Spotlight:
PPO annual deductible

The PPO plan has a calendar-year in-network deductible of $200 for individuals and $600 for families. The family maximum can be reached by a combination of all covered family members’ eligible expenses.

If you don’t reach your annual deductible by Sept. 30, a three-month carryover feature will help you in the following calendar year. Charges that apply to the annual deductible and that are incurred in October, November and December can be counted in the next year.
 
If you are one of
the more than 4,400
members taking a proton pump inhibitor, be sure to read here about an important change to the step-therapy program that will affect you.
Retiree dependent coverage

Effective May 1, rules will change for retirees covering dependents under the medical plans.

You may keep coverage on eligible dependents already covered under one of the city’s medical plans. Dependents may stay on your plan until they become ineligible according to plan rules: they turn age 25, marry, gain primary coverage under another plan, are no longer your dependent, join the armed forces, etc.

After you retire, you may not add new dependents to the medical or dental plan.

If you are already retired, you may keep coverage on eligible dependents until they become ineligible, but you cannot add new dependents.

The new rule applies to dependents you acquire after May 1, 2009. Dependent includes the following: spouse, natural born or adopted children, grandchildren, children under age 25 who return to dependency on you, children over age 25 who become disabled and dependent on you, etc.

If you drop coverage on a dependent, coverage may not be reinstated.

 
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Enrollment Checklist

You have two options for your comprehensive medical plans, HMO and PPO. Both deliver championship care with predictable, budget-friendly costs.

The HMO plan requires that all your care be directed by your primary care physician. You must use network providers, except in case of emergency or referral by your network doctor.

The PPO plan offers more flexibility, more doctors, no PCP requirement and the option to go out-of-network. But you pay more for the added flexibility, in your contribution and at the time of service.

 

Type of services

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Copayments for primary-care services and specialist services are determined by the type of service.

  • If the service is performed by the PCP in the office, the lower copayment will apply, $20 in the HMO and $30 in the PPO in-network.
  • If the service is performed in a specialist’s office, or in another location, the higher specialist copayment will apply, $45 in the HMO and $50 in the PPO in-network.
  • Most services such as home visits, family planning, infertility treatment, physical therapy, and similar services are “specialist services,” and you will pay the higher copayment. Note: artificial insemination requires a 50 percent coinsurance of usual and customary charges for each procedure.

To see a comparison of plan features and your out-of-pocket costs.

Enrollment Options

If you are currently enrolled in:

You may enroll in one of these plans during this enrollment:

HMO

PPO

OOA**

HMO

-

yes

no

PPO

yes*

-

no

OOA

yes*

yes*

-

*If you live in the plan’s service area.

**The out-of-area plan is only available to employees/retirees who live outside the PPO/HMO service area. See a list of zip codes oat www.houstontx.gov/hr/oe09.

What’s new

Not much. We’ve made a few changes to prescription benefits and contribution strategies for retirees under age 65 to help keep overall costs down.

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Two new step-therapy categories to help you win over high prices
As of May 1, two medications added to step-therapy give you a chance to save money by requiring you to try generic versions of the medicine before moving on to more-expensive brand-name drugs. Remember, generics are copies of brand-name drugs, identical in dosage, safety, strength, quality, performance and intended use. And, they only cost you $10 for a 30-day supply at your local pharmacy, or $20 for a 90-day supply through Prime Therapeutics mail order.

Proton pump inhibitors for GERD, heartburn or stomach ulcers: If you take a proton pump inhibitor, such as Nexium, Prevacid or Protonix, your doctor must first prescribe a generic PPI. This is the case even if you are currently taking another PPI. This will begin with the first refill you get after May 1. If the generic fails to sufficiently treat your condition, your doctor can request authorization to step you up to another generic or brand-name PPI.

Statins for high cholesterol: Members who begin taking a statin will be required to start with a generic statin. If the generic fails to sufficiently lower your cholesterol, your doctor can request authorization to step you up to a preferred brand-name statin.

Members who currently take a brand-name statin, such as Lipitor or Vytorin, are grandfathered and may continue to take that medication. BCBSTX can change the tier in which the brand-name drug appears, increasing or decreasing your copayment. For a complete list of step-therapy drug categories, see page 11.

Insider Tip

Triessent will now be your one-stop specialty drug pharmacy
If you take a high-cost specialty drug, such as Enbrel or Tracleer, you will soon receive a letter from Triessent asking that you call and sign up for the specialty-drug program. Once you have signed up, each month, Triessent will send a 30-day supply of the specialty medication to your home or your doctor’s office. The 30-day supply will cost you just $30 or $45.

By sending you a 30-day supply, Triessent minimizes waste from discontinued therapy or dosage changes. A representative will call you to coordinate refills.
If you do not order your specialty drugs through Triessent, you will be able to get just one refill at your local retail pharmacy. After that, refill requests will be denied. Call 888-216-6710 to sign up for the program.

Specialty drugs are used to treat many different ailments, including cancer, cystic fibrosis, hemophilia, HIV, Hepatitis C, multiple sclerosis. These drugs can cost thousands of dollars a month for a single prescription.

Triessent, a specialty pharmacy provider that manages specialty drug programs and services for the HMO and PPO, allows a more cost-effective purchase of these expensive medications. Go to www.bcbstx.com for a complete list.

The contribution strategy will change for retirees under age 65
Plan usage shows that retirees under age 65 incur greater claims costs than active employees and retirees with Medicare.

In order to offset the disparity, the aggregate contribution percentage for retirees under age 65 will increase from 33 to 38 percent.

 

  
 
 
 
 
 

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