GO LIVE SMART Consumer Guide

A Guide to Benefits

Why Go live smArt?

Understanding your health insurance benefits isn’t always easy. This GO LIVE SMART guide gives you the tools and resources you need to make the decisions you’ll feel good about. Being confident in the decisions you make about your benefits is important to us and should be to you. You’ll find answers to questions you might have, like how to find an in-network doctor, why generic drugs are just as good as brand-name, and at what age you should think about getting a colonoscopy. These questions often come up when no one is around to answer them or you just don’t know who to ask!

GO LIVE SMART is here to help you do just what it says. Live smart — when it comes to you, your health, and your well-being.

www.GoLiveSmart.com

Eligibility.........................................................................................1

Find.the.Cost.of.Care.....................................................................2

Networks.......................................................................................3

Primary.Care.Physician..................................................................4

Preventive.Care.............................................................................5

Prescription.Drugs.........................................................................6

How.to.Be.a.Smart.Shopper..........................................................9

Qualifying.Events.........................................................................10

Glossary.......................................................................................12

tABle of Contents

1

mAke sure you’re eliGiBle!

Not.sure.if.you’re.eligible.for.benefits?As an employee, you are generally eligible for benefits if you’re an active, full-time employee. Your employer’s definition of full-time can be different than others, so please check with your Human Resources department to be sure.

Your spouse is usually eligible for benefits as long as that person is your legal spouse, as recognized by the state in which you live. Again, check with your employer to see if coverage is extended to spouses.

Your child(ren) are most likely eligible for benefits, too. Most employer health plans will cover kids up to age 26.

Again, in order to be 100% sure you qualify for benefits, talk to your employer.

Your eligibility (both for you and for your family) may change during the year. Turn to page 10 for details on benefit eligibility for things like marriage, divorce, birth, and adoption.

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find the Cost of CAre

Unlike prices at your local supermarket, the cost of health care – like your insurance premiums, office visits, and prescriptions – are not always clearly marked! Luckily, there is a free tool online that can compare your coverage options, saving you time and money.

Subimo Coverage Advisorsm ToolThis website is designed to help you estimate your health care costs for the coming year. Simply enter your health insurance information, along with how often you visit your doctor, and you’ll get custom cost information just for you. The tool will guide you through the process step by step.

You’ll be able to:

Even better, the Subimo Coverage AdvisorSM tool is free, confidential, and doesn’t require a log-in. To get started, visit www.GoLiveSmart.com and look for the link on the main page.

Comparing.health.care.costs.is.like.comparing.apples.to.oranges.–.the.prices.can.vary.depending.on.where.you.shop.

Don’t forget to have your health insurance information handy!

Create profiles about yourself and anyone in your family that would be covered under your health insurance

Estimate use of doctor office visits, prescriptions, and any other expenses

View plans available to you, including details on annual premium costs, copay amounts, and coinsurance

Compare costs with a side-by-side view of your plan options

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netWork knoW-hoW

A.network.is.a.group.of.providers.(doctors,.dentists,.and.hospitals).that.make.an.agreement.with.your.health.insurance.company.

Your deductible is usually lower than it would be for out-of-network providers.

You usually don’t need to submit claim forms and wait to be reimbursed by your health insurance company.

You often have a higher level of benefits because in-network providers (doctors, dentist, or hospitals) have agreed to provide their services at a lower cost.

Some health insurance companies offer preventive care services in-network that aren’t covered out-of-network.

Some health insurance companies limit visits and services out-of-network, but offer these same services without a limit on the number of visits when the care is provided in-network.

By being part of the network, they will normally get to see more patients in exchange for reducing their normal rates. There are several reasons that it’s usually better to choose a provider that is in-network:

When you use an out-of-network provider, your cost will generally be higher.

Visit your health insurance company’s website to see if your doctor is in-network or out-of-network. If you don’t have a doctor, this is a great place to find one. You can always call your doctor, hospital, or dentist and confirm that they are a part of your health insurance company’s network.

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tAlk to your doC!When.was.the.last.time.you.talked.to.a.doctor?.If.you.can’t.remember.your.last.visit,.it.might.be.time.for.a.physical.A physical is a visit to your doctor when you’re not sick – no cough, cold, or other issues. The goal of the visit is to measure your overall health. Depending on your age and risk factors, your doctor might order a blood test, take your blood pressure and heart rate, and talk to you about your general health.

If it’s been a long time, or if you don’t even remember your doctor’s name, you might want to find a new doctor. Your doctor could be a family physician, obstetrician/gynecologist, general internist, or even a pediatrician. In some cases, you could also see a Nurse Practitioner or Physician Assistant.

Having.a.doctor.that.knows.you.is.important.Your doctor keeps a history of your health, including what shots you’ve had, what drugs you take, and any allergies you might have. They will also ask you about your family history and make notes about any conditions for which your risk is higher.

If you want to find a new doctor, ask around! Talk to your friends, coworkers, and family members. After you’ve gotten a few names, check with your health insurance company to find out if the doctors are in-network. You can also go directly to your health insurance company’s website to search for doctors in your area.

Remember, using a doctor that’s in-network means you will pay the lowest amount for your visits.

The average doctor visit lasts only 21 minutes. To make the most of your visit, write down any questions you might have beforehand and take it with you.1

Your doctor visit gives you a chance to ask general questions about your health. Here are some to think about:

1. Knowing my family history and risk factors, is there anything I should be doing right now?2. How is my weight for someone of my height and age? 3. Are there any other tests I should have done during this visit? 4. Am I getting enough physical activity?5. What else can I do to stay healthy?

1. Primary Care Visit Duration and Quality. Lena M. Chen, MD, MS; Wildon R. Farwell, MD, MPH; Ashish K. Jha, MD, MPH. Arch Intern Med. 2009;169(20):1866-1872.

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Preventive CAre Guidelines

By.taking.better.care.of.yourself,.you.can.keep.your.body.in.the.best.condition.possible..

PROCEDURE 19-26 years 27-49 years 50-59 years 60-64 years 65+ yearsCholesterol Check Every year (starting at age 45)Cervical Cancer Screening (pap smear or pelvic exam)

Every year

Clinical Breast Exam Every yearMammogram Every 1 or 2 years (starting at age 40)

PROCEDURE 19-26 years 27-49 years 50-59 years 60-64 years 65+ yearsPSA Test & Digital Rectal Exam

Every year

Cholesterol Test Every 5 years (starting at age 35)

PROCEDURE 19-26 years 27-49 years 50-59 years 60-64 years 65+ yearsColorectal Cancer Test Every yearDiabetes Test Every 2 yearsBlood Pressure Check Every 2 yearsVisit Your Dentist Every 6 monthsVisit Your Eye Doctor Every year

The following list is made up of tests and vaccines recommended by the Centers for Disease Control and Prevention:2

Males Only

Females Only

Both Males & Females

Scheduling preventive care might seem like a lot of work. But don’t get overwhelmed – talk to your doctor’s office and schedule your preventive exams all on the same day. You might think about going around your birthday for your annual physical – it’s easy to remember! And because you’re planning ahead, you’ll get your pick of dates, and probably spend less time in the waiting room.

Set.a.Date

2. Centers for Disease Control and Prevention. Recommended adult immunization schedule – United States, 2010. MMWR. 2010; 59(1).

Vaccines are also an important part of preventive care. To see a full list of recommended vaccines, visit www.GoLiveSmart.com. Download our preventive care checklist where you can keep track of your progress!

Note that not all health insurance plans cover all of the preventive care services listed in this guide. Please refer to your benefit plan summary for exact details.

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PresCriPtions

Are.you.confused.when.you.pick.up.your.prescriptions.from.the.pharmacy?.If so, you’re not alone! To be a smarter consumer at the drugstore, read on.

Types.of.Drugs

Over-the-counter These medications can be purchased at your local drugstore or supermarket without having a prescription from your doctor. Common examples are Advil®, Tylenol®, and Motrin®. In the last few years, more drugs have become available without a prescription, which can save money and time. Examples include Prilosec®, Claritin®, and Alavert® – all were drugs that required prescriptions but now, anyone can obtain them without a prescription.

Prescription These drugs require you to first see your doctor. After your doctor decides a drug is necessary, they will write you a prescription allowing you to obtain the drug at a pharmacy. Prescription drugs are approved and regulated by the Federal Drug Administration (FDA). Prescription drugs come in two forms:

Generic A drug that has the same formula as a brand-name. Generic drugs are made after a patent on a brand-name runs out. Generics are usually much less expensive than brand-name drugs.

Many generic brands are available at your local retailers for as little as $4 for a 30-day supply. To take advantage of these low costs, ask your doctor to write you a prescription for the generic medication. Visit www.GoLiveSmart.com for more info on generic drugs, including lists of the low-cost drug options available at several nationwide retail stores.

Note that not all generic drugs are a good substitute for brand-name drugs. Talk to your doctor about whether the generic would work well for you.

Brand-name A drug sold by the company that was first to patent it. The company is allowed a period of several years to sell the drug under the brand name before other companies are allowed to produce it as a generic.

Some drugs are only available as a brand-name. Drugs made to treat very specific and rare conditions, for example, normally do not have a generic available.

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Purchasing.Your.Prescriptions

Most health insurance companies have a list of pharmacies that are preferred and in-network. Before heading into your nearest pharmacy, make sure it is in-network. A simple call will do the trick.

Retail Pharmacy

If your health insurance company offers a mail-order program and you’re on a drug you take regularly, you might think about looking into a mail-order Rx program. Normally, through mail-order programs, you can buy a 90-day supply of your prescription for less money than if you purchased it monthly through a retail pharmacy. The prescription is sent to your home or work address, too – so no waiting at the pharmacy!

If you’ve changed health insurance companies, you will need to sign up for the new insurance company’s mail-order program. Your information is not usually transferred over. To start, get a new prescription from your doctor for a 90-day supply of your drug. Visit your health insurance company’s website or call the 1-800 number on the back of your insurance card for more information.

If you have time to look up cost information before you buy, that’s always a good idea. Many health insurance companies now offer tools online to show you the cost of the medication before you pick it up at the pharmacy. Some pharmacies will also tell you over the phone or on their website. There are many resources out there to help you! Visit www.GoLiveSmart.com for more information.

Mail-Order Rx Program

Beyond.the.Basics.of.Rx.Coverage

Every health insurance company has a list of drugs that are covered. That list is often organized by generic and brand-names. Most health insurance companies also divide the drugs into preferred, or formulary, lists. If you’ve ever paid a copay for a prescription, you’re probably familiar with a formulary list. The cost of the drug, whether it’s low or high, is translated into a formulary, which affects the price that you pay.

As a smart shopper, it’s important that you check the list from time to time to see if your prescription drugs are covered, especially if you have switched insurance companies or plans. Visit your health insurance company’s website or call the 1-800 number on the back of your ID card.

Prescription Drug Tiers

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Some drugs require you to get approval before your health insurance company will allow you to fill a prescription. This step, called prior authorization, usually happens the first time you go to get this type of prescription filled. Sometimes this step is needed when an equally effective but less costly option is available. Prior authorization may also be needed for medications that are prescribed for conditions not covered by health care benefits, not thoroughly tested by the scientific community, or not approved by the FDA for certain conditions. Check your health insurance company’s website or call the 1-800 number on your ID card to see if the medication you have been prescribed requires any type of prior authorization.

Sometimes calling or checking before you get to the pharmacy is not possible. If the pharmacy tells you the medication is not covered, ask questions. The drug may be covered if you get prior authorization or go through a series of steps with your doctor first. If this ever happens to you at the pharmacy and they can’t provide a detailed reason, call your health insurance company and then follow up with your doctor.

Ask.QuestionsWith costs on the rise for health care, it’s important to be a smart shopper, especially at the pharmacy. Asking questions before you buy will save you money.

Is a generic available?

Can I have a sample of this drug?

Is there anything I can take that’s just over-the-counter?

Do I really need this drug, or are there lifestyle changes I could make instead?

Are there side effects of this drug?

Is there a good time of day to take this?

Should I take it with food?

Will this medication interfere with other drugs I am taking?

Start with your doctor: Talk to the pharmacist:

Prescription Prior Authorization

Most health insurance companies will let you buy a 30-day supply of drugs at your retail pharmacy (e.g., Wal-Mart, Target, CVS, etc.), but will only let you buy a 90-day supply through a mail-order program. Check with your health insurance company or employer to see how your insurance works for this situation.

30-day Supply vs. 90-day Supply

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shoP smArter for your heAlth

Health.care.can.be.expensive..

Pay less for your prescriptions. On average, generic drugs are 80-85% cheaper than their brand-name counterparts. Most generics are available at any pharmacy – like Wal-Mart, Target, and K-Mart – where there can be great deals on 30-day and 90-day supplies. A list of generic drugs offered by each retail pharmacy can be found on their websites. If you’re taking a brand-name drug now, ask your doctor about switching to a generic.

Do your homework. Know your options before visiting a doctor or having a procedure done. Different medical facilities may charge differently for identical procedures or visits. For example, did you know that having a procedure done in an out-patient facility may be cheaper than having the out-patient procedure done in a hospital setting? Use a retail clinic. If you’re having an issue that doesn’t need immediate attention, like a cold or sore throat, many drugstores have retail clinics that can help. Take Care Clinic from Walgreen’s and the Minute Clinic from CVS are two examples of retail clinics staffed by a Nurse Practitioner or a Physician Assistant. These clinics are often less expensive than heading to the hospital or doctor’s office. And the best part (beyond the cost savings) – no lines. In, out, and on your way!

Speak up. If you get a bill in the mail that you think might be wrong, start by calling the 1-800 number on the back of your ID card and asking your health insurance company to explain the charges. If you aren’t satisfied with the explanation, you can always file an appeal, which means your bill should have been paid differently.

Stay healthy and save. The biggest way to save on health care costs is to be healthy. Make it a point to eat right, stay active, and keep stress to a minimum. Healthy habits not only reduce your spending on health related costs, but also help you to lead a healthier and happier life.

You don’t have to spend more money to get better care – in fact, you can get the same quality care for less money by doing some research. Here are some tips:

Take advantage of the perks offered by your health insurance company. They might have disease management programs, incentives for completing a Health Risk Assessment, and more. It pays to check it out!

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QuAlifyinG events

The.following.are.qualifying.events.that.often.let.you.change.your.coverage.during.the.course.of.the.year..A qualifying event is a change in your life that might impact you or your family’s benefits. Qualifying events are defined by the Internal Revenue Service (IRS) as well as your employer. Any change you wish to make to your benefit(s) must be directly associated and consistent with the qualifying event.

If you want to make changes to your benefits, please note:

YOU MUST MAKE THEM WITHIN 30 DAYS OF YOUR QUALIFYING EVENT.

If you miss the 30-day window, you will have to wait until your employer’s next open enrollment period.

BIRTH OR ADOPTION Within 30 days, you might want to make changes to your benefits like:

Health Insurance – add your new children to your health insurance

Health Care Flexible Spending Account (HCFSA) – change the amount you add

Dependent Care Flexible Spending Account (DCFSA) – begin or change amounts

Life Insurance – change your life insurance coverage

Records – contact your employer to change your dependent and tax withholding information

Beneficiaries – update your chosen beneficiaries for benefits such as life insurance or a retirement program

DEATH OF A DEPENDENT Within 30 days, you might want to make changes to your benefits like:

Health Insurance – if you were covered before by the health insurance of your deceased spouse, drop coverage and enroll yourself and your children in your employer’s health insurance

Records – contact your employer to change your dependent and tax withholding information


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MARRIAGE Within 30 days, you might want to make changes to your benefits like:

Health Insurance – add your spouse or any new children to your health insurance or choose to drop coverage and be covered on your spouse’s health insurance




Records – contact your employer to change your name, address, dependents, emergency contacts, and tax withholding information


DIVORCE OR ANNULMENT Within 30 days, you might want to make changes to your benefits like:

Health Insurance – drop your prior spouse from your health insurance and change coverage for your children after you’ve decided who will cover any children for health and other benefits


Records – contact your employer to change your marital status, name, address, dependents, emergency contacts, and tax withholding information


SPOUSE CHANGES EMPLOYMENT Within 30 days, you might want to make changes to your benefits like:

Health Insurance – add your spouse and children to your health insurance or you might want to be covered by your spouse’s new health insurance




Records – contact your employer to change your emergency contacts and tax withholding information

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GlossAry(everythinG you need to knoW ABout your insurAnCe)

B

What is a beneficiary?

The person(s) selected to receive the payment of the amount of insurance after the death of the insured. See Life Insurance and Health Savings Account (HSA).

What is a brand-name drug?

A prescription drug sold by the company that was first to patent it. The company is allowed a period of several years to sell the drug under the brand name before other companies are allowed to produce it as a generic. For example, simvastatin is the generic of Zocor®. See also Generic Drug.

CWhat is a claim?

An application for benefits provided by your health insurance company. If you see an in-network doctor, for example, their office files a claim with your health insurance company to receive payment for your visit. What is COBRA health coverage?

The Consolidated Omnibus Budget Reconciliation Act (COBRA) health benefit provision was created to provide certain former employees, spouses, and dependent children the right to continue health coverage for a temporary period of time.

What is coinsurance?

A specified percentage of the cost of treatment that you pay for covered medical expenses after a deductible has been paid. For example, if your plan pays 80% coinsurance, the plan will pay 80% of the cost. That means that if you receive $100 in covered services after your deductible is met, the plan will pay 80% of the cost, or $80. You will have to pay the 20% remaining, in this case, $20. You might pay a coinsurance percentage when you pick up a drug at a pharmacy or have a doctor visit. You may or may not have a coinsurance type of plan – check your summary of benefits.

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What is a Consumer Driven Health Plan (CHDP)?

A type of insurance plan with a high deductible that usually lacks copays, which means you are responsible for the cost of office visits and drugs. Because you are responsible for these costs, the premium is usually much lower than traditional PPO plans. These plans can also be called High Deductible Health Plans (HDHPs). See Health Savings Account.

What is a co-payment (copay)?

An up-front fixed dollar amount you’ll pay to the doctor’s office at the time of your visit. Your copay continues until your health insurance company’s maximum is reached. Many health insurance companies have copays in place for services such as doctor’s visits, prescription drugs, and hospital stays. Your insurance card will have these copay amounts listed on it.

What is a covered expense?

Service allowed under your health plan. If you are unsure if a certain service is covered, check with your insurance company before having the visit or procedure done.

DWhat is a deductible?

The dollar amount you pay for medical services before your insurance starts paying a larger share of your costs. Your deductible is reset on a yearly basis. Most medical and dental plans have a deductible, which can range from $250 to $10,000.

Who qualifies as dependents?

Either a spouse and/or children (whether natural, adopted or step) of an insured person. There are age limits that may vary from state to state.

EWhat is an effective date?

The date your insurance will actually begin. You are not covered until the policy’s effective date.

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What is the elimination period?

Length of time that must pass after you become disabled (as defined by your policy) before your disability benefits begin. This period of time varies from plan to plan, and from short- to long-term policies.

What is emergency care? Medical services done in a hospital to treat serious illnesses or injuries that require immediate attention. Because of the seriousness of emergency care, the cost of emergency room visits are much higher than alternatives like urgent care or a regular doctor visit.

What is an Explanation of Benefits (EOB)?

A summary outlining what services you received after your visit to the doctor. This statement includes how much those services cost and how much your insurance paid. The Explanation of Benefits (EOB) is not a bill, just a summary.

GWhat is a generic drug?

A generic is a prescription drug that has the same formula as a brand-name. Generic drugs are made after a patent on a brand-name runs out. Generics are normally much less expensive than brand-name drugs.

HHow can I open a Health Savings Account?

A Health Savings Account (HSA) is a type of is a tax-advantaged medical savings account available to taxpayers in the US who are enrolled in a High Deductible Health Plan (HDHP). An HSA can be opened at a bank that your employer works with or out on your own. See Consumer Driven Health Plan.

What is a High Deductible Health Plan?

See Consumer Driven Health Plan.

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What is HIPAA?

The Health Insurance Portability and Accountability Act (HIPAA) was created to protect private health care information and create a uniform standard for personal information.

IWhat are inpatient benefits?

Inpatient benefits are services that require being admitted to the hospital and an overnight hospital stay. Examples of inpatient benefits include hospital room and board, maternity costs, and additional coverage for surgery. Services that do not require an overnight stay are referred to as outpatient benefits.

LWhat is life insurance?

Life insurance is a contract between the insurance company and the policy owner where a benefit is paid to your chosen beneficiaries if a death occurs.

MWhat is the maximum plan dollar limit?

The maximum amount payable by the insurance company for your covered expenses for the insured and each covered dependent while covered under the health insurance plan.

NWhat is a network?

A network is a group of doctors, hospitals, and other health care providers contracted to provide services to insurance company’s customers for less than their usual fees. Insured individuals typically pay less for using an in-network provider.

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What is a network discount?

A network discount is the reduced price you pay for visiting a health care doctor or hospital who participates in a doctor discount network.

OWhat is Open Enrollment (OE)?

Open Enrollment is a period of time where you can enroll in health benefits or make changes to your benefits. The time of year when your open enrollment period occurs can vary based on your employer.

What are outpatient benefits?

Outpatient benefits refer to services that do not require an overnight stay in a hospital or other health care facility. Examples of outpatient benefits include: doctor office visits, preventive care, lab work, x-rays, and urgent care. Services that require an overnight stay are referred to as inpatient benefits.

What are out-of-pocket costs?

Out-of-pocket costs include premiums, co-payments, coinsurance, deductibles or other fees that you are required to pay outside of your health insurance plan.

What is the out-of-pocket maximum?

The out-of-pocket maximum is the most you would have to pay out of your own pocket (including coinsurance, co-payments, and deductibles) for eligible medical expenses in a year. Once you have reached your out-of-pocket maximum, your insurance policy will pay for 100% of your medical expenses until you reach your lifetime maximum or until your health insurance plan renews. Not all plans have an out-of-pocket maximum, however, so check your benefit summary for details.

PWhat is prior authorization?

Prior authorization is the process where your health insurance company reviews your recommended treatment and then tells the doctor, hospital or pharmacy how you will need to pay for it and whether or not they will pay for part of it. This can apply to both health care services and prescription drugs.

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What is a premium?

A premium is the fee you and/or your employer pay to your insurance company to purchase a health insurance plan. This can be paid on a monthly, quarterly, or annual basis, but normally matches up with your payroll cycle.

What are preventive care services?

Doctor visits, exams, and tests specifically meant to prevent future health problems for a person who does not currently have any symptoms. Some examples of preventive care services are: a vision exam, annual medical eye exam for diabetics, pap smear/pelvic exam, mammography, hearing test, immunizations, and a prostate specific antigen (PSA) test. Check your benefit summary to see what preventive care services your health insurance company covers.

What is a primary care physician (PCP)?

A doctor who serves as your primary contact within the health plan and provides routine care is normally considered your primary care physician.

What is a provider?

This term is used to describe professionals who provide health care services. It typically refers to doctors, but can include nurses, physical therapists, counselors, and other medical specialists.

QWhat is a qualified medical expense?

Any medical expense that counts toward you reaching your health plan deductible. A complete list is provided in IRS Publication 502, available at http://www.irs.gov.

SWhat is a Summary Plan Description (SPD)?

A document provided by the by your health insurance company that includes a description of important features of the plan such as when employees begin to participate in the plan, how service and benefits are calculated, when payment is received and in what form, and how to file a claim for benefits.

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UWhat is urgent care?

Urgent care centers are used to treat patients who have an injury or illness that requires immediate care and attention, but is not serious enough to require a visit to the emergency room. Urgent care centers are usually not open all the time like hospital emergency rooms, and usually function on a walk-in basis.

What does over usual and customary mean?

An amount by which the submitted charge exceeds the average amount charged for the same services within your doctor’s geographic area.

WWhat is a waiting period?

The time between selecting the benefit and actually benefitting. Some types of coverage, either through your employer or purchased on your own, might have a waiting period. Any incidents that occur during this time will not be paid.

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notes:

The content of this guide is furnished for informational use only, and is subject to change without notice, and should not be construed as a commitment by your employer. Your

benefit plans may not include all material referenced herein. You should read your benefit plan summaries for a full explanation of your coverage.

The unauthorized reproduction of this guide is prohibited.

GO LIVE SMART. A Guide to Benefits.© 2010. All rights reserved.

Published by First Person, Inc.

www.GoLiveSmart.com

Documents

GO LIVE SMART Consumer Guide