2011 Spring Producer Road Show reminder  

Just a reminder of the upcoming 2011 Spring Road Show meetings. During this time we will be discussing our July 1, 2011 filing and plan modifications. Refreshments will be provided. Remember to RSVP with Margaret Cheng for a location that works best for you.  

July 1, 2011 medical, RX and dental changes 

The following changes will take place, effective July 1, 2011. These changes will be discussed during our Spring Producer Road Show meetings.

Medical changes

Essential Benefit maximum increasing from $750k to $2 million

Emergency room copayment increasing from $100 to $200

Addition of the ODS Travel Network through PHCS Healthy Directions In-network and Out-of-network OOP maximums no longer comingled

Introduce new 80%/50% high deductible PPO plan options

• $1,500, $2,000, $2,500, $3,000, $4,000

Introduce new Evidence-Based Value PPO plan options

• $1,000, $1,500, $2,000

Rx changes

Remove Rx $2 $10 $30 $50

Introduce new Rx $2 $15 $45 $75

Change Rx tier modifications/proposed definitions/exclusions

• Value
• Select Generic
• Preferred
• Brand 
• Preferred Specialty 
• Specialty/Orphan

Change mail-rider & Preferred Specialty Rx from 2x to 3x Brand

(Non-Preferred) Specialty & Orphan moving to 30% with $6k OOP maximum per year

Changed Walgreens to Exclusive Specialty Pharmacy

Dental changes

Introduce new $500 maximum Premier plan, Fortify Dental.

Existing standard portfolio of dental plans will now be offered to the 2+ market (except $2,000 maximum plan)

• Supplementary bitewing X-rays frequency will change from once in any 6 months to once in any 12 months
• Complete series X-rays/Panoramic film will now be covered once any five years
• Topical application fluoride is covered once in any 6 month period for members age 18 and under. For members age 19 and over if there is a recent history of periodontal surgery or high risk of decay due to medical disease or chemotherapy or similar type of treatment.

ODS debuts new prescription price check tool

 Now, it's easier than ever for ODS members to check the price of prescription medications and find alternatives that save money. On March 1, ODS launched its new prescription price check tool.

This new tool has significant improvements over the formulary look-up previously available to members. Members get information quicker and easier, thanks to better navigation and a faster response time. Simply enter the medication name and choose from the list of matching drugs to find the cost and quantity. Members can also see options for ordering through the mail pharmacy or a retail pharmacy.

The prescription price check tool can help members save money by showing them when a lower-cost, generic option is available. At a simple glance, members can see how much is covered by their plan and what the remaining cost will be. Members can also get an estimated price from a specific pharmacy.

Members can access the new tool by logging in to myODS selecting the Pharmacy tab, and clicking on "Prescription price check."

ODS Travel Network offers members in-network coverage

A new offering from ODS gives members better coverage when they travel. Effective April 1, the ODS Travel Network will give most of your clients the option to receive in-network benefits when members travel outside their primary service area.

The ODS Travel Network is an additional network tier. When a medical member seeks care outside his or her primary service area for any reason, emergency or non-emergent, we'll review the claim to see if the provider is part of the PHCS Healthy Directions network. If so, ODS will pay the claim at the in-network benefit level.

Members will be able to search for providers quickly and easily by visiting www.phcs.com and selecting the Healthy Directions network. The PHCS Healthy Directions network boasts nearly 70,000 hospitals and medical facilities and 658,000 primary care physicians and specialists.

In addition, the ODS Travel Network can save money for members with dependents who live out of the area. Normally, these members may be subject to balance billing. However, if an out-of-area dependent seeks care from a PHCS Healthy Directions provider, ODS will pay at the in-network benefit level, providing better coverage and savings to the member. Access to the ODS Travel Network applies at the group level.

Insured groups (excluding minimum premium and refunding) will automatically have access to the ODS Travel Network upon renewal or initial enrollment. Twenty-five percent of total claim dollar savings will be applied to the group's claims experience.

ASO groups have the option to add the ODS Travel Network and will be charged 25 percent of total claim dollar savings.

Minimum premium and refunding groups have the option to add the ODS Travel Network, and 25 percent of total claim dollar savings will be applied to the group's claims experience.

The ODS Travel Network is not currently available for groups in Alaska, individual business groups in Oregon, Medicare Advantage groups or Medicaid members.

For your clients who aren't automatically enrolled, the ODS Travel Network is worth the extra step. Members will appreciate the convenience of having access to medical care away from home, and they'll love the savings from receiving care at in-network benefit levels.

The ODS Travel Network is available to members who are covered under a primary network inside and outside of Oregon, unless they're already covered by the PHCS network. Because the ODS Travel Network is not an alternative primary network, members should continue to seek care in their primary network whenever possible. Preauthorization is still required for inpatient services. Healthcare Services will direct members to in-network providers when possible.