly IEBP Healthcare Benefit Information Links
HealthX Application
Active Duty Reservist
Other Insurance Form
Right of Recovery Form
FMLA Overview
How to Obtain Assistance on a Bill or Claim
Patient Advocacy Audit, Review, Criteria, and Form
Managed Care/Cost Efficiency Audits
IEBP Health and Wellness Programs
E-Friendly IEBP Healthcare Information Links
Government Programs: Medicare, Medicaid, Exchange/Insurance
Marketplaces
Protected Health Information Guide
 Notice of Privacy Policy
 Health Information Authorization Form
 HIPAA Frequently Asked Questions
Sample
Category
Provider
Access
Plan
Documents/Agreement
Provider Relations Tool Guide
 IEBP Quality Improvement and Management Program
 IEBP Member Rights and Responsibilities Statement
 Clinical Protocol
 Website Services for Provider
 Provider Network Assistance: Primary, Secondary, Networks, Centers of Excellence
 Identification of the Covered Individual: Sample Medical ID Card
 Public/Private Alliance Provider Solution
 UnitedHealthcare Choice Plus Network
 Medication Therapy Management Program
 How Benefits are Paid
 Non –Duplication of Benefits
 Healthy Initiatives
 Medical Intelligence
 After Hours and Weekend Medical and Mental Health Care Services
 Transplant/Obesity Network Centers of Excellence in Conjunction with Network Providers
Provider Care Path Pricing Transparency
 Twenty-One Care Paths and Fifty-two procedures by Geographic Are
 Specialties Linked to Care paths
 Care Path Definition
109
Sample
Category
Open Enrollment
Open Enrollment
Forms Guide
Enrollment Forms
Enrollment Forms
Change Forms
HIPAA Frequently Asked Questions
Other Insurance Form
Sample Right of Recovery-Accident/Injury
Form
Six Ways to Understand Open Enrollment
Online Enrollment Guide
Protected Health Information Guide
Notice of Privacy Policy
HIPAA Frequently Asked Questions
Comprehensive Eligibility Guide
 Enrollment Requirements
 Active Employee
 Termination of Benefits due to Gross Misconduct
 Incomplete Eligibility Form Correspondence; Fund Contact
and Employee
 Eligibility Checklist Form
 Active Duty Reservists (Out of Medical Book)
 How to Obtain Vital Record Documentation
 Protected Health Information Authorization Form
(Execution Optional)
 Other Insurance Information
 Steps to Develop a Health Organizer
 FMLA Overview
BPS (MBI) Debit Card Flyer (Consumer Driven
Products)
Medical
BPS (MBI) Debit Card Flyer
(Consumer Driven Products:
Section 125, HRA, H.S.A.)
Employee Enrollment Important Reminder Notice
Medical Plan Benefits
Medical Summary of Benefits and Coverage
Provider Relations Tool Guide
Website Services for Providers
Provider Network Assistance: Primary, Secondary
Networks
Prompt Pay Adjudication
Sample Explanation of Benefits (EOB)
110
How Benefits are Paid
Non-Duplication of Benefits
Healthy Initiatives
After Hours Services/Telemedicine
Provider Transparency Care Paths
Preferred Lab
Centers of Excellence/Designated Centers Network
Providers
Sample
Category
Plan Documents/Agreement (most recent 5 years)
Retiree Population
Pre/Post Sixty-five Medical Retiree Benefits Guide
Retiree Benefits Guide
Medicare Overview
Medicare Overview
IEBP Benefit Plan Options
Pre Sixty-five Plan Options
Pre 65
Pre Sixty-five Supplement Plan Options
Medical Plan Book
Post Sixty-five Plan Option
Dental
Vision
Post 65
Medicare Overview
Post 65 Supplemental Benefits
Supplemental K Post 65 UnitedHealthcare
Either Prescription Option
If Supplemental and Advantage Prescription Option has to be the same
Supplemental F Post 65 UnitedHealthcare
Either Prescription Option
If Supplemental and Advantage Prescription Option has to be the same
Formulary H Full Coverage in Gap
Formulary G Generic in Gap
Advantage Plan
Value add Dental and Vision Supplements
Supplemental Plans and Stand-Alone Prescription Options
Retiree Comprehensive Eligibility Guide
Retiree Rx Creditable Coverage Letter
Retiree Rx Not Creditable Coverage Letter (for high deductible plans)
Retiree Fund Contact Letter
Retiree Fund Contact Options Forms
Retiree Letters
Pre 65 Retiree Enrollment Form
Pre 65 Retiree Change-Term Form
Sample Post 65 Retiree Enrollment Form
Medical Intelligence Health and Wellness Guide
Wellness Program that Works
Preventive/Routine Care Benefit
Population Health Engagement/Professional Health
Coaches/Chronic Care Management
Population Health Engagement Resources
Self Assessment Tools: Health Power Assessment,
Wheel of Life
Healthy Living Guides List
Healthy Living Fact Sheets List
Medical Intelligence Care Management Features
Notification Requirements
111
Continue Stay Review
Medical Intensive Care Management
Outcome Improvement Protocol/Efficient
Performance Based Outcome
Centers of Excellence Providers
Integrated Medical Home Model of Care
Sample Care Management
Correspondence
Sample
Category
Plan Documents/Agreement Helpful Resource Guides
Prescription
Dental
II, III, IV
Voluntary Dental
II, IV
Vision
Vision
Vision A
Vision B
Voluntary Vision
Voluntary Vision A
Voluntary Vision B
Consumer Centered Section 125
Plans: Section 125
Premium Only
(Flex), Health
Section 125 Stand Alone
Reimbursement
Section 125 2 month-15 day
Account (HRA), Health
Extension
Savings Account
Section 125 $500 Carryover
(H.S.A.), Debit Card
Alegeus WealthCare Debit Card
Flyer Information
Flyer
HRA Benefit Plan
Medication Therapy Management Guide
 Prescription Flowsheet
 Step Therapy/RxResults
 Prior Authorization/RxResults
 SpecialtyRx/Biotech Prescriptions/Diplomat
 Cost Share Prescriptions/Sample Cost Share Letter
 Restat REPortal
» iPhone Friendly
» Android Friendly
 Value Tiered Align Network Pharmacies
 Covered and Non-Covered Drugs
 High Deductible Health Savings Account Benefit Plans
Wellness Drug List
 IEBP Preferred Formulary/Best Brand Drug List
 Mail Order/MedVantx
 Biotech Services/Diplomat
Dental
Political Subdivision MemberCentric Guide
Extended Plan Year Benefit Impact
Overview of Plan Options
Section 125 Pre-Tax Medical Eligible Benefits
IEBP Consumer Centered Pool Plan Options replicating IRS minimum and maximum regulations
High Deductible Health Plan Overview
High Deductible Health Plan Diagram
High Deductible Wellness Drug List, OTC, PPACA No Cost Share Mandates
Health Savings Account Contribution Matrix Limits
Health Savings Account Catch-Up Contributions
Online Defined Contribution and Employer Subsidy Worksheet
Benefits Debit Card Management Tips
HSA Bank IRS Form 1099sa Instructions
HSA Bank IRS Form 5498sa Instructions
Alegeus WealthCare Debit Card Flyer (Consumer Driven Products)
112
Sample
Category
Plan Documents/Agreement Helpful Resource Guides
Continuation of
Transparency to Healthcare Benefits Guide
Coverage
COBRA Continuation of Coverage Initial Notice
COBRA Continuation of Coverage Notice Information
COBRA Continuation of Coverage Flow Sheet
COBRA COC Qualifying Event Form
COBRA COC Enrollment Form
Standard
Standard Life Overview
 Claim Procedure
 MEDEX
 Forms
 AD&D Coverage
 Sample Life/LTD/STD correspondence
Supplemental Benefit
Employee Assistance Program
Employer Options
 Supplemental Benefits Guide
» Standard Life Overview
» Public Employee Benefits Alliance
 EAP
 On-Site Wellness
 Administrative Services external vendor
 Section 125
 FMLA
 PayDirect
 COBRA
 Medical Home Model of Care
 Wellness
 International Medicine
 Security Audits
 Pre/Post Sixty-Five Retiree Benefits
 Comprehensive Eligibility Audit
 International Medicine
 Supplemental Benefit Policy
 Cancer
 Critical Care
 Accident
113
COBRA COC Fee Structure
COBRA COC 18 mos - Termination or Reduction in Hours Letter
COBRA COC 36 mos - Death Divorce Legal Separation Letter
COBRA COC 36 mos - Loss of Dependent Child Status Letter
COBRA COC Plan Changes Letter
Sample
Category
Benefit Forms
Forms Guide
 MyBenefits on Demand Form
 Sample ID Card and Request Form
 Consumer Centered Medical Enrollment Form
 Consumer Centered Medical Change-Term Form
 Consumer Centered HRA/HSA Enrollment Form
 Consumer Centered Benefit Calculator
 Medical Enrollment Form
 Active Employee-COC Participant and Dependent Eligibility
Checklist Form
 Medical Change-Term Form
 Other Insurance Form English
 Other Insurance Form Spanish
 Pre-X Routine Inquiry Form (Employee) template
 Pre-X Inquiry Form (Provider) template
 Section 125 Enrollment Form
 Section 125 Premium Only Plan Enrollment Form
 Section 125 Change Form
 Section 125 Premium Only Plan Change Form
 Section 125 Claim Form
 Section 125 Dependent Care Reimbursement Form
 Section 125 Unreimbursed Healthcare Reimbursement Form
 Section 125 Recurring Expense Service Form
 Section 125 Direct Deposit Authorization Agreement
114
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















HRA Enrollment Form
HRA Change Form
HRA Claim Form
HRA Limited Post Deductible Enrollment Form
RRA Enrollment Form (If Post Deductible RRA for access
to Consumer Centered Plans)
RRA Change Form
RRA Claim Form
HSA Enrollment Form
HSA Change Form
COBRA Continuation of Coverage Employer’s
Patient Advocacy Form
Certificate of Creditable Coverage Request
Pre Sixty-five Eligibility Form
Ease of Access
Performance Based
Healthcare
Employee Engagement
HITECH Data Analytics
HITECH/Go Green
Communication
Personal Touch
Your time is always
Appreciated
TML Conference
Walk/Run to your Health
Wednesday October 2014
5K
7:15 a.m. Runners/Walkers Meet
7:30 a.m. Fun Run/Walk Start
Discovery Green is a 12-acre urban park located across the street from
the George R. Brown Convention Center and Hilton Hotel. The perimeter
of Discovery Green is ½ mile in distance, so runners could loop around
the park about six times for a 5k, and walkers three or four times to end
at a similar time as the runners.
115

Membership Benefit Overview Plan Year 2014-2015

Transcription

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