Agenda Transition from Principal to Primary PhysicianCare (PPC) Benefits & Plan design Health Care Reform Networks PPC Information and Resources Pre-certification Quest/Lab One ID cards Pharmacy 2011 Enrollment Questions

Benefits & Plan Design No change in benefit plan design (Health Care Reform only) under the new TPA effective 6/1/11. Plans will remain the same: – PPO 500 – PPO 3000 – HDHP 2000 New unlimited lifetime maximum (Health Care Reform) Eligible dependents covered to age 26 (Health Care Reform) New Pharmacy Benefit Manager, Express Scripts

Preventive Care/Wellness The following services are covered at 100% for all plans (one per calendar year) – Routine physical exams – Routine gynecological exams – Routine colonoscopies – Routine mammograms – Hearing Exams – Well child care – Immunizations – X-ray and lab services provided during exam

Health Care Reform Changes Lifetime maximums no longer apply Calendar year maximum no longer applies to “essential benefits” Dependent children may be covered under parent’s policy to age 26 Pre-existing conditions no longer apply to children under the age of 19 Over the counter medications no longer reimbursable by flex spending account without doctor’s prescription

Networks No network disruption Texas True Choice (TTC) will remain the primary network for Schreiner University employees – PHCS will remain the secondary/out-of-state network for Schreiner University employees –

New Third Party Administrator (TPA) Principal is no longer in the health insurance administration industry. PPC will begin handling administrative services such as claims processing, customer service, etc, effective June 1, Primary is located in Charlotte, NC

Primary PhysicianCare What is a Third Party Administrator (TPA)? – An organization that processes claims or certain aspects of employee benefit plans for a separate entity. A TPA is NOT an insurance company. What is a self-funded employee benefit plan? – Rather than paying monthly premiums to an insurance company a self-funded plan is paid by the employer. Who is Primary PhysicianCare, Inc. (PPC)? – PPC manages health plans for self-funded employers. – The sole responsibility of PPC is to manage the health plan per the guidelines of the Summary Plan Description. PPC has aligned interests with Schreiner University and their employees. We want to provide members the tools and resources to make better choices about their healthcare.

Primary PhysicianCare Dedicated Service Team: – Account Representative – Customer Service Team Lead – Customer Service Specialists – Claims Processor – Eligibility Specialist Our customer service teams will be up to date with your plan benefits and able to answer any questions you may have.

PPC Contact Information Hours: – 8:00am – 7:00pm EST – Please leave messages after hours By Phone: – – Follow the prompts for customer service By Mail: – Primary PhysicianCare, Inc. P.O. Box Charlotte, NC Important information to have ready: – Your ID number (from ID card) – Your Employer name – Date of Service

Pre-certification – Process by which PPC reviews prospective inpatient hospitalizations and outpatient procedures to ensure that all patients receive optimum-quality and cost-effective care – 7 day advance notice (pre-authorization) is required for any elective service – Notice within 48 hours is required for any non-elective service

Pre-certification Services that require pre-certification: – Emergency hospital admissions, non-emergency hospital admissions (including observation), ambulatory surgery (outpatient surgery), dialysis, inpatient care in substance treatment centers, inpatient care in mental health treatment centers, inpatient care in extended care facilities, inpatient care in skilled nursing facilities, hospice care, inpatient rehabilitation services, chemotherapy/radiation therapy, durable medical equipment (rental or purchase), prosthetics, pain therapy (outpatient) and home health care.

Pre-certification In order to receive full benefits for services that require pre- certification, the covered person must complete the process prior to receiving the services or treatment at least seven days in advance. Pre-certification is the responsibility of the member. If the member is unsure whether pre-certification has been made, he or she should call to verify. For pre-certification call: :30am – 5:00pm EST Monday through Friday

Quest/Lab One Use is voluntary by the provider/member If the provider uses Quest/Lab One, expenses are paid at 100% If the provider does not use Quest/Lab One, regular benefits apply

ID Cards You will be receiving new ID Cards prior to 6/1/11 One card per employee, and each dependent over 16 Please make sure that you have provided your (and your dependents, if applicable) new PPC ID card(s) to your doctors and pharmacies to ensure accurate and timely processing of claims Do not assume that your provider’s office has updated your information, please verify with your provider

ID Cards This is a SAMPLE, your benefits have not changed

PPC Resources Create your PPC account to: – Access claims activity – View deductibles – View out-of-pocket limits – View prescriptions – Request replacement or additional cards – Print EOB’s (Explanation of Benefit’s) – Print claim forms – Much more!

Go to and click on the “Member Login” linkwww.primarypc.com

New users register here… Register as a New User

Step 1 – Member Registration

Step 2 – Verify Information

Step 3 – Registration Complete

If you have any questions or need technical support, please PPC Help Desk

Express Scripts Express Scripts will be the new Pharmacy Benefit Manager No benefit/copay changes Out of pocket expenses met prior to 6/1/11 will be transferred from Principal to Primary PhysicianCare and Express Scripts Mail order program available for maintenance medications (i.e. blood pressure, cholesterol, etc) Anyone currently using mail order will need to obtain a new prescription and submit with a mail order profile to Express Scripts

Express Scripts Generic and Brand Name Medications: What to know and what to ask. – Ask your doctor about starting a generic medication at the beginning of treatment – Doctors do not have generic samples in their offices, skip brand name samples unless your doctor confirms you can safely switch to a generic after using a brand name drug – Ask your doctor to explore generics in the same class if your brand name drug dose does not have a chemical equivalent

Express Scripts Express Scripts Contact Information: – Phone: – Website:

Tips on How to Get Your Claim Processed Quickly And Correctly Most Claims are filed electronically: However, you retain some responsibilities just as before For students over age 19: Proof of full time student status is no longer required. Eligible dependents are covered under your plan to age 26, unless they have access to other Employer coverage Accident Information: For each claim that is an accident, please include how, when and where the accident occurred. When you have other coverage: For children or spouse ’ s claims, the process can be expedited with other coverage information attached or sent in separately on a claim form. Without this information, we will hold claims and request information, which will slow down the processing Medical Supplies: Please ask doctor to include a letter of medical necessity when prescribing medical equipment and supplies

Consuming Healthcare Only use the Emergency Room for true emergencies. Use generic drugs whenever possible; ask your doctor to prescribe a generic first! Seek comparable care in lower cost settings (i.e. colonoscopies in an office vs. hospital) Call PPC and we can assist and direct you! – All contact phone numbers are on the back of your ID card

2011 Enrollment If you currently participate in Schreiner University’s health plan you will be automatically enrolled with your current coverage for the remainder of You do not need to complete a new enrollment form. If you currently participate in Schreiner University’s health plan and need to make changes (i.e. drop/add dependent, drop plan) pick up a change form today. This form will need to be returned to HR no later than April 30, If you are not currently participating in Schreiner University’s health plan but would like to join please fill out a blank enrollment form.

Questions?