First Choice Health PowerPoint Presentation

2015 Open Enrollment
2015 – Benefits Highlights
Benefits Administration: First Choice Health (medical, dental & vision)
PPO (Preferred Provider Organization) Network:
Choice Health (Northwestern US)
Health – outside of First Choice service area
Pharmacy Benefits Administrator/Network: MedImpact
FSA (Flexible Spending Account) Administration: HealthEquity
24 Hour Nurse Line
Maternity Program
No changes to medical benefits or premiums
Health Care Reform & the ASD plan:
The ASD plan is considered Grandfathered, so certain Health Care Reform provisions
aren’t applicable to our medical plan, such as copays being required for Preventive
Services and contraceptives.
Who is First Choice?
First Choice Health is a Northwest based company, established in 1985.
Headquartered in Seattle, with offices in Beaverton, Boise, Billings, Anchorage and
We provide claims administration, service, provider network access and more to just
under one million people in the Northwestern US.
First Choice Health Provider Network
Effective January 1, 2015 the Ashland School District’s medical plan will use First
Choice Health as their provider network and the First Health network for out of area
To find a provider you can visit, click on Find A Doctor, Hospital or
Facility and search the entire FCH PPO Network.
If you or an enrolled family member is under the care of a non-network physician
continuity of care arrangements may be appropriate for you. Fill out a transition planning
request form for assistance.
Medical Plan – Definitions
Health benefits have a terminology all their own. As we discuss your benefits the following
terms will be used frequently:
Deductible: A deductible is a portion of money that you pay before the plan begins to pay
benefits. Your plan only has a deductible if you choose to go out of the provider network
Copay: A fee paid directly to a provider, facility or pharmacy at time of service.
New! Copays due accrue toward your annual out of pocket maximum.
Coinsurance: The portion of the bill you are responsible to pay.
Out of Pocket Maximum: caps your member responsibility for in-network services.
Prior Authorization: certain services require medical review in order to determine medical
necessity. View the Prior Authorization listing at or in your Open
Enrollment Guide posted on the district website.
2015 Medical Plan Fast Facts
No changes to medical plan benefits, deductibles or copays
Updated Prior Authorization list
New ID cards will be mailed to your home in late December.
Each enrolled member will receive a card.
Is your acupuncturist, chiropractor or naturopath not in the First
Choice Health network? First Choice is working on adding
Ashland area alternative providers to our network. In the
meantime, visits to any out of network alternative provider will be
paid at the in-network benefit level for dates of service between
January 1 and February 28, 2015.
Medical Benefits – Plan Specifics
FCHA Network
Out of Network
$300 Individual
$900 Family
Office Visit
100% after $25 copay
50% after deductible
Preventive Office Visit
100% after $25 copay
50% after deductible
Emergency Room
80% after $100 copay
(copay waived if admitted)
Inpatient Hospital
50% after $250 copay per
Deductible applies.
What Happens When I?
FCHA Network
Out of Network
Type of Service:
You’ll Pay:
You’ll Pay:
Need to go to the
$25 copay
Deductible* & 50% of all
additional charges
Am hospitalized…
20% of the cost up to the Out
of Pocket Maximum
Deductible*, $250 per
confinement copay & 50%
of all additional charges
Visit the ER…
$100 copay then 20% of the
cost up to the Out Of Pocket
$100 copay then 20% of all
additional charges
Get my annual exam…
$25 copay
Deductible* & 50% of all
additional charges
Have outpatient surgery…
20% of the cost up to the Out
of Pocket Maximum
Deductible* & 50% of all
additional charges
*Annual Deductible $300 Individual/$900 Family
How is Alternative Care Covered?
FCHA Network
Type of Service:
You’ll Pay:
Out of Network
You’ll Pay:
Chiropractic –
20 visit Limit /Calendar Year
Massage Therapy
12 visit Limit /Calendar Year
Prescription must be submitted
with the claim.
$25 copay
$300 annual deductible* &
50% of all additional charges
Naturopathic Care
Alternative Care Enhancements: *The annual deductible indicated is the overall medical plan deductible.
• In-network providers are expected to receive a higher reimbursement rate than previously
provided by the Aetna plan.
• Invite your provider to particpate in our network, have them call Paul with 503.597.4158
or [email protected]
Prescription Benefit Highlights
Local MedImpact Participating Pharmacies:
 Ashland Drug
 Phoenix Pharmacy
 Walgreens
 Bi-Mart
 Savon
 Safeway
 Rite Aid
 Wal-Mart
 Medicap Pharmacy
 Fred Meyer
90 day fills (Pharmacy & Mail Order): 90 day supply of your prescriptions are
available at participating Choice90 pharmacies. You can also get a 90 day supply
through the MedImpact mail order program.
Generic vs. Brand Name: Members pay the difference in cost between the brand
and generic medication(s) anytime there is a genetic available and a brand name
medication is chosen when your prescribing physician allows for a generic
Prescription Benefit Copays
30 Day Supply
90 Day Supply
90 Day Supply
(Choice90 retail)
(mail order)
$15 copay
$45 copay
$30 copay
Preferred Brand
$30 copay
$90 copay
$60 copay
Non-Preferred Brand
$45 copay
$135 copay
$90 copay
How are specialty drugs (Copaxone, Embrel, etc.) covered by the plan?
Specialty drugs are covered by the plan when obtained through the Diplomat Specialty
Pharmacy. Specialty Drugs may require prior-authorization and/or have quantity limits.
Copays for Specialty Drugs align with the Generic/Preferred/Non-Preferred copay tiers.
How are compound drugs covered by the plan?
Compound drugs are covered by the plan at the applicable tier copay. Pre-Authorization is
required for compound drug charges greater than $400.
Please keep in mind:
If the cost of your drug is less than the tier copay you will pay the lower amount.
Transitioning Your Prescriptions
In order to minimize disruption to your prescription drug needs we recommend:
1. Fill any existing prescriptions you have in December.
2. Notify your pharmacist that your pharmacy benefits administrator will change
to MedImpact as of January 1, 2015.
3. Your plan is waiving the prior authorization requirement during the month of
January 2015 for a first refill. This is to allow your provider time to complete the
prior authorization process before your second refill. This exception does not apply to
new medications.
4. If you use the mail order program:
 Obtain a new 90 day prescription from your health care provider.
 After January 1, 2015 enroll in the Walgreen’s mail-order prescription program via
phone or online.
2015 Dental Benefits
FCHA Network
Out of Network
Annual Deductible
$50 Individual
$150 Family
(Waived for Preventive Services)
Annual Maximum
$1,500 Per Covered Individual
Class A Expenses – Preventive 100%
100% of allowed amount
& Diagnostic
Class B Expenses – Basic
80% of allowed amount
50% of allowed amount
Services (fillings, root scaling)*
Class C Expenses - Major
Services (crowns, dentures)*
*Obtaining a benefits pre-determination is recommended prior to beginning extensive dental services.
No changes to dental benefits in 2015.
2015 Vision Benefits
FCHA Network
Out of Network
Annual Routine Vision Exam
Vision Hardware*
100% up to $350 per calendar year
Vision Hardware includes:
Eyeglass lenses, frames, contact lenses and contact lens fitting.
*For those with vision hardware coverage.
No changes to vision benefits for 2015.
24/7 Nurse Line & Health Information Library
Available around the clock to answer your health questions!
Have a sick child at 2 am?
Unsure if you should go to the doctor or Emergency Room?
Looking for an answer to a health question?
Call the 24/7 Nurse Line to speak with a Registered Nurse who can answer your health questions
at no cost to you.
You can also access the Health Information Library, with information on over 1,500 health topics
available in English & Spanish.
Maternity Management
For a healthy pregnancy and a healthy baby.
Available at no cost to you – even if you aren’t a first time mom!
One on one support from a Registered Nurse
Regular telephone sessions with your nurse
Sessions provide educational information and ways to minimize risks to you and your baby
Your nurse can assist you with managing your diet, exercise and other ways to maintain a healthy
Continuity of Care
Are you receiving ongoing treatment or do you have a previously scheduled surgery with a
provider who is not in the First Choice Health PPO Network?
The Continuity of Care Program may be right for you; please complete the Transition Planning
Request form if:
You are pregnant
You have an upcoming planned major surgery
You are in the process of receiving post-operative follow up care within the period defined by a
global/bundled fee
You are undergoing a high dose chemotherapy regimen for a cancer condition
You are undergoing treatment following an organ transplant or waiting on an organ transplant
You are undergoing home health care, home IV infusion therapy, using rental Durable Medical
Equipment (DME) or oxygen
You are in a long term care facility
After Medical Review your approved services will be covered at the in-network benefit level through
March 31, 2015 in most cases. Maternity benefits may be paid at the in-network benefit level for a
longer period.
First Choice e-Tools
Did you know?
First Choice’s member website offers you the ability to access your plan and medical claim
information online. Create an account to:
Find a provider (local or national)
View enrollment status
Print a temporary ID card/Order a new card
Sign up for e-EOBs
Review medical plan documents
Review claims information & EOBs
Email customer service
Download forms
Please visit
Landing Page
Eligibility & Benefits
Navigate here to:
 Update your email
 Verify your eligibility
 Check your plan
deductible, out of pocket
and other benefits
 Order/view your ID card
Navigate here to:
 View claims
 Download copies
of EOBs
 Move your claim
history to an excel
file via cut & paste
 Filter by date,
family member
and claim type
Find a Provider
Navigate here to:
 Search for
providers in the
First Choice
Health Network
 Search for
providers in the
First Health
Customer Service
Navigate here to:
 Contact Customer
 View forms:
 Claim
Health Resources
Navigate here to:
 View online
Health Tools
 Access Health
What YOU Need To Do – Wrapping Up
 Complete the First Choice Health Enrollment Application –
Not making any changes? You still need to complete a form!
 Complete the Health Equity Enrollment Application for the FSA program –
Even if you aren’t enrolling, we need your declination to participate on file
 Complete Premium Withholding Form
 Turn all forms in to Human Resources by November 21, 2014
 Complete Transition of Care Form
Are you receiving care from an out of network provider? This program could benefit you.
 Get a refill of your current prescriptions by the end of December.
 Remind your providers that any claims for 2014 dates of service need to be submitted
to Aetna prior to December 31, 2015 or 15 months from the date of service,
whichever is earlier.
 First Choice Health requires all claims be filed within 12 months of the date of service.
When you choose to participate
in the ASD Flexible Spending
Account Program you can set
aside pre-tax dollars to:
• Cover medical, dental or
vision expenses not covered
by your health plan.
• Pay for non-medical
dependent care expenses.
2015 Contribution Limits:
$2,500 Healthcare FSA
$5,000 Dependent Care FSA
$300 Minimum Contribution
How an FSA Works
Sign Up
Review your medical expenses for the last year and estimate your expenses for
Determine the amount you would like to contribute to your FSA on a pre-tax
ASD will arrange to have the determined amount of your pre-tax earnings
contributed to your FSA.
Use Your Funds
When you incur a qualified expense, you can either pay with the HealthEquity
Visa debit card or submit the expenses through the HealthEquity online tool for
Save your receipts! You’ll need them to submit reimbursements or to validate
debit card expenses.
Plan Wisely When Setting Aside FSA Funds
The FSA is a tax-preferred account and federal guidelines are very specific about what
happens to funds that are not spent by the end of the plan year.
Healthcare FSA:
 Annual rollover of up to $500 is allowed
 You are eligible to roll funds over to the next year even if you decide not to make
additional contributions.
Example: Lisa set aside $1,400 in 2014 for Healthcare expenses. She spent
Lisa decides that she won’t contribute additional funds to the FSA in
Lisa has $300 that will roll over to the 2015 plan year.
 Healthcare FSA accounts with a balance of more than $500 will forfeit amounts
over $500
Dependent Care FSA:
 No rollover is available. Unused contributions are forfeited.
Qualified FSA Expenses:
Amounts not covered under 
another health plan
Annual physical examination 
Artificial limbs/teeth
Birth control
Body scans
Breast reconstruction surgery 
following mastectomy for
Contact lenses
Dental treatments
Eyeglasses/eye surgery
Hearing aids
Long-term care expenses
Medicines (prescribed, not
from other countries)
Nursing home medical care
Nursing services
Stop-smoking programs
Surgery, other than
unnecessary cosmetic surgery
Telephone equipment and
repair for hearing-impaired
Weight-loss program (if
prescribed by a physician for
a specific disease)
Wigs (if prescribed)
Examples of Non-Qualified
 Concierge services
 Diaper service
 Elective cosmetic surgery
 Future medical care
 Hair transplants
 Non-prescribed drugs
 Nutritional supplements
 Health club memberships
 Insurance Premiums
FSA Features
Convenient access
 Debit card
 Online -
 HealthEquity free mobile app
 24/7 telephone assistance
Use your HealthEquity account to
 Check your balance
 Review transactions
 Review claims
 Enroll in direct deposit reimbursement
 Submit new claims or documents
 Send payments and reimbursements
Mobile App
Available for iOS
and Android
On-the-go access for all account types
Take a photo of documentation with phone
and link to claims and payments
Ability to directly pay provider via online
tools or request reimbursement from your
FSA account
Manage debit card transactions
View claims status

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