Health Coverage for You and Your Family PPO

Health Coverage for You and Your Family

PPO Plan Overview Active. Care 1 -HD, 2 and 3 Plans 2013 -2014 Plan Year

New Deductible and Out-of-Pocket Maximum for Active. Care 1 -HD • Active. Care 1 -HD meets IRS definition of a high deductible health • • plan for all coverage tiers May contribute pretax dollars into a health savings account (HSA) to help pay for current health expenses and save for future qualified medical and retiree health expenses on a tax-free basis Individuals can establish an HSA with banks and credit unions 2012 -2013 Plan Year Deductible (employee only/family) Out-of-Pocket Maximum (employee only/family; does not include deductibles) 2013 -2014 Plan Year AC 1 -HD $1, 200/$3, 000 $2, 400/$2, 400/$4, 800 $2, 000/$6, 000 $3, 000/$5, 000 $3, 850/$4, 200 3

New Deductible and Out-of-Pocket Maximum for Active. Care 2 Deductible (individual/family) Out-of-Pocket Maximum (individual/family; does not include deductibles) 2012 -2013 Plan Year 2013 -2014 Plan Year Active. Care 2 $750/$2, 250 $1, 000/$3, 000 $2, 000/$6, 000 $4, 000/$8, 000 4

Family Deductible Illustration Amy covers spouse and three dependents Amy Ted Bob Sue Chris Active. Care 1 -HD with $4, 800 family deductible • The family deductible may be met by one or more people • Plan pays benefits once entire $4, 800 is met there is no individual deductible to meet $4, 800 Active. Care 2 with a $1, 000 individual deductible and a $3, 000 family deductible • Plan pays benefits for an individual as his/her deductible is met • Everyone helps to meet the family deductible, but no one person pays more than the individual amount Amy Ted Bob Sue Chris $1, 000 $800 $600 $400 $200 5

Out-of-Pocket (OOP) Maximum Illustration Amy covers spouse and three dependents Amy Ted Bob Sue Chris Active. Care 1 -HD with $4, 200 family OOP maximum • The family out-of-pocket maximum may be met by one or more people • Plan pays benefits once entire $4, 200 is met there is no individual amount to meet $4, 200 Active. Care 2 with a $4, 000 individual and $8, 000 family OOP maximum • Plan pays benefits for an individual as his/her OOP maximum is met • Everyone helps to meet the family OOP maximum, but no one person pays more than the individual amount Amy Ted Bob Sue Chris $4, 000 $2, 000 $1, 000 $600 $400 6

PPO Network for Active. Care 1 -HD, 2 and 3 Network Statewide (all 254 counties) No need to: – Select a Primary Care Physician – Obtain referrals for specialist care Receive highest level of benefits: – Pay less for care – No balance billing No claim forms – Provider files claim for you Always verify provider network status Non-Network: • You pay more of the cost of out-of-network benefits – Higher deductibles, coinsurance • You may need to file your own claim • You could be balance billed for amounts over allowed amount 7

PPO Plan Overview (Network Level of Benefits) Deductible Out-of-Pocket Maximum (does not include copays or deductibles) Coinsurance (Plan pays/ participant pays) Office Visit Copay Active. Care 1 -HD Active. Care 2 Active. Care 3 $2, 400 employee only $4, 800 family $1, 000 individual $3, 000 family $300 individual $900 family $3, 850 employee only $4, 200 family $4, 000 individual $8, 000 family $1, 000 per individual 80% / 20% after deductible $30 for primary $50 for specialist $20 for primary $30 for specialist Primary means care provided by family practitioners, internists, OB/GYNs and pediatricians. All other physicians are specialists. 8

PPO Plan Overview (Network Level of Benefits) Preventive Care Clarification Services Preventive Care Routine eye exam (one per plan year) Hearing exam Active. Care 1 -HD Active. Care 2 Active. Care 3 Plan pays 100% (deductible waived) Plan pays 100% (no copay required) 20% after deductible $30 for primary $50 for specialist $20 for primary $30 for specialist • 100% coverage for certain age- and gender-specific preventive care services when network providers are used • Must be billed by provider as “preventive care” 9

PPO Plan Overview (Network Level of Benefits) Benefits (continued) Services High-tech Radiology (CT scan, MRI, nuclear medicine) Inpatient Hospital Emergency Room Outpatient Surgery Active. Care 1 -HD Active. Care 2 Active. Care 3 20% after deductible $100 copay per service, plus 20% after deductible $150 copay per day, plus 20% after deductible ($750 max copay per admission; $2, 250 max/year) 20% after deductible $150 copay, plus 20% after deductible (copay waived if admitted) 20% after deductible $150 copay per visit, plus 20% after deductible 10

New!! Effective Sept. 1, 2013 Help get benefits information and find network providers for: • • • MRIs CAT or CT Scans Endoscopy procedures Colonoscopy procedures Back or spinal surgery Real-time access to current cost and quality transparency Appointment scheduling Clinical decision support tools • • BVA Knee surgery Benefits Shoulder surgery Hip or joint replacement surgery Bariatric surgery Value Advisor Understanding benefits and how to best use them Referrals to condition management programs Preauthorization coordination One-Call Solution: 1 -866 -355 -5999 Customer Service 11

Prescription Drugs Active. Care 1 -HD, 2 & 3 2013 -2014 Plan Year

Your Prescription Drug Plan • Express Scripts administers your prescription drug plans on behalf of TRS – Active. Care 1 -HD, 2, and 3 plans • Benefit includes both a retail and mail component • Express Scripts has its own mail-order pharmacy where specialist pharmacists focus on compliance and lower cost options for the patient, and the automated filling system ensures the prescription is filled accurately. * Express Scripts buys medication from the most reputable suppliers *Express Scripts’ mail-order pharmacies fill about 2 million prescriptions per week through a highly automated process that is 99. 9997% accurate and is 23 times more accurate than a retail pharmacy “Dispensing Error Rate in a Highly Automated Mail-Service Pharmacy Practice”; Nov. 2007, Pharmacology, a peer-reviewed journal of the American College of Clinical Pharmacy 13

Prescription Drug Benefits – Network Level Features Drug Deductible (per person, per plan year) Active. Care 1 -HD Active. Care 2 Active. Care 3 Subject to plan year deductible $0 generic; $200 brand $75 $20 $40* $65* $15 $35* $60* $25 $50* $80* $20 $45* $75* $45 $105* $180* $200 per fill Retail Short-Term (up to 31 -day supply) Tier 1 (Generic) Tier 2 (Preferred Brand) Tier 3 (Non-Preferred Brand) Retail Maintenance (after first fill, up to 31 -day supply) Tier 1 (Generic) Tier 2 (Preferred Brand) Tier 3 (Non-Preferred Brand) 20% coinsurance after deductible Mail Order and Retail-Plus (up to 90 -day supply) Tier 1 (Generic) Tier 2 (Preferred Brand) Tier 3 (Non-Preferred Brand) Specialty Medications (retail or mail) 20% coinsurance after deductible * If you obtain a brand-name drug when a generic equivalent is available, you are responsible for the generic copayment plus the cost difference between the brand-name drug and the generic drug. Chart illustrates benefits when network pharmacies are used. Non-network benefits are also available; see Enrollment Guide for more information. 14

New ID Cards for Active. Care Plans 1, 1 -HD and 2 Participants • All current Active. Care 1 participants will receive replacement cards for the new plan option in which they are enrolled. • Active. Care 1 -HD and Active. Care 2, participants will be mailed replacement prescription ID cards reflecting the upcoming changes to benefit design. • The effective dates printed on the cards will be the more recent of either the participant’s effective date with the plan or 9/1/10. • Participants should expect to receive new cards around mid- to late-August. • Participants making changes after the replacements have been mailed will result in a second set of cards being sent. 15

Specialized Care is the Key to Quality Outcomes Specialization and participant engagement are critical components to controlling health care costs and driving quality clinical outcomes: • Specialist pharmacist • Online Tools • Closing gaps in care • My Rx Choices® • Mobile App • Other available resources 16

Specialist Pharmacists are an integral part of the healthcare continuum 97% of patients Extremely Satisfied/Very Satisfied with overall counseling experience Specialist Pharmacists are specially trained to counsel patients about their conditions and connect with physicians and healthcare coaches • Average patient call lasts 12 minutes • Calls are monitored and recorded for training • Pharmacists spend their time focused on a • single condition “We strive to have our pharmacists deliver the level of patient care that any of us would want for our families. ” Advanced tools let pharmacists see the “whole patient” along with their drug regimen across prescribers and pharmacies Glen Stettin, M. D. , Express Scripts’ Chief Medical Officer 17

Express Scripts’ online tools and mobile apps help connect patients and their caregivers Online prescription management: § § § Refills, renewals and order status Worry-free Fills ® Transfer to mail Claims, balances and history Locate a pharmacy Preferences Benefit education and management: § Benefit highlights § Forms and cards § Pricing and coverage details § New! Accessibility features Gap In Care Alerts Omission Not Using Controller Medication for Asthma Help participants identify and address potential safety issues with their prescriptions 18

Pharmacy Care Online Alerts Adherence Omission On track 19

Close-up: Sample Alert Message Information about the alert and why it’s important Video clips relevant to each alert Ability for patients to self-close gaps as appropriate Links to additional resources Access to email Express Scripts pharmacists Printable information to take to the doctor 20

My Rx Choices® Your online savings tool • Lower your cost for prescriptions with My Rx Choices® – Features include: • Personal assessment of cost-saving opportunities based on your prescription plan and the medications you use • Print a kit to help your doctor better understand the economic impact of different medication alternatives • Alternative medications are based upon greatest cost savings to you presented in order, starting with the highest value • Brand-to-generic and retail-to-mail comparisons are shown • Simply visit www. express-scripts. com. You’ll need to take a moment to register before using this service. You can also call 1 -866 -355 -5999 • You have to shop your benefit. Prices can vary at different retail pharmacies 21

Managing prescription with ease: Transfer to mail online conversion program 22

New! Accessibility Features 23

Innovation that can help participants make better decisions for healthier outcomes Boost compliance and adherence Improve care Manage Refills and Renewals Update in real-time Save money Enable informed decisions Auto populate with personalized information Unique functionality not available anywhere in healthcare today 24

Information Resources • TRS Website – www. trs. state. tx. us/trs-activecare – – Pharmacy Benefit Highlights List of maintenance medications FAQs Download forms • Express Scripts Participant Website – www. express-scripts. com – – – Prior authorization list Formulary information Locate a participating pharmacy Generics Rx Advantage My Rx Choices® / Price a Medication Health and wellness information Mobile App Check prescription status Order mail order refills Download forms Express Scripts widget • Customer Service – 1 -866 -355 -5999 • Benefits Booklet 25

First. Care Health Plans HMO Plan Option

Company Overview • We have been part of the TRS-Active. Care program since 2003 and currently cover more than 13, 000 school employees and their dependents • We are a hospital-based health plan, founded in 1985 and are owned by Covenant Health System in Lubbock and Hendrick Medical Center in Abilene • We focus exclusively on the Texas market and have offices in Abilene, Amarillo, Lubbock, and Waco • First. Care’s mission is to provide members with comprehensive health care coverage at an affordable price 27

Rate Overview • The national average increase for health insurance premiums is 9 to 11 percent per year • For plan year 2013, the overall rate increase is less than 2. 5 percent Coverage Category 2013 - 2014 Employee Only $391. 50 Employee and Spouse $985. 06 Employee and Child(ren) $622. 62 Family $994. 84 28

Benefit Highlights • No referrals to network specialists • No routine claim forms • No pre-existing limitations • College-age dependents living outside our service area have full coverage (address must be on file) NOTE: Care must be accessed through our affiliate provider networks • Secure online access to membership and claim information at www. firstcare. com 29

Medical Benefits for 2013 -2014 No Plan Changes! 2013 - 2014 Deductible $600 per individual $1, 500 per family Out-of-Pocket Maximum $4, 000 per individual $8, 000 per family Office Visit Primary Care – $25 Specialist – $60 Inpatient / Outpatient 25% after deductible (member share) 30

Rx Benefit Comparison for 2013 -2014 2013 - 2014 Deductible $100 per Individual $300 per Family Rx Yearly Maximum Unlimited Copayment Tier 1 (Generic) – $10 Tier 2 (Preferred Brand Name) – $30 Tier 3 (Non-Preferred Brand Name) – $60 Tier 4 (Specialty)* – 20% *After $4, 000 member out-of-pocket expense, cost is covered 100% by First. Care 31

Service Area – 93 Counties Across Texas TRS-Active. Care Service Area To be eligible to enroll in First. Care, you must live, reside or work in one of the shaded counties. 32

Why Choose First. Care? • We have experience with TRS-Active. Care benefits. In fact, we cover more than 13, 000 school employees and their dependents. • We are a hospital-based health plan that supports our local communities. • Medical decisions are made locally by physicians who understand how health care is delivered in your area. • A local First. Care representative is available in your area to answer questions. • Dedicated email address for TRS-Active. Care members and Benefit Administrators – trsquestions@firstcare. com 33

Contact Us You may submit your questions or comments via email to trsquestions@firstcare. com You can also write or call customer service at: First. Care Health Plans 1901 West Loop 289 Suite #9 Lubbock, TX 79407 800 -884 -4901 http: //www. trs. state. tx. us/trs-activecare 34

How to Enroll 2013 -2014 Plan Year

Who is Eligible to Enroll? To be eligible for TRS-Active. Care coverage, you must: • Be employed by a participating district/entity and – Be an active, contributing TRS member or – Be employed 10 or more regularly scheduled hours each week Health care coverage for public school employees and their families 36

Employees NOT Eligible to Enroll • State of Texas employees or retirees • Higher education employees or retirees • TRS retirees, receiving or who declined coverage under TRS-Care These individuals are not eligible to enroll for TRS-Active. Care coverage as employees, but they can be covered as a dependent of an eligible employee. 37

Dependent Eligibility Spouse, including common law spouse A child under age 26: a natural child, an adopted child (or a child who is lawfully placed for legal adoption), foster child, or child under legal guardianship of the employee “Any other child” under the age of 26 (unmarried) in a regular parent-child relationship with the employee – Must meet residency and support criteria A grandchild under age 26 Unmarried disabled dependent (age 26+) – Must live with employee • A dependent does not include a brother or sister of an employee unless the sibling is an unmarried individual under 26 years of age who is either: (1) under the legal guardianship of the employee, or (2) in a regular parentchild relationship with the employee and meets the “any other child” criteria • Parents and grandparents of the covered employee do not meet the definition of an eligible dependent 38

Special Eligibility Situations • If employee and spouse both work for a participating district/entity: – A spouse may be covered as an employee or as a dependent of an employee – Only one parent can cover dependent children • A child (under age 26) employed by a district/entity and a contributing TRS member cannot be covered as a dependent – The child must be covered as an employee – If the child is not a contributing TRS member, the child may be covered as a dependent 39

Three Steps to Enroll 2 Complete an Enrollment Application and Change Form 1 Choose your health plan Available from your Benefits Administrator 3 Sign, date and submit form to your Benefits Administrator 40

Enrollment • Enrollment Periods for 2013 -2014 Plan Year: – April 22 – May 24 (Spring Enrollment) – August 1 – August 31 (Summer Enrollment) • No pre-existing condition exclusion applies except for those who previously declined coverage (may be reduced by prior creditable coverage) • Passive enrollment – If no plan or coverage changes, then no form required Exception: If an employee is enrolled in Active. Care 1, he or she will be automatically enrolled in Active. Care 1 -HD effective September 1, 2013, unless he or she submits an Enrollment Application and Change Form to select a different TRS-Active. Care plan option or terminate coverage • Premium adjusted to reflect any rate change, effective September 1 41

Enrollment Application and Change Form Who needs to submit a form? • New hires – Enrolling or declining TRS-Active. Care coverage – Enrolling for TRS-Active. Care coverage with a different participating district/entity • ALL current employees: – In an effort to get everything correct from the start, everyone must complete a new enrollment form; even if you decline coverage. 42

Enrollment Application and Change Form (Cont’d) Enrolling for the first time: • Forms due to the Benefits Administrator before: – The end of the plan enrollment period, or – 31 calendar days after the employee’s actively-at-work date, or – 31 calendar days after a special enrollment event • New hires may choose their effective date of coverage – Actively-at-work date, or – First of the month following their actively-at-work date Full premium for the month will be due if choosing actively-at-work date; premiums are not pro-rated 43

Pre-existing Condition Exclusions • Pre-existing condition exclusions will not apply: – To any individual under the age of 19 – To employees that initially enroll when the district/entity begins participating in TRS-Active. Care – To new hires who enroll within 31 days after their actively-at-work date – To HMO enrollees Exception: If a participant has been covered at any time since 2002, pre-x may apply if employee is hired by another participating district/entity (or rehired by same district/entity) • A 12 -month pre-x waiting period may apply to employees or dependents enrolling in the Active. Care PPO plans due to: – A special enrollment event – A transfer to another participating district/entity (or rehire by the same participating district/entity), if the employee or any covered dependent has any remaining pre-existing waiting period or a gap in coverage of 63 or more consecutive days. 44

Making Changes/Special Enrollment Events Enrollees may be able to enroll for coverage, change plan options, or change the dependents he or she covers during the plan year within 31 days after a special enrollment event occurs • New dependent – Marriage, birth, adoption or placement for adoption – Special rules apply to newborns • Loss of other coverage Changing districts/entities is not considered a special enrollment event 45

Newborns • Covered first 31 days if employee has coverage – Does not apply to newborn grandchildren • Must add newborn within 60 days after the date of birth or up to one year after the date of birth if: – Employee has “employee and family” or “employee and child(ren)” coverage at the time of birth and at the time of enrollment • Plan changes must be made within 31 days after the newborn’s date of birth • Not necessary to wait for newborn’s Social Security number – Submit application without SSN to enroll – Re-submit another form after SSN is issued 46

Cost for Health Coverage 2013 -2014 Plan Year

Cost of Coverage Funding to Help Offset the Cost of TRS-Active. Care Coverage District/Entity (minimum) State of Texas Total Per Month $198. 33 $75 $273. 33 Funding applies to active, contributing TRS members Cost charts illustrate the monthly gross premiums 48

Monthly Cost for Coverage • See page 17 of Enrollment Guide • $273. 33 in district/entity and state funds to help pay for coverage 49

Application to Split Premium • Married couples working for different participating entities may “pool” funds • Optional • Requires an Application to Split Premium form to be completed by both employees and employers • Form available online 50

ID Cards (mailed to your home) • PPO plans (Active. Care 1 -HD, 2 and 3) – Separate cards for medical and prescription drugs • Blue Cross and Blue Shield of Texas • Express Scripts – BCBSTX will reissue ID cards to existing plan participants transitioning from AC 1 -HD to Active. Care 1 (medical plan ID cards do not expire) – Prescription drug ID cards will be reissued by Express Scripts for Active. Care 1 -HD and Active. Care 2 plan participants • HMO plans – All HMO participants will receive new cards – Each individual covered under the plan will receive a card 51

Online Enrollment Support Available online – www. trs. state. tx. us/trs-activecare and www. bcbstx. com/trs • Enrollment guide • Summary of Benefits and Coverage (SBC) • Downloadable forms (application and change form, application to split premium, claim form, etc. ) • Provider locator • Enrollment presentation 52

Blue Access for Members Enrollment Info www. bcbstx. com/trs 53

Blue Access for Members. SM Online member management tool • Research health conditions • View claims history and print Explanation of Benefits (EOB) statements EOBs are available online; you must log in and elect to receive paper copies Send secure email messages to BCBSTX Customer Advocates Monday thru Friday 7 a. m. to 10 p. m. (CT) • Locate a network doctor or hospital • Order additional ID cards, or print a temporary ID • Take a confidential health assessment 54

Blue Access Mobile SM Blue Access for Members SM Secure Site – Log-in Required • • ID Card My Coverage – Benefits / Eligibility Visits and Claims Health and Wellness – Diabetes, Obesity, Nutrition, Fitness, Metabolic Syndrome, Maternity Care, Member Care Profile • User Profile • Register for Blue Access for Members Public Site – No log-in required • • Health Care 101 Find a Doctor or Hospital Blue Access for Members Log-in Contact Information Provider Finder App For i. Phone® and Android® phones Text Messaging Static – One-Way SMS Messaging Diabetes Management, Claim Status Notification Alerts Dynamic – Two-Way Messaging member initiates text with keyword (ID Card Management) 55

What if I Have Questions? Personalized Service • Call TRS-Active. Care customer service for: – Claim questions/status – Network provider information – Membership and eligibility – Medical and Rx coverage questions – Inquiries (telephone and email) – ID card requests – Transition of care information – Help with online tools! Customer Service 1 -866 -3555999 56