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Prescription Drugs

Health Care 101: What’s an ANOC, EOC and Formulary?

If you are enrolled in a Medicare Rx Option, Medicare requires the Health Options Program to send you the additional materials below. Here’s a quick overview on what they are, why they are important and when to expect them.

Annual Notice of Change (ANOC): A document listing any changes in plan coverage, service area or costs that will go into effect January 2020. Your ANOC can help you decide whether your current coverage will continue to meet your health and prescription drug needs, or if you should consider switching to another plan. If you are enrolled in a Medicare Rx Option (Enhanced, Basic or Value) in 2019, you received an ANOC with your Option Selection Period materials.

Evidence of Coverage (EOC): A document that describes in detail the health care benefits covered by your health plan. It provides documentation of what that plan covers and how it works, including how much you pay (premiums, deductibles, copayments and coinsurance). Every member who is enrolled in a Medicare Rx Option, will receive an EOC in late fall 2019. This mailing is done separately from the other Option Selection Period materials.

Abridged Formulary versus Comprehensive Formulary: A formulary is the list of medications covered by a prescription drug plan. The Abridged Formulary is a partial formulary and includes the more commonly used drugs under the plan. If you are enrolled in a Medicare Rx Option for 2019, you received a 2020 Abridged Formulary with your Option Selection Period materials. The Comprehensive Formulary is the complete list of drugs covered by the plan. You can find the most recent Comprehensive Formulary at www.HOPbenefits.com.

Categories
Annual Enrollment Prescription Drugs

How to Check if Your Drugs are Covered

In most cases, a plan does not pay benefits for any drug not listed on the formulary, which is a list of all the medications covered by a plan. The formulary can also indicate if a prior authorization or step therapy is required for certain drugs as well as any quantity or day supply limitations.

If you are enrolled in one of the Medicare Rx Options under the Health Options Program, the comprehensive formulary for each Option is posted to the website and updated monthly.

There are two ways to look up your medications in the formulary:

  • Medical Condition. The drugs are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category “Cardiovascular Agents.” If you know what your drug is used for, look for the category name. Then look under the category name for your drug.
  • Alphabetical Listing. If you are not sure what category to look under, you should look for your drug in the Index. The Index provides an alphabetical list of all of the drugs included in the formulary. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

You can also use the online Part D Formulary Lookup Tool to see if a medication is covered. To search for drug pricing information, you must be registered on the OptumRx website. OptumRx is the administrator for the Medicare Rx Options under the Health Options Program.

As a reminder, the 2020 Materials page has links to the electronic files of all the materials that were mailed to current members. Click on a link to view, print or download a copy of each document.

If you are enrolled in a Medicare Advantage Plan, ask the insurance provide for their formulary.

Categories
Dental Option Selection Period

Smile: It’s the MetLife Dental Plan

With the 2020 Option Selection Period, the Health Options Program is offering an Open Enrollment for the MetLife Dental Plan. This means if you are not currently enrolled for dental benefits, you can elect the MetLife Dental Plan for 2020 as long as you are enrolled in the HOP Medical Plan or the Value Medical Plan. The MetLife Dental Plan is not available on a standalone basis or with a Medicare Advantage plan. Carefully consider if enrolling in dental coverage is the right choice for you. 

Read more in the current issue of HOP News and the MetLife Dental Plan flyer.

Categories
Health Options Program PSERS

Individual Consultation Schedule – Fall

The Fall 2019 schedule of face-to-face Health Options Program individual consultations is now available.

You can schedule a 30-minute face-to-face individual appointment (not a group meeting) with a staff member of the Health Options Program if you need help that cannot be provided over the telephone by a customer service representative at the HOP Administration Unit.

Walk-in appointments are NOT available and the number of appointments at each location is limited. Visit the information sessions page for details on how to make an appointment, to see the Individual Consultation schedule and to find driving directions to each location.

Categories
OSP

Attention Health Options Program Members: Mark Your Calendar

The Option Selection Period—the time when individuals currently enrolled in the Health Options Program can make changes to their coverage for 2020—runs through November 15. If you’re a current enrollee, this is a great time to evaluate your options and decide if you want to make any changes to your Health Options Program coverage for 2020.

Watch your mail for more information. You’ll receive your Option Selection Period materials explaining what’s new for 2020 and the coverage options available. Consider these materials carefully, particularly if you have moved, or are about to move, to a new area. If you’re currently enrolled in the Enhanced, Basic or Value Medicare Rx Option, the package will also include information about these plans. Unless you notify us otherwise during the Option Selection Period, your current medical and/or prescription drug or dental coverage will continue in 2020.

Don’t delay! The Option Selection Period ends November 15, 2019, so be sure to review all the information and submit all necessary forms before then. If you have any questions about the coverage options available to you, call the HOP Administration Unit at 1-800-773-7725.

Note: These mailings are exclusively for members currently enrolled in the Health Options Program. If you are not enrolled in health coverage under the Health Options Program, you will not receive the materials described above. If you are not enrolled in the Health Options Program, you may enroll if you experience a Qualifying Event (i.e., turning 65 or losing employer-sponsored coverage).

Categories
Awareness Health

Protect Yourself From Summer Pests

As the days get warmer and sun light lasts longer, most people welcome the idea of enjoying the great outdoors. But we’re not alone out there—don’t forget to guard yourself from summer’s flying and crawling pests. Tick and mosquito activity peaks in the summer. In most cases, a bite from either is only a mild irritation; however, they both can carry diseases that cause serious health conditions. The more you know, the better you can protect yourself.

Mosquitos

  • Peak time: late July through September
  • Diseases they can carry: West Nile virus; neuroinvasive diseases, such as encephalitis or meningitis; Saint Louis Encephalitis (SLE); Dengue; Zika
  • Behavior: Generally most active from dusk to dawn
  • Places to avoid: Standing water and swampy areas
  • Did you know? Apply sunscreen before insect repellent
  • Prevention: Wear long sleeves/pants, use repellent and remove sources of standing water around your house as that can be a breeding ground for mosquitos.

Ticks

  • Peak time: late March to mid-October
  • Diseases they can carry: anaplasmosis; babesiosis; ehrlichiosis; Lyme disease; RMSF; tularemia
  • Behavior: Ticks perch on tall blades of grass or plant stems and wait for something to brush past
  • Places to avoid: High grass and wooded areas
  • Did you know? Ticks secrete a natural anesthetic when they bite, so you may not know you were bitten
  • Prevention: Check yourself after being outdoors. If you find a tick, grab it as close as possible to the skin with tweezers and pull straight out. Wash your hands and the area around the bite with soap and water.

Watch out for more serious symptoms. Below are some warning signs that a bite may be more than a mild irritation. If you think you’re experiencing a serious health reaction to a bug bite, call your doctor right away.

  • Fever, chills and joint aches
  • A rash with a bull’s eye-like appearance
  • Swollen lymph nodes
  • Intense migraines
  • Dizziness and shortness of breath
  • Problems with short-term memory.

Also, if you have certain health conditions like cancer, diabetes, high blood pressure, kidney disease or are taking immune-suppressant drugs, you may be at higher risk for the diseases these pests can carry. Talk to your doctor about the prevention that’s right for you.

Categories
Medical

What is an authorized representative?

An authorized representative is someone you’ve designated to represent you and act on your behalf in matters related to your medical claims. Under the Health Options Program, your authorized representative is allowed to view your health information—including your claims. For example, an authorized representative would be able to speak with the HOP Administration on your behalf if you were in the hospital and had questions about how a procedure is going to be covered. If you are enrolled in a plan under the Health Options Program and want to designate an authorized representative, complete the “CMS’ Appointment of Representative” form posted to the “Forms/Resources” page on www.hopbenefits.com. Once completed, send it to the HOP Administration Unit. 

If you are not enrolled in the Health Options Program, check with you insurance provider about their authorized representative designation process.

Categories
Health

Health Care 101: Benefit Maximums

As part of an ongoing series about health care terms, below describes plan design components related to how much you and the plan will pay for services.

Benefit Term What It Means
Benefit Maximums Some health care services have a benefit maximum. This is the most your health plan will pay in a given calendar year, or lifetime, toward certain covered expenses
Out-of-Pocket Maximum The most you will pay out-of-pocket in a calendar year for covered expenses. Once you reach the out-of-pocket maximum, the Plan will pay 100% of covered expenses for the rest of the calendar year; excluding any expenses above a benefit maximum for a particular service.
“Your Responsibility” as listed on an Explanation of Benefits (EOB) Every time you receive medical care, you’ll get an EOB that shows the service, how much it cost, how much is covered by the Plan and how much you have to pay (i.e., your responsibility). If an expense is higher than a benefit maximum, if there’s limited coverage or if the coverage pays only a certain percentage of the expense, any remaining balance will be shown as “your responsibility” on the EOB.
Categories
Health Options Program Prescription Drugs

Quality Improvement Award

The prescription drug options under the Health Options Program are being recognized by the Pharmacy Quality Alliance for significant improvements in medication quality measures. These categories are part of the overall CMS star rating. The Program received an overall rating of 4.5 stars for 2019, and at least a 4 star rating on medication quality measures. This represents significant improvement in star ratings from 2018 to 2019.

CMS awards a star rating to prescription drug plans based on performance in categories such as customer service, overall member satisfaction and patient safety. The Pharmacy Quality Alliance works with CMS on these measures and recognizes plans with an Excellence in Quality Award and the Quality Improvement Award. The Health Options Program is pleased to share this recognition.

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