2015 Medicare Advantage Annual Enrollment Period (AEP) Key Information AEP is an especially important time period. From October 15 through December 7, all members have the chance to make a change to their Medicare Advantage or stand alone Medicare Prescription Drug Plan. The member can enroll, disenroll or change plans during this time period. Contained in this guide is information related to Highmark's 2015 plans, benefits and premiums as well as FAQs. KEY INFORMATION....................................... 2 Why Highmark? The Highmark Difference Highmark is Reliable Highmark Helps our Members Live a Healthy Life News About 2015 Premiums, Benefits and Plans........... 3 Part C Benefit Changes Part D Benefit and Formulary Changes Plan Consolidations and Closings Community Blue Medicare HMO FREQUENTLY ASKED QUESTIONS.......................... 6 Premiums Benefit Changes Formulary Changes Plan Consolidations and Closings Network Health Care Reform Star Ratings Community Blue Medicare HMO CHANGING PLANS....................................... 10 Note: Changes to 2015 plans cannot be discussed prior to 10/01 with the exception of inquiries due to the receipt of an ANOC/EOC mailing. Plan changes & enrollments can only start on 10/15 without a valid ICEP or SEP.
KEY CHANNELS CUSTOMER SERVICE/CCC HEALTH COACHES BROKERS RETAIL STORES EMPLOYEES/FRIENDS/FAMILY PROVIDERS PROVIDER FACING STAFF PHARMACY (ESI) PARTNERS (MATRIX, CENSEO, NAVIHEALTH) KEY INFORMATION WHY HIGHMARK? THE HIGHMARK DIFFERENCE Highmark has 75 years of experience providing health care coverage in the markets we serve. We have been providing Medicare plans since the program began in 1965. At Highmark, we recognize that individuals with Medicare have unique needs, which is why we have a broad product portfolio for all consumers. We can balance medical needs with an affordable premium that provides these individuals with the value they need. For 2015, we've worked hard to ensure our members have affordable out-of-pocket costs by improving many of the benefits our members value and utilize the most, including: Preventive dental is now covered on all plans PCP copays have been lowered on most plans Lower copays for outpatient surgery performed in an Ambulatory Surgical Center (ASC) $0 or lower copays on lab tests performed in a freestanding lab or physician office Enhanced routine vision benefit including $0 copay on annual routine eye exam Addition of lower cost generic drug options Highmark's new Community Blue Medicare HMO plan delivers a high value network at a low premium. This plan includes an enhanced service model with dedicated representatives to assist members in finding doctors, making medical appointments and coordinating medical records and other health information between providers. Our exceptional Customer Service Representatives are dedicated to our Medicare Advantage members and live in the communities we serve. HIGHMARK IS RELIABLE Highmark has a 75 year history of stability, reliability, and adherence to the highest ethical standards. Count on us for dedicated service when you need it, including fast and accurate claims processing. Ranked #1 by Becker's Hospital Review as having the most accurate claims payments in Pennsylvania and the fastest in the country. 2
Our members recently rated Highmark as the area's most preferred health insurance company and the number one most trusted. Our extensive provider network provides continued access to quality providers including UPMC doctors and hospitals in western PA. Plus, Freedom Blue PPO members have access to all participating Blue Cross Blue Shield Medicare Advantage PPO providers for routine care coast to coast. Highmark has the experience to help you smoothly navigate the continuous changes in health insurance. HIGHMARK HELPS OUR MEMBERS LIVE A HEALTHY LIFE Highmark is committed to being your partner in health by including enhanced vision and dental benefits on all Medicare Advantage plans, plus a package of wellness extras you won't find anywhere else. Highmark's SilverSneakers Fitness program offers free access to fitness classes, pools and exercise equipment at over 11,000 participating locations nationwide. Highmark gives you 24/7 access to health and wellness coaching facilitated by a Registered Nurse Health Coach. Highmark provides no-cost preventive exams and screenings designed to help our members stay healthy, independent and help avoid or delay the onset of illness or disease. Highmark's advanced discharge planning programs ensure members receive the right care, in the right place for the right amount of time and smooth the way to going home or to a post-acute care facility. Highmark has specialized programs designed to support those dealing with a serious, lifelimiting illness by providing emotional support, coordinating care services and arranging referrals to community services. NEWS ABOUT 2015 PREMIUMS, BENEFITS AND PLANS Highmark's premiums have increased for 2015 based upon a number of factors, but the single biggest driver is reduced government funding for the Medicare Advantage program as a result of the Affordable Care Act. Because of this, changes in premiums and some benefits have been required to maintain attractive options for Medicare beneficiaries looking to receive coverage that exceeds that of Original Medicare. In response to this challenge, Highmark reviewed its plan offerings to balance premium increases with benefit changes, maintaining costs for the most commonly used benefits whenever possible. PART C BENEFIT CHANGES Preventive dental benefit now offered on all plans Lower PCP copay on most plans $0 or lower cost sharing on lab tests performed in freestanding lab or physician office More affordable outpatient surgery option when performed in an Ambulatory Surgical Center (ASC) Routine vision benefit enhanced across all plans ($0 annual exam; annual frames/lenses/contacts) 3
PART D BENEFIT AND FORMULARY CHANGES Each year, we assess and modify our formulary balancing drug access and cost. Some of the changes we've made to our formulary include: Removed drugs that pose a high risk to seniors All plans now have 5 drug tiers (preferred generic, non-preferred generic, preferred brand, non-preferred brand and specialty) 35 high cost drugs moved to specialty tier Generic tier split into preferred generic & non-preferred generic Higher cost drugs that have a lower cost alternative were moved to non-preferred tiers Some plans have moved from incentive formulary to closed formulary Quantity limits added to certain drugs Initial coverage limit raised from $2,850 to $2,960 Out-of-pocket limit raised from $4,550 to $4,700 Richer standard benefit in coverage gap: 65% generic coinsurance & 45% brand coinsurance KEY FORMULARY CHANGES Top 20 Drugs Removed from the Formulary: NEXIUM RX COMBIVENT RESPIMAT AVODART PROVENTIL HFA DIOVAN DEXILANT TOPROL XL TRICOR FLOVENT HFA HUMULIN 70/30 KWIKPEN ACTONEL TUDORZA PRESSAIR XOPENEX HFA VYTORIN NIASPAN DULERA JALYN LINZESS CARISOPRODOL ARMOUR THYROID Top 8 Drugs Moving to a Non-Preferred Brand Tier: NAMENDA ADVAIR DISKUS NASONEX LOVAZA SEREVENT DISKUS THEO-24 NUVIGIL ROXICET PLAN CONSOLIDATIONS AND CLOSINGS Due to claims expenses far outpacing revenues associated with government funding and member premiums, Highmark was forced to close or consolidate some plans. Western PA Security Blue HMO HD plan will close and will be consolidated into ValueRx plan Freedom Blue PPO HD plan will be closed with no consolidation West Virginia Highmark will be exiting 22 counties and merging regions 1 and 2 into a single 33-county service area Freedom Blue PPO Value plan will be closed Freedom Blue PPO HD and Deluxe plans will be consolidated into the ValueRx and Standard plans respectively 4
First State PDP Highmark will be closing First State PDP, which was Highmark's standalone Part D plan offered in Delaware, District of Columbia and Maryland All members in plans that are closing and not consolidating will be sent a Notice of Non- Renewal in early October NEW PLAN INTRODUCING COMMUNITY BLUE MEDICARE HMO Highmark supports the needs of individuals with Medicare by giving them the products, programs and services they need to remain healthy and active. We created a select network product for Medicare beneficiaries seeking high quality at a lower cost. A select high value network of Allegheny Health Network and other community doctors and hospitals. The network does not include UPMC and certain other doctors and community hospitals. The Community Blue Medicare HMO network is different than the Commercial (non-medicare) Community Blue network. Community Blue Medicare HMO will offer two new plans in 23 western PA counties. Community Blue Medicare HMO is not available in Bedford, Blair, Cambria, Huntingdon and Potter counties. Community Blue Medicare HMO Signature: $0 premium with medium to high cost sharing Community Blue Medicare HMO Prestige: $193 premium with minimal cost sharing Members will have dedicated support to provide assistance with making medical appointments, finding network providers and getting medical records transferred Members new to Community Blue Medicare HMO, who are currently under care with a nonparticipating provider, may need additional time to transfer to a participating provider. Members can contact Customer Service and request a Transition of Care. The request must be made within the first 60 days of enrollment and will be subject to review and approval. KEY TAKEAWAY: There are significant changes to plan premiums. However, we've worked hard to ensure our members have a range of plan options at various price points and maintained affordable out-of-pocket costs in exchange for increased premiums. Reinforce this message to the members. If a member is satisfied with their current plan, there is no need to change or do anything to remain enrolled. However, if a member is not satisfied with their current plan, encourage them to consider other Highmark plan options, including Community Blue Medicare HMO. 5
Frequently Asked Questions PREMIUMS Q: WHY ARE MY PREMIUMS SO HIGH? A: Premiums have increased for 2015 based upon a number of factors. The biggest driver is reduced government funding for the Medicare Advantage program as a result of the Affordable Care Act. Since the Federal government pays plans like Security Blue HMO / Freedom Blue PPO to provide care to our members, and that payment is not keeping pace with the cost of member care, Highmark needed to review its plan offerings to balance premium increases with benefit changes, maintaining costs for the most commonly used benefits whenever possible. Highmark offers a variety of plan options and premium ranges to ensure that all people with Medicare continue to have access to plans that meet their health needs and budget. Q: HOW CAN OTHER PLANS CHARGE LESS? A: It is important to look beyond the premium when comparing plans and consider the total cost of health care inside the plan. If premium or out of pocket costs are the main concern, we may have other options that the member can select to meet their needs. In the case of other plans that are available from other companies, be sure the member considers the benefits, network and out of pocket costs that they would incur beyond the premium. Highmark offers a variety of plan options and premium ranges to ensure that all people with Medicare continue to have access to plans that meet their health needs and budget. Our members will continue to have access to one of the largest networks of doctors, hospitals and other providers in the region. And, members in western PA Security Blue HMO and Freedom Blue PPO will still have access to all UPMC, Allegheny Health Network and other key doctors and community hospitals. BENEFIT CHANGES Q: I SEE THAT MY PLAN NOW INCLUDES A NEW DENTAL BENEFIT. WHY WAS THIS BENEFIT ADDED? A: We heard feedback from members about what is most important regarding their health plan, where dental was the most preferred benefit to be added. In response to this feedback, we've taken a look at ways to ensure that you continue to get the value you expect from your health plan. We've been able to add a new preventive dental benefit to your plan while protecting the benefits that you value the most, so you're getting more coverage than last year. 6
FORMULARY CHANGES Q. WHY DOES HIGHMARK CHANGE ITS DRUG LIST (FORMULARY) EACH YEAR? A. Each year, Highmark reviews its formulary to ensure we are providing low-cost alternatives for our members. It comes down to balancing access and cost. We need to contain rising health care costs and ensure medication safety. For example, one of the changes we made to our formulary included removing drugs that pose a high risk to seniors. Q: WHY DID YOU REMOVE MY DRUG FROM THE DRUG LIST (FORMULARY) / MOVE IT TO A HIGHER COST SHARING TIER? A: In order to contain rising health care costs and ensure medication safety, particularly in prescription drugs, we needed to make adjustments to our drug list (formulary). To accomplish this we: Removed drugs that pose a high risk to seniors Added a preferred generic drug tier to provide members with access to more low-cost drug options Certain high cost drugs have been moved to the Specialty tier Higher cost drugs that have a lower cost alternative were moved to the non-preferred tiers Generally speaking, the lower the cost of the drug, the lower the cost sharing tier you will pay. If your drug is no longer covered, or you wish to potentially lower the costs you pay for your drugs, you have several options: You can talk to your doctor about prescribing a lower cost alternative You can move to another Highmark Medicare Advantage plan that <includes your drug / includes your drug on a lower cost sharing tier> You have the right to talk to your doctor about filing an exception Q: WHY DID YOU MOVE MY DRUG TO A HIGHER COST SHARING TIER? A: In order to contain rising health care costs and medication safety, we needed to make adjustments to our drug list (formulary). Every year, we review our list of covered drugs to assure that lower cost drugs remain in the lower cost tiers. Generally speaking, the lower the cost of the drug, the lower the cost sharing tier you will pay. Certain high cost drugs were moved to the Specialty tier. Higher cost drugs that have a lower cost alternative were moved to non-preferred tiers. You have several options, you can talk to your doctor about prescribing a lower cost alternative, you can move to another Highmark Medicare Advantage plan that includes your drug in a lower cost sharing tier, or you have the right to talk to your doctor about filing an exception. 7
PLAN CONSOLIDATIONS/CLOSINGS Q: WHY DID YOU ELIMINATE MY PLAN? (FREEDOM BLUE PPO HD (WPA) / FREEDOM BLUE PPO VALUE (WV) / 22 WV NON-RENEWED COUNTIES) A: We were unable to continue offering this plan due to claims expenses far outpacing revenue from the Federal government. We would have needed to either significantly increase the cost sharing on certain services beyond what original Medicare offers, which is not permissible, or significantly raise the premium. We instead decided to eliminate the plan and allow our members to look for a plan that better fits their needs at a price they can afford. Note: Impacted members will receive a CMS mandated non-renewal notice in early October outlining their options. Q: WHY DID YOU MOVE ME INTO ANOTHER PLAN? (SECURITY BLUE HD TO VALUERX / FREEDOM BLUE PPO HD TO VALUERX IN WV / FREEDOM BLUE PPO DELUXE TO STANDARD IN WV) A: We were unable to continue offering this plan due to claims expenses far outpacing revenue from the Federal government. We would have needed to either significantly increase the cost sharing on certain services beyond what original Medicare offers, which is not permissible, or significantly raise the premium. We chose to move you to a plan that was close to your current plan in cost sharing and premium so that you would have the security of knowing that you are still covered by Highmark. Note: Impacted members will be notified of their change in plans through their Annual Notice of Change letter. Q: WHAT IF I DON'T WANT TO STAY IN THE PLAN THIS NEW PLAN? (SECURITY BLUE HD TO VALUERX / FREEDOM BLUE PPO HD TO VALUERX IN WV / FREEDOM BLUE PPO DELUXE TO STANDARD IN WV) A. During Medicare's Annual Enrollment Period (AEP) you have the opportunity to change to another Medicare Advantage plan or return to Original Medicare. You have until December 7 to make a change. Highmark offers plan options and premium ranges to ensure that all people with Medicare continue to have access to plans that meet their needs and budget. Q. WHY DID YOU ELIMINATE MY DRUG PLAN, FIRST STATE PDP, ONLY AFTER ONE YEAR? A. Due to declining funding from the Federal government coupled with very low enrollment, we made the decision to close the plan and allow our members to find a Part D plan that better fits their needs and budget. NETWORK Q: WILL I STILL HAVE ACCESS TO UPMC DOCTORS AND HOSPITALS? A: Yes. Both UPMC and Highmark have publicly stated their commitment to people with Medicare Advantage, and we intend to honor these statements. Our Security Blue HMO and Freedom Blue PPO members will continue to have access to UPMC hospitals and doctors as well as Allegheny Health Network and other key doctors and community hospitals. Our 8
Security Blue HMO and Freedom Blue PPO members do not need to take any action in order to continue using their current providers. Members in Community Blue Medicare HMO will not have access to UPMC providers except in an emergency. HEALTH CARE REFORM Q: HOW WILL/DOES HEALTHCARE REFORM AFFECT ME? A: Health Care Reform has already had a positive effect on people with Medicare. As part of the reform law, a greater emphasis has been placed on prevention and wellness. All cost sharing has been eliminated for certain preventive exams and screenings. And for people with Part D drug coverage, the law reduces the Part D coverage gap from 2011 to 2020, which is positive for anyone who uses their Part D coverage. The law also includes changes in funding to Medicare Advantage plans. This reduced funding is one of the main drivers for increased premiums in 2015. STAR RATINGS Q. WHAT ARE HIGHMARK'S STAR RATINGS? A. The latest information we've received from the Centers for Medicare and Medicaid Services show that Highmark's Star Ratings continue to improve and are strong. The 2015 Star Ratings have Freedom Blue PPO in PA at 4.5 Stars, Security Blue HMO at 4 Stars and Freedom Blue PPO in WV at 3.5 Stars. We continue to invest to improve our services and continue to place our customers at the center of everything we do. COMMUNITY BLUE MEDICARE HMO Q: ARE THERE ANY NEW PLANS AVAILABLE? (WPA ONLY EXCLUDING BEDFORD, BLAIR, CAMBRIA, HUNTINGDON AND POTTER COUNTIES) A: Yes. We have added Community Blue Medicare HMO plans that deliver a high value at a lower premium. Community Blue Medicare HMO is supported by a select network which includes Allegheny Health Network and other community doctors and hospitals. It does not include UPMC and certain other doctors and community hospitals. There will be two Community Blue Medicare HMO plans offered in 2015: Signature plan that includes a $0 premium with medium to high cost sharing Prestige plan that includes a $193 premium with minimal cost sharing Both plans offer Part D prescription drug coverage Q: HOW DO I KNOW IF MY HOSPITAL OF DOCTOR ACCEPTS COMMUNITY BLUE MEDICARE HMO? A: I can check to see if your provider is participating. If you would like to check yourself, you can view our online provider directory at www.highmarkbcbs.com and select Find a Doctor or Rx. In the Select a Plan box, make sure you click on Community Blue Medicare HMO. There will be special symbols by the provider's name to indicate that they participate in Community 9
Blue Medicare HMO. Be sure to pay special attention and make sure that your doctor has admitting privileges to a Community Blue Medicare HMO participating hospital. Our printed provider directory also includes instructions for finding participating Community Blue Medicare HMO participating doctors and hospitals and also contains special symbols to identify them. (Please note that St. Clair Hospital system providers were listed in the provider directory as participating Community Blue Medicare HMO providers in error.) Q. WAS THIS PRODUCT DESIGNED TO STEER PEOPLE AWAY FROM UPMC? A. No. Our goal is to provide product choices for individuals seeking high-quality, lower-cost coverage. In addition, this product will not replace our Security Blue HMO or Freedom Blue PPO products, which will continue to offer access to all UPMC doctors and hospitals. Q. WHAT IF I NEED TO CONTINUE SEEING MY DOCTOR WHO ISN T PARTICIPATING IN COMMUNITY BLUE MEDICARE HMO? A. We want to ensure that all of your needs are being met through the Community Blue Medicare HMO provider network. If you need additional time to transfer to a participating provider, you may request a Transition of Care by calling Customer Service. Your request to continue care with a non-participating doctor will be reviewed and you will be informed of the outcome. You must make this request within the first 60 days of your enrollment in the plan. Q. WHY AREN T UPMC (OR OTHER NON-PARTICIPATING PROVIDER) PROVIDERS INCLUDED IN THE COMMUNITY BLUE MEDICARE HMO NETWORK? A. UPMC (or other non-participating health systems) was offered the opportunity to participate in the Community Blue Medicare HMO network, but chose not to do so. Keep in mind that having a select network of high quality community hospitals and doctors enables Community Blue Medicare HMO to offer comprehensive benefits at a lower premium. CHANGING PLANS Choosing a plan should focus on more than just premium. Members need to compare the plan's features and benefits, along with costs. Members should look at their situation and make sure they're getting all the benefits they need. Q. DOES THEIR CURRENT HIGHMARK PLAN MEET THEIR NEEDS? A. If yes, they don't have to do anything. If not: Q. Do they like their current Highmark plan but want a more affordable option? Q. Are they interested in moving from Freedom Blue PPO to Security Blue HMO? Q. Does Community Blue Medicare HMO appeal to them? A. We make it easy for members to change to the Highmark Medicare Advantage plan that is right for them. And, we have a plan to fit everyone's needs. Before advising the member on plan change options, it is important to have a conversation with the individual to assure that they need/want to change their plan. Ensure that you reiterate the positive news about their 2015 plan. If after your discussion, the member feels they still want to review their plan options, the following plan change channels are available: 10
Plan Change Line Members should only be transferred to a Highmark Medicare Advisor if they really need or want to make a plan change. We can take verbal plan changes over the phone and it takes approximately 5-8 minutes. This line cannot handle calls that are not specific to a consultative sell or plan change. Calls can only be made or transferred between October 15 and December 7. The number to the plan change line is 1-800-307-4116 (TTY 711) Local Agent/Broker Members who have an existing relationship can call their local independent agent. Agents are knowledgeable on all Highmark plan options. Retail Stores Members can visit any one of our 9 Highmark Direct retail store locations in Pennsylvania to have a one-on-one consultation regarding their current plan, reviewing plan options and changing to another plan. Members in northeastern PA can also visit a Blue Cross of Northeastern PA Retail Store. Member Benefit Meetings (PA only) Let the member know that there may be a Member Benefit Forum in their area. Ask if they would like to attend. If a member is interested, a CSR can search meeting locations/dates/times and RSVP by going to http://reservations.highmark.com and clicking on the Already a Highmark Medicare Advantage Member section. You can also instruct a member to go online, search and RSVP to a meeting. Meeting dates, times and availability may be limited. Online Plan Option/Change On October 1st, Highmark will be launching a website for people with Medicare. The Medicare site will have several different sections where a member can Compare & Shop for plans as well as Enroll (make plan changes beginning October 15th). The four main sections of the site include: Discover Medicare 101 information for those new to Medicare Compare & Shop Side by side listings of benefits - with Rx and medical cost estimators Enroll MA/PDP (Plan Changes or New Applications) as well as Medicare Supplement (PA, WV and DE) Resources Includes brochures, EOCs, provider and formulary search, etc. Members do not need to have a user ID and password in order to review plans or make a plan change. The site is very user friendly and will allow for easy plan review and plan change if the members desire. Direct the member to: HTTPS://SHOP.HIGHMARK.COM/MEDICARE 11