2016 Benefit Guide State Members

2016 Benefit Guide State Members

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1 Summary of Benefits & Coverage

3 Member Information

Health Savings Account Plan

Notice of Privacy Practices

PPO 600 Plan

Appeal Procedures

PPO 300 Plan Uniform Glossary

4 Premiums

2 Coverage Information Medical Plan Overview

Medical Plan Premiums Dental, Vision, and TRICARE Supplement Plan Premiums

Health Savings Account Plan Overview Health Savings Account Information PPO 600 Plan Overview PPO 300 Plan Overview Non-Medicare Prescription Drug Plan Medicare Prescription Drug Plan TRICARE Supplement Plan Dental Plan Vision Plan Strive for Wellness­ Program and Incentives ®

®

Strive for Wellness Health Center Employee Assistance Program Disease Management Services Women’s Health and Cancer Rights Notice

5 Contact Contact Information

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Section 1

Summary of Benefits & Coverage

Health Savings Account Plan PPO 600 Plan PPO 300 Plan Uniform Glossary

MCHCP: Health Savings Account Plan

Coverage Period: 01/01/2016 — 12/31/2016 Summary of Benefits and Coverage: What This Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: High-Deductible This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.mchcp.org or by calling 800-487-0771. Important Questions

Answers

Why this Matters:

What is the overall deductible?

$1,650 individual/$3,300 family (network) Does not apply to preventive care $4,000 individual/$8,000 family (non-network)

You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. The deductible starts over each year on Jan. 1. See the chart starting on Page 7 for how much you pay for covered services after you meet the deductible.

Are there other deductibles for specific services?

No.

You don’t have to meet deductibles for specific services, but see the chart starting on Page 7 for other costs for services this plan covers.

Is there an out-of-pocket limit on my expenses?

Yes. $3,300 individual/$6,600 family (network) $5,000 individual/$10,000 family (non-network)

The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.

What is not included in the out-of-pocket limit?

Premium, balance bill charges, health care this plan doesn’t cover

Even though you pay these expenses, they don’t count toward the out-of-pocket limit.

Is there an overall annual limit on what the plan No. pays?

The chart starting on Page 7 describes any limits on what the plan will pay for specific covered services, such as office visits.

Does this plan use a network of providers?

If you use a network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your network doctor or hospital may use a non-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on Page 7 for how this plan pays different kinds of providers.

Yes. Contact ESI, UMR or Aetna for a list of network providers.

Do I need a referral to see No. a specialist?

You can see the specialist you choose without permission from this plan.

Are there services this Some of the services this plan doesn’t cover are listed on Page 11. See your Yes. plan doesn’t cover? policy or plan document for additional information about excluded services. Questions: Call 1-800-487-0771 or visit us at www.mchcp.org. If you aren’t clear about any of the underlined terms used in this form, see the Glossary on Page 34. 6

Summary of Benefits & Coverage

MCHCP: Health Savings Account Plan Summary of Benefits and Coverage: What This Plan Covers & What it Costs

Coverage Period: 01/01/2016 — 12/31/2016 Coverage for: Individual + Family | Plan Type: High-Deductible

Copayments are fixed dollar amounts (for example, $35 for a formulary brand prescription) you pay for covered health care, usually when you receive the service. • Coinsurance is your share of the cost of a covered service, calculated as a percent of the allowed amount for the service. You pay the deductible amount. Once the deductible has been met, you pay coinsurance. For example, if the health plan’s allowed amount for an overnight hospital stay is $1,000 and you’ve met your deductible, your coinsurance payment of 20% would be $200. If you haven’t met any of the deductible, you would pay the full cost of the hospital stay. • The amount the plan pays for covered services is based on the allowed amount. If a non-network provider charges more than the allowed amount, you may have to pay the difference. For example, if a non-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) • This plan encourages you to use network providers by charging you lower deductibles, copayments and coinsurance amounts. •

Common Medical Event

Services You May Need Primary care visit to treat an injury or illness

20% coinsurance

40% coinsurance

Specialist visit

20% coinsurance

40% coinsurance

If you visit a health care provider’s Other practitioner/chiropractor office visit office or clinic

If you have a test

Your cost if you use a Network Non-network Provider Provider

Limitations & Exceptions None

20% coinsurance

40% coinsurance

Preauthorization (PA) required for some visits. If you fail to get PA, the service may not be covered.

Preventive care/screening/immunization

No Charge

40% coinsurance

Non-network Immunizations: No charge from birth to 72 months

Diagnostic test (X-ray, blood work)

20% coinsurance

40% coinsurance

None

Imaging (CT/PET scans, MRIs)

20% coinsurance

40% coinsurance

PA required. If you fail to get PA, the service may not be covered.

Questions: Call 1-800-487-0771 or visit us at www.mchcp.org. If you aren’t clear about any of the underlined terms used in this form, see the Glossary on Page 34. 2016 Benefit Guide

State Members

7

MCHCP: Health Savings Account Plan

Coverage Period: 01/01/2016 — 12/31/2016 Summary of Benefits and Coverage: What This Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: High-Deductible Common Medical Event

Services You May Need Generic drugs

Your cost if you use a Network Non-network Provider Provider 10% coinsurance 40% coinsurance

Formulary brand drugs If you need drugs Non-formulary drugs to treat your illness or condition

Specialty drugs

If you have outpatient surgery

If you need immediate medical attention

20% coinsurance

40% coinsurance

50% coinsurance

20% coinsurance

No coverage

Some prescriptions are subject to PA, quantity level limits or step therapy requirements. If you fail to follow requirements, the prescription may not be covered. Network: No charge for preventive formulary prescriptions and flu/shingles vaccinations Specialty drugs must be filled through Accredo, with the exception of the first fill of drugs needed immediately. Members who go to a retail pharmacy will be charged the full discounted price of the drug.

Facility fee (e.g., ambulatory surgery center) 20% coinsurance

40% coinsurance

Physician/surgeon fees

20% coinsurance

40% coinsurance

Emergency room services

20% coinsurance

20% coinsurance after network deductible

None

20% coinsurance

20% coinsurance after network deductible

PA required for non-emergent use of emergency medical transportation. If you fail to get PA, the service may not be covered.

Emergency medical transportation

Questions: Call 1-800-487-0771 or visit us at www.mchcp.org. If you aren’t clear about any of the underlined terms used in this form, see the Glossary on Page 34. 8

Limitations & Exceptions

Summary of Benefits & Coverage

PA required. If you fail to get PA, the service may not be covered.

MCHCP: Health Savings Account Plan Summary of Benefits and Coverage: What This Plan Covers & What it Costs Common Medical Event

Services You May Need

If you need immediate medical Urgent care attention If you have a hospital stay If you have mental health, behavioral health, or substance abuse needs

Coverage Period: 01/01/2016 — 12/31/2016 Coverage for: Individual + Family | Plan Type: High-Deductible

Your cost if you use a Network Non-network Provider Provider 20% coinsurance 20% coinsurance after network deductible

None

Facility fee (e.g., hospital room)

20% coinsurance

40% coinsurance

PA required except for an observation stay. If you fail to get PA, the service may not be covered.

Physician/surgeon fee

20% coinsurance

40% coinsurance

None

Mental/behavioral health outpatient services 20% coinsurance

40% coinsurance

Mental/behavioral health inpatient services

20% coinsurance

40% coinsurance

Substance abuse disorder outpatient services 20% coinsurance

40% coinsurance

Substance abuse disorder inpatient services

20% coinsurance

40% coinsurance

PA required for services provided at hospital except for an observation stay. If you fail to get PA, the service may not be covered.

Prenatal and postnatal care

20% coinsurance

40% coinsurance

No charge for routine prenatal care

If you are pregnant

If you need help recovering or have other special health needs

Limitations & Exceptions

Delivery and all inpatient services

20% coinsurance

40% coinsurance

PA required for some services. If you fail to get PA, the service may not be covered.

Home health care

20% coinsurance

40% coinsurance

PA required. If you fail to get PA, the service may not be covered.

Rehabilitation services

20% coinsurance

40% coinsurance

Habilitation services

20% coinsurance

40% coinsurance

PA required for some services. If you fail to get PA, the service may not be covered.

Questions: Call 1-800-487-0771 or visit us at www.mchcp.org. If you aren’t clear about any of the underlined terms used in this form, see the Glossary on Page 34. 2016 Benefit Guide

State Members

9

MCHCP: Health Savings Account Plan

Coverage Period: 01/01/2016 — 12/31/2016 Summary of Benefits and Coverage: What This Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: High-Deductible Common Medical Event

Services You May Need

Skilled nursing care If you need help recovering or have other special health needs

Your cost if you use a Network Non-network Provider Provider 20% coinsurance

40% coinsurance

Limited to 120 days per calendar year. PA required for some services. If you fail to get PA, the service may not be covered.

Durable medical equipment

20% coinsurance

40% coinsurance

PA required for some services. If you fail to get PA, the service may not be covered. No charge for breast pumps.

Hospice service

20% coinsurance

40% coinsurance

PA required. If you fail to get PA, the service may not be covered.

Eye exam

20% coinsurance

40% coinsurance

One per calendar year

20% coinsurance

40% coinsurance

Coverage limited to fitting of eye glasses or contact lenses following cataract surgery

Not covered

Not covered

None

If you need Glasses Excluded Services & Other Covered Services: dental or eye care Dental checkup

Questions: Call 1-800-487-0771 or visit us at www.mchcp.org. If you aren’t clear about any of the underlined terms used in this form, see the Glossary on Page 34. 10

Limitations & Exceptions

Summary of Benefits & Coverage

MCHCP: Health Savings Account Plan Summary of Benefits and Coverage: What This Plan Covers & What it Costs

Coverage Period: 01/01/2016 — 12/31/2016 Coverage for: Individual + Family | Plan Type: High-Deductible

Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.) • • • •

Acupuncture Cosmetic surgery Dental Care (adult) Exercise equipment

• • • •

Infertility treatment Long-term care Private-duty nursing Routine foot care

• Strive for Wellness® Health Center • Weight-loss programs

Other Covered Services (This isn’t a complete list. Check your policy for other covered services and your costs for these services.) • Bariatric surgery • Chiropractic care • Hearing aids

• Non-emergency care when traveling outside the U.S. covered as a non-network benefit • Routine eye care (adult)

Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending on the circumstances, federal and state laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at 800-487-0771. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.

Your Appeal Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal. For questions about your rights, this notice, or assistance, you can contact UMR at 888-200-1167; Aetna at 800-245-0618; or ESI at 800-797-5754 (non-Medicare) or 866-544-6963 (Medicare). Additionally, a consumer assistance program can help you file your appeal. Contact the Missouri Department of Insurance, 301 W. High St., Room 530, Jefferson City, MO 65101; call 800-726-7390; visit www.insurance.mo.gov; or email [email protected].

Questions: Call 1-800-487-0771 or visit us at www.mchcp.org. If you aren’t clear about any of the underlined terms used in this form, see the Glossary on Page 34. 2016 Benefit Guide

State Members

11

MCHCP: Health Savings Account Plan

Coverage Period: 01/01/2016 — 12/31/2016 Summary of Benefits and Coverage: What This Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: High-Deductible

Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have coverage that qualifies as “minimum essential coverage.” This plan or policy does provide minimal essential coverage.

Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits for a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides.

Language Access Services: Para obtener asistencia en Español, llame MCHCP al 800-701-8881.

To see examples of how this plan might cover costs for a sample medical situation, see the next page.

Questions: Call 1-800-487-0771 or visit us at www.mchcp.org. If you aren’t clear about any of the underlined terms used in this form, see the Glossary on Page 34. 12

Summary of Benefits & Coverage

MCHCP: Health Savings Account Plan

Coverage Period: 01/01/2016 — 12/31/2016 Coverage for: Individual + Family | Plan Type: High-Deductible

Coverage Examples

About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans.

This is not a cost estimator. Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care also will be different. See the next page for important information about these examples.

Having a baby

Managing type 2 diabetes

(normal delivery)

(routine maintenance of a well-controlled condition)

■■Amount owed to providers: $7,540 ■■Plan pays $3,490 ■■Patient pays $4,050 Sample care costs: Hospital charges (mother) Routine obstetric care Hospital charges (baby) Anesthesia Laboratory tests Pharmacy Radiology Vaccines, other preventive Total

$2,700 $2,100 $900 $900 $500 $200 $200 $40 $7,540

Patient pays: Deductible Copayments Coinsurance Limitations or exclusions Total

$3,300 $0 $600 $150 $4,050

■■Amount owed to providers: $5,400 ■■Plan pays $1,820 ■■Patient pays $3,580 Sample care costs: Pharmacy Medical Equipment and Supplies Office Visits and Procedures Education Laboratory tests Vaccines, other preventive Total

$2,900 $1,300 $700 $300 $100 $100 $5,400

Patient pays: Deductible Copayments Coinsurance Limitations or exclusions Total

$3,300 $0 $200 $80 $3,580

Questions: Call 1-800-487-0771 or visit us at www.mchcp.org. If you aren’t clear about any of the underlined terms used in this form, see the Glossary on Page 34. 2016 Benefit Guide

State Members

13

MCHCP: Health Savings Account Plan Coverage Examples

Coverage Period: 01/01/2016 — 12/31/2016 Coverage for: Individual + Family | Plan Type: High-Deductible

Questions and answers about the Coverage Examples: What are some of the assumptions behind Coverage Examples? • • •

• • • • •

Costs don’t include premiums. Costs are based on family coverage benefit levels. Sample care costs are based on national averages supplied to the U.S. Department of Health and Human Services, and are not specific to a particular geographic area or MCHCP. The patient’s condition was not an excluded or pre-existing condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from network providers. If the patient had received care from non-network providers, costs would have been higher.

What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited. Does the Coverage Example predict my own care needs?

No. Treatments shown are just examples.

The care you would receive for this condition could be different based on your doctor’s advice, your age, how serious your condition is, and many other factors.

Does the Coverage Example predict my future expenses?

No. Coverage Examples are not cost

estimators. You can’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows.

Questions: Call 1-800-487-0771 or visit us at www.mchcp.org. If you aren’t clear about any of the underlined terms used in this form, see the Glossary on Page 34. 14

Summary of Benefits & Coverage

Can I use Coverage Examples to compare plans?

Yes. When you look at the Summary of

Benefits & Coverage for other plans, you’ll find the same Coverage Examples. When you compare plans, check the “Patient Pays” box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans?

Yes. An important cost is the premium you

pay. Generally, the lower your premium, the more you’ll pay in out-of-pocket costs, such as copayments, deductibles and coinsurance. You also should consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses.

MCHCP: PPO 600 Plan

Coverage Period: 01/01/2016 — 12/31/2016

Summary of Benefits and Coverage: What This Plan Covers & What it Costs

Coverage for: Individual + Family | Plan Type: PPO

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.mchcp.org or by calling 800-487-0771. Important Questions What is the overall deductible?

Answers $600 individual/$1,200 family (network) Does not apply to preventive care $1,200 individual/$2,400 family (non-network)

Why This Matters: You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. The deductible starts over each year on Jan. 1. See the chart starting on Page 16 for how much you pay for covered services after you meet the deductible.

Are there other deductibles for specific services?

No.

Is there an out-of-pocket limit on my expenses?

Yes. $1,500 individual/$3,000 family (network medical) The out-of-pocket limit is the most you could pay during a coverage period $3,000 individual/$6,000 family (usually one year) for your share of the cost of covered services. This limit helps (non-network medical) $5,100 individual/$10,200 family you plan for health care expenses. (prescription)

What is not included in the out-of-pocket limit?

Even though you pay these expenses, they don’t count toward the Premium, balance bill charges, health care this plan doesn’t cover out-of-pocket limit.

You don’t have to meet deductibles for specific services, but see the chart starting on Page 16 for other costs for services this plan covers.

Is there an overall annual limit on what the plan No. pays?

The chart starting on Page 16 describes any limits on what the plan will pay for specific covered services, such as office visits.

Does this plan use a network of providers?

If you use a network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your network doctor or hospital may use a non-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on Page 16 for how this plan pays different kinds of providers.

Yes. Contact ESI, UMR or Aetna for a list of network providers.

Do I need a referral to see No. a specialist? Are there services this Yes. plan doesn’t cover?

You can see the specialist you choose without permission from this plan. Some of the services this plan doesn’t cover are listed on Page 20. See your policy or plan document for additional information about excluded services.

Questions: Call 1-800-487-0771 or visit us at www.mchcp.org. If you aren’t clear about any of the underlined terms used in this form, see the Glossary on Page 34. 2016 Benefit Guide

State Members

15

MCHCP: PPO 600 Plan

Coverage Period: 01/01/2016 — 12/31/2016

Summary of Benefits and Coverage: What This Plan Covers & What it Costs

Coverage for: Individual + Family | Plan Type: PPO

• Copayments are fixed dollar amounts (for example, $35 for a formulary brand prescription) you pay for covered health care, usually when you receive the service. • Coinsurance is your share of the cost of a covered service, calculated as a percent of the allowed amount for the service. You pay the deductible amount. Once the deductible has been met, you pay coinsurance. For example, if the health plan’s allowed amount for an overnight hospital stay is $1,000 and you’ve met your deductible, your coinsurance payment of 10% would be $100. If you haven’t met any of the deductible, you would pay the $600 deductible plus 10% coinsurance on the $400 balance, for a total of $640. • The amount the plan pays for covered services is based on the allowed amount. If a non-network provider charges more than the allowed amount, you may have to pay the difference. For example, if a non-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) • This plan encourages you to use network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event

Services You May Need

Your cost if you use a NonNetwork Provider

Primary care visit to treat an injury or illness

10% coinsurance

30% coinsurance

Specialist visit

10% coinsurance

30% coinsurance

None

10% coinsurance

30% coinsurance

Preventive care/screening/immunization

100% coverage

30% coinsurance

Non-network Immunizations: No charge from birth to 72 months

Diagnostic test (X-ray, blood work)

10% coinsurance

30% coinsurance

None

Imaging (CT/PET scans, MRIs)

10% coinsurance

30% coinsurance

PA required for some visits. If you fail to get PA, the service may not be covered.

Questions: Call 1-800-487-0771 or visit us at www.mchcp.org. If you aren’t clear about any of the underlined terms used in this form, see the Glossary on Page 34. 16

Limitations & Exceptions

Preauthorization (PA) required for some visits. If you fail to get PA, the service may not be covered.

If you visit a health care provider’s Other practitioner/chiropractor office visit office or clinic

If you have a test

Your cost if you use a Network Provider

Summary of Benefits & Coverage

MCHCP: PPO 600 Plan

Coverage Period: 01/01/2016 — 12/31/2016

Summary of Benefits and Coverage: What This Plan Covers & What it Costs Common Medical Event

Services You May Need

Generic drugs

Formulary brand drugs If you need drugs to treat your illness or condition

Coverage for: Individual + Family | Plan Type: PPO

Your cost if you use a Network Non-network Provider Provider $8/$16/$24 copayment for up to 31/60/90 days (retail) You pay full price $20 copayment of prescription and 61 to 90 days file claim. (mail order) You are reimbursed $35/$70/$105 the cost of the copayment for up drug based on the to 31/60/90 days network discounted (retail) amount, less $87.50 copayment the applicable 61 to 90 days copayment. (mail order) Medicare retirees do not have coverage for nonnetwork providers.

Non-formulary drugs

$100/$200/$300 copayment for up to 31/60/90 days (retail) $250 copayment 61 to 90 days (mail order)

Specialty drugs

$8 formulary generic copayment; $35 formulary No coverage brand copayment; $100 non-formulary brand copayment

Limitations & Exceptions Some prescriptions are subject to PA, quantity level limits or step therapy requirements. If you fail to follow requirements, the prescription may not be covered. Network: No charge for preventive formulary prescriptions and flu/shingles vaccinations If non-Medicare members purchase a brand-name drug when a generic is available, they pay the generic copayment plus the difference in the cost of the drugs.For Medicare retirees, after yearly out-of-pocket drug costs reach $4,850, the copayment amounts may be less than what is listed here. Specialty drugs must be filled through Accredo, with the exception of the first fill of drugs needed immediately. Members who go to a retail pharmacy will be charged the full discounted price.

Questions: Call 1-800-487-0771 or visit us at www.mchcp.org. If you aren’t clear about any of the underlined terms used in this form, see the Glossary on Page 34. 2016 Benefit Guide

State Members

17

MCHCP: PPO 600 Plan

Coverage Period: 01/01/2016 — 12/31/2016

Summary of Benefits and Coverage: What This Plan Covers & What it Costs Common Medical Event If you have outpatient surgery

Services You May Need

Coverage for: Individual + Family | Plan Type: PPO

Your cost if you use a Network Non-network Provider Provider

Facility fee (e.g., ambulatory surgery center) 10% coinsurance

30% coinsurance

Physician/surgeon fees

30% coinsurance

Emergency room services

10% coinsurance

Urgent care

If you have a hospital stay

$100 copayment plus 10% coinsurance

$100 copayment plus 10% coinsurance after network deductible

10% coinsurance

10% coinsurance after network deductible

PA required for non-emergent use of emergency medical transportation. If you fail to get PA, the service may not be covered.

10% coinsurance

10% coinsurance after network deductible

None

Facility fee (e.g., hospital room)

10% coinsurance

30% coinsurance

PA required except for an observation stay. If you fail to get PA, the service may not be covered.

Physician/surgeon fee

10% coinsurance

30% coinsurance

None

Questions: Call 1-800-487-0771 or visit us at www.mchcp.org. If you aren’t clear about any of the underlined terms used in this form, see the Glossary on Page 34. 18

PA required. If you fail to get PA, the service may not be covered. Copayment applies to the outof-pocket maximum, but not the deductible. The copayment is waived if admitted to the hospital or if the service is considered a “true emergency”. Medicare retirees will not owe copayments; they are only charged coinsurance.

If you need immediate medical attention Emergency medical transportation

Limitations & Exceptions

Summary of Benefits & Coverage

MCHCP: PPO 600 Plan

Coverage Period: 01/01/2016 — 12/31/2016

Summary of Benefits and Coverage: What This Plan Covers & What it Costs

Common Medical Event

Coverage for: Individual + Family | Plan Type: PPO

Your cost if you use a Services You May Need Network Non-network Provider Provider Mental/behavioral health outpatient services 10% coinsurance 30% coinsurance

If you have mental health, Mental/behavioral health inpatient services 10% coinsurance behavioral health, or substance abuse Substance abuse disorder outpatient services 10% coinsurance needs Substance abuse disorder inpatient services 10% coinsurance Prenatal and postnatal care

10% coinsurance

30% coinsurance 30% coinsurance 30% coinsurance

PA required for services provided at hospital except for an observation stay. If you fail to get PA, the service may not be covered.

30% coinsurance

No charge for routine prenatal care.

If you are pregnant

If you need help recovering or have other special health needs

Limitations & Exceptions

Delivery and all inpatient services

10% coinsurance

30% coinsurance

PA required for some services. If you fail to get PA, the service may not be covered.

Home health care

10% coinsurance

30% coinsurance

PA required. If you fail to get PA, the service may not be covered.

Rehabilitation services

10% coinsurance

30% coinsurance

Habilitation services

10% coinsurance

30% coinsurance

Skilled nursing care

Durable medical equipment

10% coinsurance

10% coinsurance

PA required for some services. If you fail to get PA, the service may not be covered.

30% coinsurance

Limited to 120 days per calendar year. PA required. If you fail to get PA, the service may not be covered.

30% coinsurance

PA required for some services. If you fail to get PA, the service may not be covered. No charge for breast pumps.

Questions: Call 1-800-487-0771 or visit us at www.mchcp.org. If you aren’t clear about any of the underlined terms used in this form, see the Glossary on Page 34. 2016 Benefit Guide

State Members

19

MCHCP: PPO 600 Plan

Coverage Period: 01/01/2016 — 12/31/2016

Summary of Benefits and Coverage: What This Plan Covers & What it Costs Common Medical Event If you need help recovering or have other special health needs

If you need dental or eye care

Coverage for: Individual + Family | Plan Type: PPO

Your cost if you use a Network Non-network Provider Provider

Services You May Need

Limitations & Exceptions

Hospice service

10% coinsurance

30% coinsurance

PA required. If you fail to get PA, the service may not be covered.

Eye exam

10% coinsurance

30% coinsurance

One per calendar year

Glasses

10% coinsurance

30% coinsurance

Coverage limited to fitting of eye glasses or contact lenses following cataract surgery

Dental checkup

Not covered

Not covered

None

Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.) • • • •

Acupuncture Cosmetic surgery Dental Care (adult) Exercise equipment

• • • •

Infertility treatment Long-term care Private-duty nursing Routine foot care

• Strive for Wellness® Health Center • Weight-loss programs

Other Covered Services (This isn’t a complete list. Check your policy for other covered services and your costs for these services.) • Bariatric surgery • Chiropractic care • Hearing aids

• Non-emergency care when traveling outside the U.S. covered as a non-network benefit • Routine eye care (adult)

Questions: Call 1-800-487-0771 or visit us at www.mchcp.org. If you aren’t clear about any of the underlined terms used in this form, see the Glossary on Page 34. 20

Summary of Benefits & Coverage

MCHCP: PPO 600 Plan

Summary of Benefits and Coverage: What This Plan Covers & What it Costs

Coverage Period: 01/01/2016 — 12/31/2016 Coverage for: Individual + Family | Plan Type: PPO

Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending on the circumstances, federal and state laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at 800-487-0771. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.

Your Appeal Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal. For questions about your rights, this notice, or assistance, you can contact UMR at 888-200-1167; Aetna at 800-245-0618; or ESI at 800-797-5754 (non-Medicare) or 866-544-6963 (Medicare). Additionally, a consumer assistance program can help you file your appeal. Contact the Missouri Department of Insurance, 301 W. High St., Room 530, Jefferson City, MO 65101; call 800-726-7390; visit www.insurance.mo.gov; or email [email protected].

Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have coverage that qualifies as “minimum essential coverage.” This plan or policy does provide minimal essential coverage.

Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits for a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides.

Language Access Services: Para obtener asistencia en Español, llame MCHCP al 800-701-8881. To see examples of how this plan might cover costs for a sample medical situation, see the next page.

Questions: Call 1-800-487-0771 or visit us at www.mchcp.org. If you aren’t clear about any of the underlined terms used in this form, see the Glossary on Page 34. 2016 Benefit Guide

State Members

21

MCHCP: PPO 600 Plan

Coverage Period: 01/01/2016 — 12/31/2016

Coverage Examples

About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans.

This is not a cost estimator. Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care also will be different. See the next page for important information about these examples.

Coverage for: Individual + Family | Plan Type: PPO

Having a baby

Managing type 2 diabetes

(normal delivery)

(routine maintenance of a well-controlled condition)

■■Amount owed to providers: $7,540 ■■Plan pays $6,180 ■■Patient pays $1,360 Sample care costs: Hospital charges (mother) Routine obstetric care Hospital charges (baby) Anesthesia Laboratory tests Pharmacy Radiology Vaccines, other preventive Total

$2,700 $2,100 $900 $900 $500 $200 $200 $40 $7,540

Patient pays: Deductible Copayments Coinsurance Limitations or exclusions Total

$600 $10 $600 $150 $1,360

Questions: Call 1-800-487-0771 or visit us at www.mchcp.org. If you aren’t clear about any of the underlined terms used in this form, see the Glossary on Page 34. 22

Summary of Benefits & Coverage

■■Amount owed to providers: $5,400 ■■Plan pays $4,220 ■■Patient pays $1,180 Sample care costs: Pharmacy Medical Equipment and Supplies Office Visits and Procedures Education Laboratory tests Vaccines, other preventive Total

$2,900 $1,300 $700 $300 $100 $100 $5,400

Patient pays: Deductible Copayments Coinsurance Limitations or exclusions Total

$500 $600 $0 $80 $1,180

MCHCP: PPO 600 Plan

Coverage Period: 01/01/2016 — 12/31/2016

Coverage Examples

Coverage for: Individual + Family | Plan Type: PPO

Questions and answers about the Coverage Examples: What are some of the assumptions behind Coverage Examples? • • •

• • • • •

Costs don’t include premiums. Costs are based on family coverage benefit levels. Sample care costs are based on national averages supplied to the U.S. Department of Health and Human Services, and are not specific to a particular geographic area or MCHCP. The patient’s condition was not an excluded or pre-existing condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from network providers. If the patient had received care from non-network providers, costs would have been higher.

What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited. Does the Coverage Example predict my own care needs?

No. Treatments shown are just examples.

The care you would receive for this condition could be different based on your doctor’s advice, your age, how serious your condition is, and many other factors.

Does the Coverage Example predict my future expenses?

No. Coverage Examples are not cost

estimators. You can’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows.

Can I use Coverage Examples to compare plans?

Yes. When you look at the Summary of

Benefits & Coverage for other plans, you’ll find the same Coverage Examples. When you compare plans, check the “Patient Pays” box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans?

Yes. An important cost is the premium you

pay. Generally, the lower your premium, the more you’ll pay in out-of-pocket costs, such as copayments, deductibles and coinsurance. You also should consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses.

Questions: Call 1-800-487-0771 or visit us at www.mchcp.org. If you aren’t clear about any of the underlined terms used in this form, see the Glossary on Page 34. 2016 Benefit Guide

State Members

23

MCHCP: PPO 300 Plan

Coverage Period: 01/01/2016 — 12/31/2016

Summary of Benefits and Coverage: What This Plan Covers & What it Costs

Coverage for: Individual + Family | Plan Type: PPO

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.mchcp.org or by calling 800-487-0771. Important Questions What is the overall deductible?

Answers $300 individual/$600 family (network) Does not apply to preventive care $600 individual/$1,200 family (non-network)

Why This Matters: You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. The deductible starts over each year on Jan. 1. See the chart starting on Page 25 for how much you pay for covered services after you meet the deductible.

Are there other deductibles for specific services?

No.

Is there an out-of-pocket limit on my expenses?

Yes. $1,500 individual/$3,000 family (network medical, includes The out-of-pocket limit is the most you could pay during a coverage period copayments) $3,000 individual/$6,000 family (usually one year) for your share of the cost of covered services. This limit helps (non-network medical) you plan for health care expenses. $5,100 individual/$10,200 family (prescription)

What is not included in Premium, balance bill charges, the out-of-pocket limit? health care this plan doesn’t cover Is there an overall annual limit on what the plan No. pays? Does this plan use a network of providers?

Yes. Contact ESI, UMR or Aetna for a list of network providers.

You don’t have to meet deductibles for specific services, but see the chart starting on Page 25 for other costs for services this plan covers.

Even though you pay these expenses, they don’t count toward the out-of-pocket limit. The chart starting on Page 25 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use a network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your network doctor or hospital may use a non-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on Page 25 for how this plan pays different kinds of providers.

Do I need a referral to see No. You can see the specialist you choose without permission from this plan. a specialist? Are there services this Some of the services this plan doesn’t cover are listed on Page 30. See your Yes. plan doesn’t cover? policy or plan document for additional information about excluded services. Questions: Call 1-800-487-0771 or visit us at www.mchcp.org. If you aren’t clear about any of the underlined terms used in this form, see the Glossary on Page 34. 24

Summary of Benefits & Coverage

MCHCP: PPO 300 Plan

Coverage Period: 01/01/2016 — 12/31/2016

Summary of Benefits and Coverage: What This Plan Covers & What it Costs

Coverage for: Individual + Family | Plan Type: PPO

• Copayments are fixed dollar amounts (for example, $25 for a primary care office visit) you pay for covered health care, usually when you receive the service. • Coinsurance is your share of the cost of a covered service, calculated as a percent of the allowed amount for the service. You pay the deductible amount. Once the deductible has been met, you pay coinsurance. For example, if the health plan’s allowed amount for an overnight hospital stay is $1,000 and you’ve met your deductible, your coinsurance payment of 10% would be $100. If you haven’t met any of the deductible, you would pay the $300 deductible plus 10% coinsurance on the $700 balance, for a total of $370. • The amount the plan pays for covered services is based on the allowed amount. If a non-network provider charges more than the allowed amount, you may have to pay the difference. For example, if a non-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) • This plan encourages you to use network providers by charging you lower deductibles and coinsurance amounts. Common Medical Event

Services You May Need

Your cost if you use a Network Non-network Provider Provider

Primary care visit to treat an injury or illness

$25 copayment and/ 30% coinsurance or 10% coinsurance

Specialist visit

$40 copayment and/ 30% coinsurance or 10% coinsurance

If you visit a health care provider’s office or clinic Other practitioner/chiropractor office visit

Chiropractor: $20 copayment and/ 30% coinsurance or 10% coinsurance

Preventive care/screening/immunization

100% coverage

30% coinsurance

Limitations & Exceptions Medicare retirees are not charged copayments. They will pay coinsurance for the visit. Copayment covers office visit only. Coinsurance will be applied to lab, X-ray or other services associated with the visit. Chiropractor copayment may be less than $20 if it is more than 50% of the total cost of the service. Preauthorization (PA) required for some visits. If you fail to get PA, the service may not be covered. Non-network Immunizations: No charge from birth to 72 months

Questions: Call 1-800-487-0771 or visit us at www.mchcp.org. If you aren’t clear about any of the underlined terms used in this form, see the Glossary on Page 34. 2016 Benefit Guide

State Members

25

MCHCP: PPO 300 Plan

Coverage Period: 01/01/2016 — 12/31/2016

Summary of Benefits and Coverage: What This Plan Covers & What it Costs Common Medical Event If you have a test

Coverage for: Individual + Family | Plan Type: PPO

Diagnostic test (X-ray, blood work)

Your cost if you use a Network Non-network Provider Provider 10% coinsurance 30% coinsurance

Imaging (CT/PET scans, MRIs)

10% coinsurance

Generic drugs

$8/$16/$24 copayment for up to 31/60/90 days (retail) $20 copayment 61 to 90 days (mail order)

Services You May Need

If you need drugs to treat your Formulary brand drugs illness or condition

Non-formulary drugs

$35/$70/$105 copayment for up to 31/60/90 days (retail) $87.50 copayment 61 to 90 days (mail order) $100/$200/$300 copayment for up to 31/60/90 days (retail) $250 copayment 61 to 90 days (mail order)

30% coinsurance

You pay full price of prescription and file claim.

Summary of Benefits & Coverage

None PA required. If you fail to get PA, the service may not be covered. Some prescriptions are subject to PA, quantity level limits or step therapy requirements. If you fail to follow requirements, the prescription may not be covered.

Network: No charge for You are reimbursed preventive formulary prescriptions and flu/shingles the cost of the vaccinations drug based on the network discounted If non-Medicare members amount, less purchase a brand-name drug the applicable when a generic is available, they copayment. pay the generic copayment plus the difference in the cost of the Medicare retirees drugs. do not have For Medicare retirees, after yearly coverage for nonout-of-pocket drug costs reach network providers. $4,850, the copayment amounts may be less than what is listed here.

Questions: Call 1-800-487-0771 or visit us at www.mchcp.org. If you aren’t clear about any of the underlined terms used in this form, see the Glossary on Page 34. 26

Limitations & Exceptions

MCHCP: PPO 300 Plan

Coverage Period: 01/01/2016 — 12/31/2016

Summary of Benefits and Coverage: What This Plan Covers & What it Costs Common Medical Event

Services You May Need

If you need drugs to treat your Specialty drugs illness or condition

If you have outpatient surgery

Coverage for: Individual + Family | Plan Type: PPO

Your cost if you use a Network Non-network Provider Provider $8 formulary generic copayment; $35 formulary No coverage brand copayment; $100 non-formulary brand copayment

Facility fee (e.g., ambulatory surgery center) 10% coinsurance

30% coinsurance

Physician/surgeon fees

30% coinsurance

10% coinsurance

Emergency room services

$100 copayment plus 10% coinsurance

$100 copayment plus 10% coinsurance after network deductible

Emergency medical transportation

10% coinsurance

10% coinsurance after network deductible

If you need immediate medical attention

Limitations & Exceptions Specialty drugs must be filled through Accredo, with the exception of the first fill of drugs needed immediately. Members who go to a retail pharmacy will be charged the full discounted price. PA required. If you fail to get PA, the service may not be covered. Copayment applies to the outof-pocket maximum, but not the deductible. The copayment is waived if admitted to the hospital or if the service is considered a “true emergency”. Medicare retirees are not charged copayments; they are only charged coinsurance. PA required for non-emergent use of emergency medical transportation. If you fail to get PA, the service may not be covered.

Questions: Call 1-800-487-0771 or visit us at www.mchcp.org. If you aren’t clear about any of the underlined terms used in this form, see the Glossary on Page 34. 2016 Benefit Guide

State Members

27

MCHCP: PPO 300 Plan

Coverage Period: 01/01/2016 — 12/31/2016

Summary of Benefits and Coverage: What This Plan Covers & What it Costs Common Medical Event

Services You May Need

If you need immediate medical Urgent care attention

If you have a hospital stay

Facility fee (e.g., hospital room)

Coverage for: Individual + Family | Plan Type: PPO

Your cost if you use a Network Non-network Provider Provider

Copayment covers office visit only. Coinsurance will be applied $50 copayment and/ to lab, X-ray or other services $50 copayment and/ or 10% coinsurance associated with the visit. or 10% coinsurance after network Medicare retirees are not charged deductible copayments; they are charged coinsurance. PA required except for an observation stay. If you fail to 10% coinsurance 30% coinsurance get PA, the service may not be covered.

Physician/surgeon fee

10% coinsurance

Mental/behavioral health outpatient services

$25 copayment and/ 30% coinsurance or 10% coinsurance

30% coinsurance

If you have Mental/behavioral health inpatient services 10% coinsurance 30% coinsurance mental health, behavioral health, $25 copayment and/ 30% coinsurance or substance abuse Substance abuse disorder outpatient services or 10% coinsurance needs Substance abuse disorder inpatient services

10% coinsurance

30% coinsurance

Questions: Call 1-800-487-0771 or visit us at www.mchcp.org. If you aren’t clear about any of the underlined terms used in this form, see the Glossary on Page 34. 28

Summary of Benefits & Coverage

Limitations & Exceptions

None Copayment covers office visit only. Coinsurance will be applied to lab, X-ray or other services associated with the visit. Medicare retirees are not charged copayments; they are charged coinsurance. PA required for services provided at hospital except for an observation stay.

MCHCP: PPO 300 Plan

Coverage Period: 01/01/2016 — 12/31/2016

Summary of Benefits and Coverage: What This Plan Covers & What it Costs Common Medical Event

Services You May Need

Coverage for: Individual + Family | Plan Type: PPO

Your cost if you use a Network Non-network Provider Provider

Prenatal and postnatal care

10% coinsurance

30% coinsurance

No charge for routine prenatal care

Delivery and all inpatient services

10% coinsurance

30% coinsurance

PA required for some services. If you fail to get PA, the service may not be covered. PA required. If you fail to get PA, the service may not be covered.

If you are pregnant

If you need help recovering or have other special health needs

Limitations & Exceptions

Home health care

10% coinsurance

30% coinsurance

Rehabilitation services

10% coinsurance

30% coinsurance

Habilitation services

10% coinsurance

30% coinsurance

Skilled nursing care

Durable medical equipment

Hospice service

10% coinsurance

10% coinsurance

10% coinsurance

PA required for some services. If you fail to get PA, the service may not be covered.

30% coinsurance

Limited to 120 days per calendar year. PA required. If you fail to get PA, the service may not be covered.

30% coinsurance

PA required for some services. If you fail to get PA, the service may not be covered. No charge for breast pumps.

30% coinsurance

PA required. If you fail to get PA, the service may not be covered.

Questions: Call 1-800-487-0771 or visit us at www.mchcp.org. If you aren’t clear about any of the underlined terms used in this form, see the Glossary on Page 34. 2016 Benefit Guide

State Members

29

MCHCP: PPO 300 Plan

Coverage Period: 01/01/2016 — 12/31/2016

Summary of Benefits and Coverage: What This Plan Covers & What it Costs Common Medical Event

Coverage for: Individual + Family | Plan Type: PPO

Your cost if you use a Network Non-network Provider Provider

Services You May Need

$40 copayment and/ 30% coinsurance or 10% coinsurance

Eye exam If you need dental or eye care

Limitations & Exceptions Copayment covers office visit only. Coinsurance will be applied to lab, X-ray or other services associated with the visit. Medicare retirees are not charged a copayment; they are charged coinsurance. One per calendar year

Glasses

10% coinsurance

30% coinsurance

Coverage limited to fitting of eye glasses or contact lenses following cataract surgery

Dental checkup

Not covered

Not covered

None

Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.) • • • •

Acupuncture Cosmetic surgery Dental Care (adult) Exercise equipment

• • • •

Infertility treatment Long-term care Private-duty nursing Routine foot care

• Strive for Wellness® Health Center • Weight-loss programs

Other Covered Services (This isn’t a complete list. Check your policy for other covered services and your costs for these services.) • Bariatric surgery • Chiropractic care • Hearing aids

• Non-emergency care when traveling outside the U.S. covered as a non-network benefit • Routine eye care (adult)

Questions: Call 1-800-487-0771 or visit us at www.mchcp.org. If you aren’t clear about any of the underlined terms used in this form, see the Glossary on Page 34. 30

Summary of Benefits & Coverage

MCHCP: PPO 300 Plan

Summary of Benefits and Coverage: What This Plan Covers & What it Costs

Coverage Period: 01/01/2016 — 12/31/2016 Coverage for: Individual + Family | Plan Type: PPO

Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending on the circumstances, federal and state laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at 800-487-0771. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.

Your Appeal Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal. For questions about your rights, this notice, or assistance, you can contact UMR at 888-200-1167; Aetna at 800-245-0618; or ESI at 800-797-5754 (non-Medicare) or 866-544-6963 (Medicare). Additionally, a consumer assistance program can help you file your appeal. Contact the Missouri Department of Insurance, 301 W. High St., Room 530, Jefferson City, MO 65101; call 800-726-7390; visit www.insurance.mo.gov; or email [email protected].

Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have coverage that qualifies as “minimum essential coverage.” This plan or policy does provide minimal essential coverage.

Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits for a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides.

Language Access Services: Para obtener asistencia en Español, llame MCHCP al 800-701-8881. To see examples of how this plan might cover costs for a sample medical situation, see the next page.

Questions: Call 1-800-487-0771 or visit us at www.mchcp.org. If you aren’t clear about any of the underlined terms used in this form, see the Glossary on Page 34. 2016 Benefit Guide

State Members

31

MCHCP: PPO 300 Plan

Coverage Period: 01/01/2016 — 12/31/2016

Coverage Examples

About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans.

This is not a cost estimator. Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care also will be different. See the next page for important information about these examples.

Coverage for: Individual + Family | Plan Type: PPO

Having a baby

Managing type 2 diabetes

(normal delivery)

(routine maintenance of a well-controlled condition)

■■Amount owed to providers: $7,540 ■■Plan pays $6,480 ■■Patient pays $1,060 Sample care costs: Hospital charges (mother) Routine obstetric care Hospital charges (baby) Anesthesia Laboratory tests Pharmacy Radiology Vaccines, other preventive Total

$2,700 $2,100 $900 $900 $500 $200 $200 $40 $7,540

Patient pays: Deductible Copayments Coinsurance Limitations or exclusions Total

$300 $10 $600 $150 $1,060

Questions: Call 1-800-487-0771 or visit us at www.mchcp.org. If you aren’t clear about any of the underlined terms used in this form, see the Glossary on Page 34. 32

Summary of Benefits & Coverage

■■Amount owed to providers: $5,400 ■■Plan pays $4,220 ■■Patient pays $1,080 Sample care costs: Pharmacy Medical equipment & supplies Office visits & procedures Education Laboratory tests Vaccines, other preventive Total

$2,900 $1,300 $700 $300 $100 $100 $5,400

Patient pays: Deductible Copayments Coinsurance Limitations or exclusions Total

$300 $700 $0 $80 $1,080

MCHCP: PPO 300 Plan

Coverage Period: 01/01/2016 — 12/31/2016

Coverage Examples

Coverage for: Individual + Family | Plan Type: PPO

Questions and answers about the Coverage Examples: What are some of the assumptions behind Coverage Examples? • • •

• • • • •

Costs don’t include premiums. Costs are based on family coverage benefit levels. Sample care costs are based on national averages supplied to the U.S. Department of Health and Human Services, and are not specific to a particular geographic area or MCHCP. The patient’s condition was not an excluded or pre-existing condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from network providers. If the patient had received care from non-network providers, costs would have been higher.

What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited. Does the Coverage Example predict my own care needs?

No. Treatments shown are just examples.

The care you would receive for this condition could be different based on your doctor’s advice, your age, how serious your condition is, and many other factors.

Does the Coverage Example predict my future expenses?

No. Coverage Examples are not cost

estimators. You can’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows.

Can I use Coverage Examples to compare plans?

Yes. When you look at the Summary of

Benefits & Coverage for other plans, you’ll find the same Coverage Examples. When you compare plans, check the “Patient Pays” box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans?

Yes. An important cost is the premium you

pay. Generally, the lower your premium, the more you’ll pay in out-of-pocket costs, such as copayments, deductibles and coinsurance. You also should consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses.

Questions: Call 1-800-487-0771 or visit us at www.mchcp.org. If you aren’t clear about any of the underlined terms used in this form, see the Glossary on Page 34. 2016 Benefit Guide

State Members

33

34

Summary of Benefits & Coverage

2016 Benefit Guide

State Members

35

36

Summary of Benefits & Coverage

2016 Benefit Guide

State Members

37

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Section 2

Coverage Information

Medical Plan Overview Health Savings Account Plan Overview Health Savings Account Information PPO 600 Plan Overview PPO 300 Plan Overview Non-Medicare Prescription Drug Plan Medicare Prescription Drug Plan TRICARE Supplement Plan Dental Plan Vision Plan ® Strive for Wellness Program and Incentives ® Strive for Wellness Health Center Employee Assistance Program Disease Management Services Women’s Health and Cancer Rights Notice

Medical & Pharmacy Plan Overview Benefit

Health Savings Account Plan (HSA Plan) Through UMR (All Regions) or Aetna (Southwest & South Central Regions Only)1 Network

Non-Network

You pay the deductible and coinsurance amounts until you reach the out-of-pocket maximum. Your HSA can be used to help pay medical and prescription expenses.

Plan Description Individual

$1,650

$4,000

Family

$3,300

$8,000

Medical Out-of-Pocket Maximum

Individual

$3,300

$5,000

Family

$6,600

$10,000

Prescription Out-of-Pocket Maximum

Individual

Deductible

Annual Health Savings Account Contribution Preventive Services

Family Active members only Annual physical exams, Immunizations Age-specific screenings

Combined with medical Individual Coverage: $300 Family Coverage: $600 MCHCP pays 100%

40% coinsurance

Office Visit

20% coinsurance

40% coinsurance

Urgent Care

20% coinsurance

20% coinsurance

Emergency Room

20% coinsurance

20% coinsurance

Hospital (Inpatient)

20% coinsurance

40% coinsurance

Lab and X-ray

20% coinsurance

40% coinsurance

Surgery

20% coinsurance

40% coinsurance

Generic: 10% coinsurance Brand: 20% coinsurance Non-formulary: 40% coinsurance

Generic and Brand: 40% coinsurance Non-Formulary: 50% coinsurance

Prescription Drugs

Deductible: The annual amount a member must pay before the plan begins to pay for covered medical services. Coinsurance: The percentage of a medical bill that a member must pay after the deductible is met. Out-of-Pocket Maximum: The maximum amount a member must pay before the plan pays 100 percent of covered services for the rest of the year.

40

Coverage Information

Medical & Pharmacy Plan Overview PPO 600 Plan Through UMR (All Regions) or Aetna (Southwest & South Central Regions Only)1

PPO 300 Plan Through UMR (All Regions) or Aetna (Southwest & South Central Regions Only)1

Network

Non-Network

Network

Non-Network

You pay the deductible and coinsurance amounts until you reach the out-of-pocket maximum.

You pay a higher deductible and coinsurance amounts until you reach the out-of-pocket maximum.

You pay the deductible and coinsurance amounts until you reach the out-of-pocket maximum.

You pay a higher deductible and coinsurance amounts until you reach the out-of-pocket maximum.

   $600

$1,200

   $300

  $600

 $1,200

$2,400

   $600

$1,200

 $1,500

$3,000

 $1,500

$3,000

 $3,000

$6,000

 $3,000

$6,000

 $5,100

 $5,100

$10,200

$10,200

N/A

N/A

MCHCP pays 100%

30% coinsurance

MCHCP pays 100%

30% coinsurance

10% coinsurance

30% coinsurance

Primary Care or Mental Health: $25 copayment Specialist: $40 copayment Chiropractor: $20 copayment or 50% of total cost of service, whichever is less

30% coinsurance

10% coinsurance

10% coinsurance

$50 copayment

$50 copayment

$100 copayment plus 10% coinsurance

$100 copayment plus 10% coinsurance

$100 copayment plus 10% coinsurance

$100 copayment plus 10% coinsurance

10% coinsurance

30% coinsurance

10% coinsurance

30% coinsurance

10% coinsurance

30% coinsurance

10% coinsurance

30% coinsurance

10% coinsurance

30% coinsurance

10% coinsurance

30% coinsurance

Days’ Supply

Generic

Brand

Non-Formulary

Prescription Drug PPO Plan Copayments apply when filled at a network pharmacy.

1 to 31 days

 $8

 $35

$100

32 to 60 days

$16

  $70

$200

*See page 48 for non-network pharmacy benefits.

61 to 90 days (home delivery)

$20

 $87.50

$250

61 to 90 days (retail)

$24

$105

$300

1. Southwest Region Counties: Barry, Barton, Cedar, Christian, Dade, Dallas, Greene, Hickory, Jasper, Laclede, Lawrence, McDonald, Newton, Polk, St. Clair, Stone, Taney, Vernon and Webster. South Central Region Counties: Douglas, Howell, Oregon, Ozark, Shannon, Texas and Wright. 2016 Benefit Guide

State Members

41

UMR Aetna UMR Available in all regions www.umr.com 888-200-1167

Aetna Southwest & South Central regions only www.aetna.com 800-245-0618

ID Cards Issued

Go to Page 6 to review the HSA Plan Summary of Benefits and Coverage

Health Savings Account Plan Overview Health Savings Account Plan

Network

Deductible

To enroll in the Health Savings Account Plan (HSA Plan), you cannot be covered by another medical plan unless it is a qualified high deductible health plan, and cannot be claimed as a dependent on someone else’s tax return.

Network providers have contracts with your plan that limit the amount they can bill you for services. Services from these providers cost less than services from non-network providers.

The plan will not pay for medical and prescription drug expenses until the entire deductible is met. If two or more family members are covered, the family deductible must be met before the plan begins claims payment for any family member. Premiums, balance-billed charges or non-covered services do not apply to the deductible.

You do not qualify if you are also enrolled in: • Medicare • TRICARE • Health care flexible spending account (FSA) • Health Reimbursement Account (HRA) • Veteran’s benefits that have been used in the past three months You qualify for this plan even if you are covered by any of the following: • • • • • •

Drug discount cards Accident insurance Disability insurance Dental insurance Vision insurance Long-term care insurance

Prescription Drug Plan When you enroll in an MCHCP medical plan, you are automatically enrolled in a prescription drug plan. You will receive separate ID cards from the prescription benefit administrator. To learn more about the prescription drug plan, go to page 48.

Preventive Care Preventive care — such as preventive exams, vaccinations and age-specific screenings — is covered at 100 percent by MCHCP, regardless of whether you have met your deductible.

42

Coverage Information

Present your ID card at the time of service. Network providers will submit the claim for you. Non-network providers may request full payment at the time of service, and you may need to file the claim with your plan to be reimbursed. MCHCP limits the amount it will pay to non-network medical providers to 80 percent of usual and customary charges. Non-network providers may bill you the difference between the amount MCHCP pays and the billed charge.

You will owe the allowed amount — the maximum a provider may bill you for a service, based on the provider’s agreement with the plan — until you have met the deductible. After you have paid the deductible amount, the plan will begin paying a percentage of the fees charged by providers and pharmacies for covered services.

Billing

Coinsurance

After the claim is processed, you will receive an explanation of benefits (EOB) from your medical plan. The EOB is not a bill. It details the service received, the amount covered by the plan and the amount the provider may bill you. The EOB also lists the deductibles and out-of-pocket maximums for your plan. Keep the EOB for your records, so you can keep track of your deductible and out-of-pocket balances. After you receive the EOB, you can expect a bill from the provider. The amount billed should match the amount listed on the EOB. Send payment to the provider. Sometimes you may receive a bill from your provider before you receive the EOB. If this occurs, contact the medical plan before you pay your provider to ensure you’re paying the proper amount.

Once the deductible is met, you will pay a percentage of the fees charged by providers and pharmacies for covered services. This is your coinsurance. You pay the coinsurance until you reach the entire out-of-pocket maximum for the year.

Out-of-Pocket Maximum The amounts you pay toward your deductible and for coinsurance are applied to the out-of-pocket maximum. The plan will begin paying 100 percent of covered services once the entire out-of-pocket maximum amount is met. If two or more family members are covered, the family outof-pocket maximum must be met before the plan begins paying 100 percent of covered services. Premiums, balance-billed charges or non-covered services do not apply to the out-of-pocket maximum.

Central Bank Website mohsa.centralbank.net

Phone 573-634-1243 or 877-554-5535

Availability Available in all regions to employees with a Health Savings Account Plan I was in a PPO Plan in 2015 and will have a balance in my health care flexible spending account (FSA) on Dec. 31, 2015. If I enroll in the HSA Plan for 2016, will I get a contribution in my health savings account in January? If you have a balance in your health care FSA on Dec. 31, 2015, you will be in a grace period during the first 2 ½ months of 2016. The grace period provision of your health care FSA provides that any remaining balance on Dec. 31, 2015, is not forfeited and those funds can be used for qualified expenses with a date of service through March 15, 2016. You will have until April 15, 2016, to claim those expenses. However, you cannot be in a health care FSA and be eligible for an HSA at the same time. Therefore, you will not be eligible to have HSA contributions until April 2016. MCHCP will make its annual contribution to your HSA in April rather than in January. This may affect the maximum annual contribution you may make to your health savings account. File your claim(s) early to ensure a zero balance. If you have a zero balance in your health care FSA on Dec. 31, 2015, you will be eligible to receive HSA contributions from MCHCP in Jan. 2016.

Health Savings Account Information HSAs allow you to enjoy tax reductions and more affordable health insurance premiums. Among the benefits: • Contributions are 100 percent tax deductible, and HSA contributions made by MCHCP are excluded from your gross income • HSA balance rolls over from year to year. You own the funds, and they go with you at retirement or with a job change • Tax-deferred interest or earnings on the HSA • Funds can be used tax-free for qualified medical expenses MCHCP will contribute to the HSAs of active employees enrolled in the HSA Plan. To receive this contribution and make voluntary pre-tax payroll contributions as an active state employee, you must open an HSA with MCHCP’s partner bank and be

eligible for the contribution on the date it is made. The IRS establishes a maximum annual contribution amount each year, but there is no limit on the balance in the HSA. Once your account is open, you will receive: • A debit card • Access to your account using online banking • A variety of investment options, including self-directing your funds with an investment representative You can use your HSA funds to pay for qualified medical expenses. IRS Publications 969 and 502 explain the rules for how you can use your HSA funds. For example, non-prescription medicines (other than insulin) are not considered qualified medical expenses for HSA purposes. A medicine or drug

will be a qualified medical expense for HSA purposes only if the medicine or drug:

1. Requires a prescription, 2. Is available without a prescription (an over-the-counter medicine or drug) and you get a prescription for it, or 3. Is insulin. The IRS family contribution limit is based on your family as reported to the IRS on your federal tax return and applies regardless of whether two state employees are married and eligible for the HSA. For example, if one employee is covering a dependent and the other employee is covered as subscriber-only, the maximum contribution for the entire family is $6,750.

2016 HSA Annual Contribution Limits Subscriber Only

Subscriber/Spouse, Subscriber Child(ren) or Subscriber/Family

IRS Contribution Limit1

$3,350

$6,750

IRS Contribution Limit Age 55 and older

$4,350

$7,750

MCHCP Contribution Active employees

$300

$600

You may contribute

$3,050

$6,150

You may contribute Age 55 and older

$4,050

$7,150

Contributions

1

1. Contribution rules for HSAs are complex. You should consult your tax advisor about your individual circumstances and the maximum contribution you can make. MCHCP does not provide individual tax advice. 2016 Benefit Guide

State Members

43

UMR Aetna UMR Available in all regions www.umr.com 888-200-1167

Aetna Southwest & South Central regions only www.aetna.com 800-245-0618

ID Cards Issued

Go to Page 15 to review the PPO 600 Plan Summary of Benefits and Coverage

PPO 600 Plan Overview PPO plans offer members the following: • Freedom to choose care from any primary care provider, specialist or hospital • No referrals are needed to make appointments with specialists • Non-network benefits are available

Prescription Drug Plan When you enroll in an MCHCP medical plan, you are automatically enrolled in a prescription drug plan. To learn more about the prescription drug plan, go to page 48. You will receive separate ID cards from the prescription benefit administrator.

Preventive Care Preventive care — such as preventive exams, vaccinations and age-specific screenings — is covered at 100 percent by MCHCP, regardless of whether you have met your deductible.

Network Network providers have contracts with your plan that limit the amount they can bill you for services. Services from these providers cost less than services from non-network providers. Present your ID card at the time of service. Network providers will submit the claim for you. Non-network providers may request full payment at the time of service, and you may need to file the claim with your plan to be reimbursed.

44

Coverage Information

MCHCP limits the amount it will pay to non-network medical providers to 80 percent of usual and customary charges. Non-network providers may bill you the difference between the amount MCHCP pays and the billed charge.

Billing After the claim is processed, you will receive an explanation of benefits (EOB) from your medical plan. The EOB is not a bill. It details the service received, the amount covered by the plan and the amount the provider may bill you. The EOB also lists the deductibles and out-of-pocket maximums for your plan. Keep the EOB for your records, so you can keep track of your deductible and out-ofpocket balances. After you receive the EOB, you can expect a bill from the provider. The amount billed should match the amount listed on the EOB. Send payment to the provider. Sometimes you may receive a bill from your provider before you receive the EOB. If this occurs, contact the medical plan before you pay your provider to ensure you’re paying the proper amount.

Deductible You will owe the allowed amount — the maximum a provider may bill you for a service, based on the provider’s agreement with the plan — until you have met the deductible for your plan.

Premiums, copayments, balance-billed charges or non-covered services do not apply to the deductible. If two or more family members are covered and one family member reaches the individual deductible, the medical plan begins paying a percentage of the fees for covered services charged by providers for the individual. No more charges incurred by the individual may be used to satisfy the family deductible. If one or more additional family members meet the individual deductible, the medical plan begins paying a percentage of the fees for covered services charged by providers for the entire family.

Coinsurance Once the deductible is met, you will pay a percentage of the fees charged by providers for covered services. This is your coinsurance. You pay the coinsurance until you reach the entire out-of-pocket maximum for the year.

Copayments You have a copayment for emergency room (ER) services. Copayments do not count toward your deductible. The ER copayment is in addition to your deductible and coinsurance that you may also owe for the ER service. The copayment is waived if you are admitted to the hospital or the services are considered by your plan

UMR Aetna UMR Available in all regions www.umr.com 888-200-1167

Aetna Southwest & South Central regions only www.aetna.com 800-245-0618

ID Cards Issued

Go to Page 15 to review the PPO 600 Plan Summary of Benefits and Coverage

PPO 600 Plan Overview to be a “true emergency.” Even if the copayment is waived, you will still have to pay any deductible or coinsurance that may be owed for the ER service. You will pay a copayment until you meet your out-of-pocket maximum for the year. Go to Page 48 to learn about copayments for pharmacy services.

Out-of-Pocket Maximum The amounts you pay for your deductible, ER copayment and coinsurance are applied to the outof-pocket maximum. The plan will begin paying 100 percent of covered services once the entire out-of-pocket maximum amount is met. Premiums, balance-billed charges or non-covered services do not apply to the out-ofpocket maximum. If two or more family members are covered and one family member reaches the individual out-ofpocket maximum, the medical plan begins paying 100 percent covered services charged by providers for the individual. If one or more additional family members meet the individual out-ofpocket maximum, the medical plan begins paying 100 percent for covered services charged by providers for the entire family. Go to Page 48 to learn about the outof-pocket maximum for pharmacy services.

2016 Benefit Guide

State Members

45

UMR Aetna UMR Available in all regions www.umr.com 888-200-1167

Aetna Southwest & South Central regions only www.aetna.com 800-245-0618

ID Cards Issued

Go to Page 24 to review the PPO 300 Plan Summary of Benefits and Coverage

PPO 300 Plan Overview PPO plans offer members the following: • Freedom to choose care from any primary care provider, specialist or hospital • No referrals are needed to make appointments with specialists • Non-network benefits are available

Prescription Drug Plan When you enroll in an MCHCP medical plan, you are automatically enrolled in a prescription drug plan. To learn more about the prescription drug plan, go to page 48. You will receive separate ID cards from the prescription benefit administrator.

Preventive Care Preventive care — such as preventive exams, vaccinations and age-specific screenings — is covered at 100 percent by MCHCP, regardless of whether you have met your deductible.

Network Network providers have contracts with your plan that limit the amount they can bill you for services. Services from these providers cost less than services from non-network providers. Present your ID card at the time of service. Network providers will submit the claim for you. Non-network providers may request full payment at the time of service, and you may need to file the claim with your plan to be reimbursed. MCHCP limits the amount it will pay to non-network medical providers to 80 percent of usual and customary charges. Non-network providers may

46

Coverage Information

bill you the difference between the amount MCHCP pays and the billed charge.

Billing After the claim is processed, you will receive an explanation of benefits (EOB) from your medical plan. The EOB is not a bill. It details the service received, the amount covered by the plan and the amount the provider may bill you. The EOB also lists the deductibles and out-of-pocket maximums for your plan. Keep the EOB for your records, so you can keep track of your deductible and out-ofpocket balances. After you receive the EOB, you can expect a bill from the provider. The amount billed should match the amount listed on the EOB. Send payment to the provider. Sometimes you may receive a bill from your provider before you receive the EOB. If this occurs, contact the medical plan before you pay your provider to ensure you’re paying the proper amount.

Deductible You will owe the allowed amount — the maximum a provider may bill you for a service, based on the provider’s agreement with the plan — until you have met the deductible for your plan. Premiums, copayments, balance-billed charges or non-covered services do not apply to the deductible. If two or more family members are covered and one family member reaches the individual deductible,

the medical plan begins paying a percentage of the fees for covered services charged by providers for the individual. No more charges incurred by the individual may be used to satisfy the family deductible. If one or more additional family members meet the individual deductible or out-of-pocket maximum, the medical plan begins paying a percentage of the fees for covered services charged by providers for the entire family.

Coinsurance Once the deductible is met, you will pay a percentage of the fees charged by providers for covered services. This is your coinsurance. You pay the coinsurance until you reach the entire out-of-pocket maximum for the year.

Copayments You have a copayments for office visits, urgent care and emergency room (ER) services. Copayments do not count toward your deductible. The ER copayment is in addition to your deductible and coinsurance that you may also owe for the ER service. The ER copayment is waived if you are admitted to the hospital or the services are considered by your plan to be a “true emergency.” Even if the copayment is waived, you will still have to pay any deductible or coinsurance that may be owed for the ER service. You will pay copayments until you meet your out-of-pocket maximum for the year.

UMR Aetna UMR Available in all regions www.umr.com 888-200-1167

Aetna Southwest & South Central regions only www.aetna.com 800-245-0618

ID Cards Issued

Go to Page 24 to review the PPO 300 Plan Summary of Benefits and Coverage

PPO 300 Plan Overview Go to Page 48 to learn about copayments for pharmacy services.

Out-of-Pocket Maximum The amounts you pay for your deductible, copayments and coinsurance are applied to the outof-pocket maximum. The plan will begin paying 100 percent of covered services once the entire out-of-pocket maximum amount is met. Premiums, balance-billed charges or non-covered services do not apply to the out-ofpocket maximum. If two or more family members are covered and one family member reaches the individual out-ofpocket maximum, the medical plan begins paying 100 percent covered services charged by providers for the individual. If one or more additional family members meet the individual out-ofpocket maximum, the medical plan begins paying 100 percent for covered services charged by providers for the entire family. Go to Page 48 to learn about the outof-pocket maximum for pharmacy services.

2016 Benefit Guide

State Members

47

Express Scripts, Inc. Website www.express-scripts.com

Phone 800-797-5754

Availability Available to non-Medicare members in all regions

ID Cards Issued

Non-Medicare Prescription Drug Plan When you enroll in an MCHCP medical plan, you are automatically enrolled in a prescription drug plan. The non-Medicare prescription copayment and coinsurance information may be found in the Summary of Benefits & Coverage section of this guide. Express Scripts, Inc. (ESI) administers the prescription drug benefits. This plan maintains a broad choice of covered drugs and promotes the use of generic drugs. ESI maintains a nationwide pharmacy network. You can fill a prescription from any provider at a network pharmacy or through ESI’s home delivery program. For additional information on the formulary, contact ESI.

Drug Formulary The drug formulary is a list of Food and Drug Administration (FDA)approved prescription drugs and supplies developed by ESI. The formulary is updated on a semiannual basis, but it can change throughout the year. Generic drugs, approved by the FDA, are proven to provide the same reliable, effective treatment as brandname versions, but at lower prices. If a generic drug is not available, talk to your doctor about taking a lower-cost brand-name drug on the formulary. If you purchase a brand drug when a generic is available, you will pay the generic copayment plus the difference in the cost of the drugs unless your

48

Coverage Information

health care provider has indicated you must take the brand drug. Most, but not all, prescribed drugs that are not on the formulary may still be covered at a higher copayment level.

Retail (Network) You may obtain up to a 31-day supply of a non-specialty prescription at a retail pharmacy. Select pharmacies provide up to a 90-day supply of some medication.

Retail (Non-Network) For prescriptions filled at a nonnetwork pharmacy, you must: • Pay the full price of the prescription • Request a claim form from ESI or MCHCP, or download a copy from ESI or MCHCP’s website • File the claim with ESI within 365 days of when you filled the prescription. ESI reimburses the cost of the drug at the network discounted amount, less the applicable copayment or coinsurance • Attach a prescription receipt or label from the pharmacy to the claim form. Patient history printouts from the pharmacy are acceptable but must be signed by the pharmacist. Cash register receipts are acceptable only for diabetic supplies.

Home Delivery Option The ESI home delivery program provides convenient home or office

delivery of maintenance medications while saving you money. Maintenance medications are taken on a longterm basis and are available in more economical quantities through the home delivery program. Members must decide how they want to get their maintenance prescriptions filled: either by a retail pharmacy or home delivery. You may fill a maintenance prescription twice at a retail pharmacy while you decide. If you do not contact ESI and notify them of your decision by the third fill of a prescription, you will pay the full allowed amount for the prescription.

100% Coverage There are certain medications that MCHCP will pay the complete cost, when accompanied by a prescription and filled at a network pharmacy: • Formulary birth control (nonformulary may be covered if criteria is met) • Generic vitamin D, 1,000 IU or less • Over-the-counter (OTC) nicotine replacement therapy • Formulary tobacco cessation for members aged 18 and over • Generic Tamoxifen, generic Raloxifene, and brand Soltamox (Tamoxifen liquid for patients who have difficulty swallowing Tamoxifen tablets) for the prevention of breast cancer • Generic Aspirin, 81mg for women up to age 55 with preeclampsia risk

Express Scripts, Inc. Website www.express-scripts.com

Phone 800-797-5754

Availability Available to non-Medicare members in all regions

ID Cards Issued

Non-Medicare Prescription Drug Plan • Generic Aspirin, up to 325mg for men 45-79 years of age and women 55-79 years of age for the prevention of cardiovascular events • Generic Folic Acid, 400 to 800 mcg/ day for women up to age 50 • Generic bowel prep (formulary and OTC) • Influenza vaccination – members aged 6 months and over • Shingles vaccination – members aged 50 and over (pharmacists in Missouri may only be able to administer the vaccination to those aged 60 and over) • Fluoride for children aged 6 months through 12 years • Iron Supplement for members aged 6 months through 12 months

Preauthorization ESI requires preauthorization, or prior authorization for specific medications. This means proof of medical necessity is required before a prescription for certain drugs is paid by the plan. The purpose is to prevent misuse and off-label use of expensive and potentially dangerous drugs. If you take a new prescription to the pharmacy and the pharmacist says it requires prior authorization, ask your physician to call ESI’s Prior Authorization line at 800-417-8164.

Quantity Level Limits Quantities of some medications may be limited based on FDA labeling and medical literature. Limits are in place to ensure safe and effective drug use and to guard against stockpiling of medicines.

Step Therapy Step therapy is designed for people who have certain ongoing medical conditions that require them to take medications on a regular basis. MCHCP uses step therapy to ensure members get the safest drugs at the best cost possible before moving to a more costly therapy. The step therapy program varies based on the drug prescribed and your doctor’s recommended treatment plan. Occasionally, you may be required to try more than one first-step drug. • First-Step Drugs –– Primarily generic drugs that have been proven safe and effective –– Lowest copayment or cost applies –– Drugs must be tried before the plan pays for a second-step drug • Second-Step Drugs –– Drugs recommended if first-step drugs don’t work –– Primarily brand-name drugs –– Higher copayment or cost normally applies Second-step drug prescriptions processed at your pharmacy for the first-time trigger a message to your pharmacist indicating the use of step therapy. You’ll need to speak with your doctor about the next plan of action. One of the following may occur: • Your doctor may decide to prescribe a first-step drug because he or she thinks it will work with your treatment plan. Only your doctor can change the prescription

• If your doctor decides, for medical reasons, your treatment requires a second-step drug without trying a first-step drug, your doctor must request prior authorization from ESI. You could pay a higher copayment than a first-step drug

Pharmacy Lock-In Program The Pharmacy Lock-In Program applies to members that have been identified as misusing pharmacy benefits. Once identified, the member will be limited to a designated network pharmacy for filling of prescriptions for controlled substances and muscle relaxants for a minimum of twelve (12) months. The lock-in period may be extended if it is determined the member continues to misuse benefits.

Specialty Medications Specialty medications are drugs that treat chronic, complex conditions. They require frequent dosage adjustments, clinical monitoring, specialty handling, and are often unavailable at retail pharmacies. Accredo is ESI’s home delivery specialty pharmacy provider. Specialty drugs must be filled through Accredo. You may get the first fill at a retail pharmacy only of those specialty drugs that ESI has identified as being needed immediately. After the first fill for those specialty drugs that met criteria, you must get those drugs through Accredo. Members who continue to go to a retail pharmacy will be charged the full discounted price of the specialty drug.

2016 Benefit Guide

State Members

49

Express Scripts, Inc. Website www.express-scripts.com

Phone 800-797-5754

Availability Available to non-Medicare members in all regions

ID Cards Issued

Non-Medicare Prescription Drug Plan You can receive up to a 30-day supply of each specialty medication each time. The medications are delivered to your home or any approved location at no additional charge. Expert clinical support staff is available to answer all of your medication questions.

Split-Fill Program Many times, a member’s provider will advise them to stop taking a specialty medication before the 30-day supply is depleted, typically due to undesirable side effects or lack of effectiveness. To help avoid cost for medications that will go unused and to reduce waste, the split-fill program provides members with a 15-day supply of some specialty drugs, rather than a full 30-day supply. Once it is determined that the member can tolerate the medication, the remaining 15-day supply will be filled. The copayment will be prorated based on the given days’ supply dispensed. For example, if your copayment is $35 for a 30-day supply, you will pay $17.50 for the first 15-day supply and then $17.50 for the second 15-day supply, if a second supply is filled. For the first three (3) months of taking a new prescription, the member will be in regular contact with a Therapeutic Resource Center (TRC)— specialist pharmacists, nurses and doctors — as well as their own health care provider,

50

Coverage Information

in order to monitor for any potential complications. By the fourth (4th) month, if the medication is to be continued, a full 30-day supply will be dispensed. The split-fill program only applies to specialty drugs that are packaged to allow split-filling and those that are filled via Accredo specialty mail order pharmacy, beginning with the first fill.

Disease Management Rewards Members enrolled and actively participating in a Disease Management (DM) Program through Alere may see reductions in prescription drug costs. Please see pages 60-61 for more details.

Express Scripts Medicare Website www.express-scripts.com

Phone 866-544-6963

Availability Available to Medicare members in all regions

ID Cards Issued

Medicare Prescription Drug Plan (PDP) Medicare-primary MCHCP members are automatically enrolled in the Express Scripts Medicare PDP when Medicare becomes the primary payer. Non-Medicare members will be in the Non-Medicare PDP. Medicare primary retirees have the option of choosing MCHCP coverage for prescription drugs only, without MCHCP medical coverage. This allows members to shop the competitive Medicare market to supplement Medicare coverage.

Coverage Express Scripts Medicare PDP is a Medicare Part D plan with additional coverage to ensure Medicare members have similar benefits to non-Medicare members. It may be helpful to know that in addition to providing coverage of Medicare Part D drugs, MCHCP provides coverage for Medicare Part B medications at retail, as well as for some other non-Part D medications that are not normally covered by a Medicare PDP. The amounts paid for non-Part D medications will not count toward your total drug costs or total out-of-pocket costs.

Out-of-Network Coverage You must use Express Scripts Medicare network pharmacies to fill your prescriptions.

Covered Medicare Part D drugs are available at out-of-network pharmacies only in special circumstances, such as illness while traveling outside of Express Scripts Medicare’s service area where there is no network pharmacy. You may have to pay additional costs for drugs received at out-of-network pharmacies.

•

•

Plan Information • You will receive additional plan information directly from Express Scripts Medicare, including a benefit overview, formulary, pharmacy directory and monthly explanations of benefits • The service area for this plan is all 50 states, the District of Columbia, and Puerto Rico. You must live in one of these areas to participate in Express Scripts Medicare. Express Scripts Medicare may reduce the service area and no longer offer services in the area in which you reside • Express Scripts Medicare uses a formulary—a list of covered drugs. Express Scripts may periodically add or remove drugs, make changes to coverage limitations on certain drugs, or change how much you pay for a drug. If any formulary change limits your ability to fill a prescription, you will be notified before the change is made • Express Scripts Medicare may require you to first try one drug

•

•

to treat your condition before it will cover another drug for that condition Your health care provider must get prior authorization (prior approval) from Express Scripts Medicare for certain drugs If the actual cost of a drug is less than the normal cost-sharing amount (copayment/coinsurance) for that drug, you will pay the actual cost, not the higher copayment or coinsurance amount If you or your health care provider requests an exception for a drug and Express Scripts Medicare approves the exception, you will pay the Non-Preferred Brand Drug cost sharing amount for that drug You must continue to pay your Medicare Part B premium, if not otherwise paid for under Medicaid or by a third party

2016 Benefit Guide

State Members

51

Express Scripts Medicare

Medicare Prescription Drug Plan (PDP)

Website

Medicare Prescription Drug Plan Coverage

www.express-scripts.com

Phone 866-544-6963

This prescription drug coverage is considered creditable coverage, which means it is as good as or better than the standard Medicare prescription drug coverage. The following table provides a summary of your benefit, including final cost-sharing information. This plan provides coverage across all stages of your benefit.

Availability Available to Medicare members in all regions

ID Cards Issued

Initial Coverage stage You will pay the following until your total yearly drug costs (what you and the plan pay) reach $2,960*

Tier

Retail One-Month (31-day) Supply

Retail Two-Month (60-day) Supply

Retail Three-Month (90-day) Supply

Home Delivery Three-Month (90-day) Supply

Tier 1: Generic Drugs

$8 copayment

$16 copayment

$24 copayment

$20 copayment

Tier 2: Preferred Brand Drugs

$35 copayment

$70 copayment

$105 copayment

$87.50 copayment

Tier 3: Non-Preferred Brand Drugs

$100 copayment

$200 copayment

$300 copayment

$250 copayment

If your doctor prescribes less than a full month’s supply of certain drugs, you will pay a daily costsharing rate based on the actual number of days’ supply and tier of the drug received. You may receive up to a 90-day supply of certain maintenance drugs (medications taken on a longterm basis) through your retail pharmacy or by mail through home delivery service. There is no charge for standard shipping. Not all drugs are available for a 90-day supply, and not all retail pharmacies offer a 90-day supply. Please contact Express Scripts Medicare Customer Service at 866-544-6963 for more information.

Coverage Gap stage

After your total yearly drug costs (what you and the plan pay), reach $3,310*, you will continue to pay the same cost-sharing amount as in the Initial Coverage stage until your yearly out-of-pocket drug costs reach $4,850*. You will receive a monthly Explanation of Benefits to help you track your out-of-pocket costs.

Catastrophic Coverage stage

After your yearly out-of-pocket drug costs (what you and others pay on your behalf, including manufacturer discounts but excluding payments made by your Medicare prescription drug plan) reach $4,850*, you will pay: • The greater of 5% coinsurance or a $2.95 copayment for covered generic drugs (including brand drugs treated as generics), with a maximum not to exceed the standard copayment during the Initial Coverage stage. • The greater of 5% coinsurance or a $7.40 copayment for all other covered drugs, with a maximum not to exceed the standard copayment during the Initial Coverage stage.

* Amounts paid by the member or the plan for Medicare Part B or non-Part D medications, will not count toward your total drug costs or total out-of-pocket costs.

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Coverage Information

Selman & Company Website

TRICARE Supplement Plan

800-638-2610

The TRICARE Supplement Plan is administered by Selman & Company. It is designed to work with TRICARE, the Department of Defense’s health benefit program for the military community.

Availability

Eligibility

www.selmantricareresource.com/ MCHCP

Phone

Available to TRICARE members

ID Card Issued

You are eligible for this plan as an active state employee, retiree, terminated vested subscriber or survivor, if you fall under one of these categories: • Military retiree entitled to retired military pay • Retired Reservists and National Guardsmen between the ages of 60 and 65, and entitled to retirement pay • Retired Reservists and National Guardsmen younger than 60 and enrolled in TRICARE Retired Reserves (TRR) • Spouse or surviving spouse of those above • Military retirees and their spouses or surviving spouses who are 65 or older and live outside the U.S. or its territories (must be enrolled in Medicare) • Military retirees and their spouses or surviving spouses who are age 65 or older and ineligible for Medicare (must have received a Statement of Disallowance from the Social Security Administration) • Spouse, surviving spouse or dependent child up to age 21 (23 if a full-time student). Coverage

extends to younger than 26 for adult dependents enrolled in a TRICARE Young Adult (TYA) program • Disabled dependents may continue coverage past policy age limits as long as TRICARE continues

Enrollment

To determine if you qualify for TRICARE, call the Defense Enrollment Eligibility Reporting Systems (DEERS) at 800-538-9552.

During the annual Open Enrollment period, you may change plans and/or your level of coverage.

Available Services Features include: • Employee paid premium by pre-tax dollars through payroll deduction • No deductibles • No pre-existing condition limitations • No copayments or coinsurance amounts • Ability to use civilian physicians

How to Use the Plan You are not required to choose a primary care physician with the supplement plan. You should not be responsible for any out-of-pocket costs including copayments and deductibles for services covered by TRICARE and the TRICARE Supplement Plan.

You must submit a copy of your military identification card to enroll in the TRICARE Supplement Plan. As long as you are also enrolled, you may enroll eligible dependents in the plan.

If your dependent child is 21 and not a full-time student, you may elect to: • Continue coverage with the TRICARE Supplement Plan, and your dependent may continue coverage through COBRA • As long as the child is still eligible under MCHCP guidelines, you may change coverage for yourself and your dependent(s) to another available plan through MCHCP Once you become eligible for Medicare, you are no longer eligible for the TRICARE Supplement Plan. At that time, you must elect one of the following: • Another MCHCP medical plan • TRICARE For Life

If you enroll in the TRICARE Supplement Plan, you are not eligible to participate in Disease Management Rewards, or receive the Partnership or Tobacco-Free incentives.

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State Members

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Delta Dental of Missouri Website www.deltadentalmo.com/stateofmo

Phone 866-737-9802

Availability

Dental Plan You may visit the dentist of your choice and select dentists on a treatment-bytreatment basis. Your out-of-pocket costs may vary depending on your choice. You have three options:

Delta Dental PPO Network

Available to all members in all regions

This network offers you cost-control and claim-filing benefits.

ID Card

Delta Dental Premier Network

Issued

This network also offers you costcontrol and claim-filing benefits. However, out-of-pocket expenses

(coinsurance amounts) may be higher with a Premier dentist. All participating dentists (PPO and Premier) have the forms to submit your claim. Delta Dental (DDMO) participating dentists will usually file claims for you, and DDMO will pay them directly. Visit MCHCP’s or DDMO’s website to find out if your dentist participates, or contact DDMO for PPO and Premier participating dentists in your area.

Non-Participating Dentist If you go to a dentist not contracted with a Delta Dental plan, DDMO will make payment directly to you. It will be your obligation to make full payment to the dentist and file your claim. Obtain a claim form from MCHCP’s or DDMO’s website. The chart below is a summary of the covered services. Visit the MCHCP website for more information.

Additional Benefits Two additional cleanings are allowed per calendar year for members who are pregnant, diabetic, have a suppressed immune system or have a history of periodontal therapy.

Dental Services* Coverage

Service

You Pay

Note

To be eligible for the additional cleanings, you must submit a SelfReport form, which can be obtained from MCHCP’s or DDMO’s website or by contacting DDMO.

Diagnostic and Preventive

Examinations Prophylaxes (teeth cleaning) Fluoride Bitewing X-rays Sealants

No deductible 0% coinsurance

Dental exams, X-rays, cleanings and fluoride treatment do not apply to the individual plan maximum

If periodontal therapy has already been reported on your claims, the SelfReport form is not necessary.

Basic and Restorative

Emergency Palliative Treatment Space Maintainers All Other X-rays Minor Restorative Services (fillings) Simple Extractions

$50/person deductible1 20% coinsurance

X-rays do not apply to the individual plan maximum

Major Services

Prosthetic Device Repair All Other Oral Surgery Periodontics Endodontics Prosthetic devices (bridges, dentures) Major Restorative Services (crowns, inlays, onlays) Implants/Bone Grafts

$50/person deductible1 50% coinsurance

12-month waiting period for Coverage C services. The waiting period is waived with proof of 12 months of continuous dental coverage for major services immediately prior to the effective date of coverage in MCHCP’s dental plan

*  Coverage is limited to $1,000 per person per calendar year benefit period. 1. Coinsurance amounts apply after the $50 individual deductible is met under either Basic and Restorative or Major Services combined

54

Coverage Information

National Vision Administrators, L.L.C. Website www.e-nva.com User Name mchcp Password vision1

Vision Plan When receiving services from a National Vision Administrators (NVA) provider, NVA pays the provider directly. If you use a non-network provider, you must pay the provider and file the claim.

Phone 877-300-6641

ID Card Issued

Availability Available to all members in all regions

EyeEssential Discount Plan When members exhaust their annual benefits, NVA offers the EyeEssential Discount Plan — a low cost, memberfriendly vision plan, which includes significant discounts on materials

through participating NVA network providers. For example, the plan covers one pair of frames every 2 calendar years for adults, but you can get discounts on additional frames purchased throughout the 24-month period.

Vision Services – Basic Plan Benefit

Service

Network

Non-network

Exams Once every calendar year

Vision Exam (Two annual exams covered for children up to age 18)

$10 copayment

Reimbursed up to $45

Lenses Once every calendar year One $25 copayment for lenses

Single-vision lenses (per pair)

$25 copayment

Reimbursed up to $30

Bifocal lenses (per pair)

$25 copayment

Reimbursed up to $50

Trifocal lenses (per pair)

$25 copayment

Reimbursed up to $65

Lenticular lenses (per pair)

$25 copayment

Reimbursed up to $100

Polycarbonate lenses (per pair) Applies to children up to age 18

100% coverage

Not covered

Frames

Once every 2 calendar years Once every calendar year for children up to age 18

Up to $125 retail allowance and 20% discount off remaining balance1

Reimbursed up to $70

Contact lenses Once every calendar year in place of eye glass lenses

Elective If member prefers contacts to glasses

Up to $125 retail allowance and 15% discount off conventional or 10% discount off disposable remaining balance2

Contact lenses reimbursed up to $105

Necessary

Additional costs covered at 100%

Contact lenses reimbursed up to $210

Fitting and Evaluation

$20 copayment for daily contact lenses $30 copayment for extended contact lenses $50 copayment for specialty contact lenses

Reimbursed up to $20 for daily contact lenses or $30 for extended or specialty contact lenses

Optional Items (cosmetic extras)

Discount applied to all lens options

Not covered

Other

1. At Walmart or Sam’s Club Locations, frame price point is $55 2. At Walmart or Sam’s Club Locations, contact lens price point is $92 2016 Benefit Guide

State Members

55

National Vision Administrators, L.L.C.

Vision Plan

Website

Applies to Basic and Premium Plans NVA members will pay a maximum amount for corrective laser surgery:

www.e-nva.com User Name mchcp Password vision1

LASIK Discounts

• Traditional PRK – $1,500 per eye

• Traditional LASIK – $1,800 per eye • Custom LASIK – $2,300 per eye Members may receive additional benefits at LasikPlus locations nationwide: • Special pricing on select technologies

Phone 877-300-6641

Vision Services – Premium Plan

ID Card

Benefit

Service

Issued

Exams

Vision Exam (Two annual exams

Availability

Once every calendar year

covered for children up to age 18)

Available to all members in all regions

Lenses

Single-vision lenses (per pair)

Once every calendar year

• Free initial consultation and comprehensive LASIK vision exam • Advanced laser technologies including Wavefront and IntraLase (All-Laser LASIK) • Financing options available

Network

Non-network

$10 copayment

Reimbursed up to $45

$25 copayment

Reimbursed up to $30

Bifocal lenses (per pair)

$25 copayment

Reimbursed up to $50

Trifocal lenses (per pair)

$25 copayment

Reimbursed up to $65

Lenticular lenses (per pair)

$25 copayment

Reimbursed up to $100

Polycarbonate lenses (per pair) Applies to children up to age 18

100% coverage

Not covered

Standard anti-reflective coating

$30 copayment

Not covered

Standard progressive multifocal Discount applied to all lens options

$50 copayment

Not covered

Frames

Up to $175 retail allowance and 20% discount off remaining balance1

Reimbursed up to $70

Up to $175 retail allowance and 15% discount off conventional or 10% discount off disposable remaining balance2

Contact lenses reimbursed up to $105

Necessary

Additional costs covered at 100%

Contact lenses reimbursed up to $210

Fitting and Evaluation

$20 copayment for daily contact lenses $30 copayment for extended contact lenses $50 copayment for specialty contact lenses

Reimbursed up to $20 for daily contact lenses or $30 for extended or specialty contact lenses

One $25 copayment for lenses

Contact lenses Once every calendar year in place of eye glass lenses

Other

Once every 2 calendar years Once every calendar year for children up to age 18 Elective If member prefers contacts to glasses

Optional Items (cosmetic extras)

Discount applied to all lens options

Not covered

1. At Walmart or Sam’s Club Locations, frame price point is $77 2. At Walmart or Sam’s Club Locations, contact lens price point is $129

56

Coverage Information

2016 Benefit Guide

State Members

56

Missouri Consolidated Health Care Plan Alere Website my.mchcp.org

Phone

Strive for Wellness® Program Strive for Wellness ® focuses on understanding health risks, making smart lifestyle choices and empowering you to take an active role in your health. Strive for Wellness ® includes two monthly premium incentives.

800-487-0771 or 844-24MCHCP

Partnership Incentive

Availability

MCHCP offers the Partnership Incentive, a $25 monthly premium reduction. New for 2016: eligible members can start earning the Incentive at any time throughout the year.

The Partnership Incentive is available to active employee and non-Medicare subscribers. The Tobacco-Free Incentive is available to active employee and nonMedicare subscribers, as well as their covered non-Medicare spouses. Tricare Supplement Plan members are not eligible for either Incentive.

ID Card Not Issued

To receive the Incentive, subscribers must complete the Partnership Promise and online Health Assessment through their myMCHCP accounts. The Incentive begins the first day of the second month after the required steps are completed. For example, participants who complete the required steps on Feb. 19, 2016, will begin receiving the Incentive on April 1. Participants who complete the required steps before Nov. 30, 2015, will begin receiving the Incentive on Jan. 1, 2016. New members adding medical coverage with an effective date on or after Dec. 1, 2015, must complete the required steps within 31 days of their effective date for the incentive to begin the same date that coverage begins. Incentive participants will receive a T-shirt upon reporting the completion of an MCHCP-approved health action. Examples of MCHCP-approved health actions include receiving an annual

preventive exam, attending two Strive for Wellness ® lunch-and-learns, or walking 1,000,000 steps.

Tobacco-Free Incentive MCHCP also offers the Tobacco-Free Incentive, a $40 per person monthly premium reduction. New for 2016: eligible members can start earning the Incentive at any time throughout the year. Members who are tobacco-free, meaning they have not used tobacco in the past three months and will not use tobacco, can complete the TobaccoFree Promise form. Members who are NOT tobaccofree can complete the Quit Tobacco Promise form, as well as a quit tobacco program. These programs include: • Quit Tobacco Health Coaching provided by Alere • Strive for Wellness ® Quit Tobacco Course* It is the member’s responsibility to contact Alere and begin the Quit Tobacco Health Coaching program. The Incentive begins the first day of the second month after:

on April 1. Members who complete the required steps before Nov. 30, 2015, will begin receiving the Incentive on Jan. 1, 2016. New members adding medical coverage with an effective date on or after Dec. 1, 2015, must complete the required steps within 31 days of their effective date for the incentive to begin the same date that coverage begins. Participants who earned the Incentive may lose it by using tobacco or failing to complete a quit tobacco program. Once the Incentive is lost, it cannot be renewed until the following plan year. MCHCP plans include 100 percent coverage for formulary tobacco cessation medications and over-thecounter nicotine replacement therapy with a prescription. To learn more, call ESI at 800-797-5754. A waiver may be granted if a member requests one in writing along with a provider’s written certification that it is medically inadvisable. *Active employees only, when available in the Jefferson City area

• MCHCP receives the member’s Tobacco-Free Promise form; or • MCHCP receives the member’s Quit Tobacco Promise form and the member completes one call or class of a quit tobacco program. For example, participants who complete the required steps on Feb. 19, 2016, will begin receiving the Incentive

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State Members

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Strive for Wellness® Cerner Missouri Consolidated Health Care Plan Website my.mchcp.org

Phone 573-526-3175

Address Truman Building, Room 478 301 West High Street Jefferson City, MO, 65101

Availability Available to active state employees enrolled in an MCHCP medical plan

Hours Monday, Wednesday and Thursday 8 a.m. - 1 p.m. and 2 - 5 p.m. Tuesday and Friday 7 - 11 a.m. and noon - 4 p.m.

Strive for Wellness® Health Center The Strive for Wellness ® Health Center brings basic health care to active state employee subscribers enrolled in an MCHCP medical plan. The Center offers routine care for common illnesses and basic preventive care at hours designed to fit into a hectic workday. Examples of services include: • Treatment of sinus and ear infections, flu and allergies • Vaccines such as flu, Hepatitis B, meningitis, and shingles • Health screenings It is conveniently located in Jefferson City’s Harry S Truman Building. Parking passes for reserved spaces are available. The office visit fee covers the services for the entire visit and is as follows: • PPO plans have a $15 office visit fee • HSA Plan has a $45 office visit fee • Preventive services are covered at 100 percent Cash, check or major credit cards will be accepted. Payment is due at the time of the appointment. Health Center services are outside the MCHCP medical plan benefits. Fees do not apply toward the medical plan’s deductible or out-of-pocket maximum. To schedule an appointment, call 573-526-3175 or log in to your myMCHCP account and select the Strive for Wellness ® Health Center logo.

58

Coverage Information

ComPsych Website www.guidanceresources.com

Phone 800-808-2261

ID Card Not Issued

Availability Available to all active employees and members of their household

Employee Assistance Program (EAP) The Employee Assistance Program (EAP) through ComPsych is a confidential counseling and referral service that can help employees and their families successfully deal with life’s challenges. EAP services are available at no cost 24 hours a day, every day of the year. Resources include timely articles, HelpSheetsSM, tutorials, streaming videos and selfassessments. The EAP can help with challenges such as: • • • • • • • • •

Stress; Parenting; Alcohol and drug abuse; Marital problems; Anxiety and/or depression; Identity theft; Consumer fraud; Legal issues; and Financial concerns.

The EAP covers up to six sessions per problem, per year for individual household members. There is no annual limit on the number of different problems. Counseling required by the employer is covered, but will not count as one of the six sessions. Additional counseling sessions may be covered by the employee’s medical plan.

financial services professionals and attorneys. For in-person legal representation, the employee may receive a 30-minute consultation at no cost and a 25% reduction in customary legal fees with a ComPsych network attorney.

Identity Theft and Consumer Fraud Protection Contact the EAP at the beginning of a fraud-related emergency and receive a 60-minute consultation at no cost to employees. Trained fraud-resolution specialists will assist with expediting fraud claims and restoring credit.

FamilySource® EAP offers assistance with worklife balance by helping clients locate quality child care, elder care, education, adoption, and pet care. The FamilySource® program offers personalized and comprehensive referral packets which include: • A minimum of three local referrals with detailed maps to each • Specific state-licensing standards for facilities and providers • HelpSheetsSM related to the individual’s concerns • Checklists to evaluate facilities and providers

Legal and Financial Concerns For legal and financial concerns, the EAP offers unlimited phone consultations with ComPsych’s

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State Members

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Alere Website my.mchcp.org

Phone 844-246-2427 (844-24MCHCP)

ID Card Not Issued

Disease Management Services Disease Management (DM) is a program offered to help manage specific chronic conditions. This program is available at no cost to the member. To qualify for DM, members must be 18 or over (unless otherwise noted), not have primary Medicare or TRICARE Supplement coverage, and have one of the following conditions: • Asthma (6 years and older); • Chronic Obstructive Pulmonary Disease (COPD); • Congestive heart failure; • Coronary artery disease; • Depression; • Diabetes (6 years and older); • Musculoskeletal/Chronic pain, including low back pain; • Obesity, defined as having a Body Mass Index more than or equal to 30; or • Hypertension, when managed with another condition above. Members identified with one of these conditions, through medical and pharmacy claims, may participate in a DM program through Alere. Once enrolled, members will receive regular phone calls from a DM nurse, helping the member better understand and manage their condition. Alere may also communicate with the member’s health care provider, so that the provider can make health care decisions that are right for the member.

60

Coverage Information

The DM program is completely confidential and follows medical privacy standards established by federal and state law.

Disease Management Rewards Upon participating in a DM program through Alere, eligible members can receive the following rewards:

• Formulary glucometer (one per year), and prescribed formulary test strips and lancets* • Four visits with a Certified Diabetes Educator* *Covered at 100 percent for PPO members or 100 percent after deductible is met for HSA Plan members, when received through a network provider.

• Lower prescription copayments/ coinsurance

Disease Management participants receive reduced prescription drug costs HSA Plan Coinsurance Reduced coinsurance amount Generic

5% coinsurance after deductible has been met

(Diabetes medication only)

Brand

10% coinsurance after deductible has been met 20% coinsurance after deductible has been met

(Diabetes medication only)

Non-Formulary (All medications)

PPO Plan Copayments Supply

Generic

Brand

(Diabetes

(Diabetes

NonFormulary

medication only)

medication only)

(All medications)

Up to 31-day

 $4

$17.50

 $50

Up to 60-day

 $8

$35

$100

Up to 90-day (Retail) $12

$52.50

$150

Up to 90-day (Home Delivery)

$43.75

$125

$10

Alere Website my.mchcp.org

Phone 844-246-2427 (844-24MCHCP)

ID Card Not Issued

Disease Management Services Alere will contact all eligible members three times by phone to enroll and begin a DM program. Eligible members may also self-enroll by contacting Alere directly. If Alere is unable to reach a member over the phone, Alere will mail the member a notice to contact a DM nurse. Upon receiving the notice to contact, it is the member’s responsibility to call Alere within two (2) weeks of the letter date to begin participation. Once a member has completed the first call with a DM nurse, they have started participation in a DM program.

Members who stop participating will lose DM Rewards for the remainder of the year. The loss effective date is the 1st day of the 2nd month after MCHCP learns the member has stopped participating. For example, if MCHCP is notified on Feb. 19, 2016, the member will lose DM Rewards beginning on April 1.

Participation means one of the following: • Work one-on-one with a DM nurse; or • Meet initial goals to control the condition and receive up to two (2) calls per year from a DM nurse until the condition can be managed independently. DM Rewards begin no earlier than Jan. 1, 2016, and end on Dec. 31, 2016. Members who are participating in a DM program on Dec. 1, 2015, will begin receiving DM Rewards on Jan. 1, 2016. If a member starts after Dec. 1, 2015, DM Rewards begin the 1st day of the 2nd month after the member has completed the first one-on-one phone call with a DM nurse. For example, if a member completes a call on Feb. 19, 2016, he/ she will begin receiving DM Rewards on April 1.

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Women’s Health and Cancer Rights Notice If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomyrelated benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for: • All stages of reconstruction of the breast on which the mastectomy was performed; • Surgery and reconstruction of the other breast to produce a symmetrical appearance; • Prostheses; and • Treatment of physical complications of the mastectomy, including lymphedema These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan. If you would like more information on WHCRA benefits, call UMR at 888-200-1167 or Aetna at 800-245-0618.

62

Coverage Information

Section 3

Member Information

Notice of Privacy Practices Appeal Procedures

Effective September 1, 2013

Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. If you have any questions about this notice, please contact Missouri Consolidated Health Care Plan’s Privacy Officer at 832 Weathered Rock Court,

disclose protected health information with your providers (pharmacies, physicians, hospitals, etc.) to assist in your treatment.

PO Box 104355, Jefferson City, MO 65110, or by calling 573-751-8881 or toll free 800-701-8881.

For Payment We may use and disclose protected health information about you so that the treatment and services you receive will be paid. For example, we may use or disclose protected health information in order for your claims to be processed, coordinate your benefits, review health care services provided to you and evaluate medical necessity or appropriateness of care or charges. We may also use or disclose your protected health information to determine whether a treatment is a covered benefit under the health plan. We may use and disclose your protected health information to determine eligibility for coverage, in order to obtain pretax payment of your premiums from your employer or sponsoring entity, and for determining wellness premium incentives. We may use and disclose your protected health information for underwriting purposes, but, if we do, we are prohibited from using your genetic information for such purposes.

This notice describes the information privacy practices followed by workforce members of Missouri Consolidated Health Care Plan. For purposes of this notice, the pronouns “we”, “us” and “our” and the acronym “MCHCP” refer to Missouri Consolidated Health Care Plan. This notice applies to the information and records we have about your health care and the services you receive. We are required by law to maintain the privacy of your protected health information and to notify you if there has been a breach of your protected health information. We are also required by law to give you this notice. It will tell you about the ways in which we may use and disclose health information about you and describes your rights and our obligations regarding the use and disclosure of that information.

How We May Use and Disclose Health Information About You For Treatment We may use or disclose protected health information about you to assist in providing you with medical treatment or services. For example, we may use and

64

Member Information

For Health Care Operations We may use and disclose protected health information for our health care operations. For example, we may use and disclose your protected health information to address or resolve complaints or appeals regarding your medical benefits. We may use or disclose

protected health information with our wellness or disease management programs in which you participate. We may use your protected health information to conduct audits, for purposes of rate-making, as well as for purposes of risk management. We may also disclose your protected health information to our attorneys, accountants and other consultants who assist us in performing our functions. We may disclose your protected health information to health care providers or entities for certain health care operations activities, such as quality assessment and improvement activities, case management and care coordination. In this case, we will only disclose your protected health information to these entities if they have or have had a relationship with you and your protected health information pertains to that relationship, such as with other health plans or insurance carriers in order to coordinate benefits, if you or your family members have coverage through another health plan.

Disclosures to Employer We may also use and disclose protected health information with your employer as necessary to perform administrative functions. Employers who receive this type of information are required by law to have safeguards in place to protect against inappropriate use or disclosure of your information.

Effective September 1, 2013

Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Disclosures to Family Members or Others We may disclose health information about you to your family members or friends if we obtain your written authorization to do so. Also, unless you object, we may disclose relevant portions of your protected health information to a family member, friend, or other person you indicate is involved in your health care or in helping you receive payment for your health care. For example, we may assume you agree to our disclosure of your personal health information to your spouse when you bring your spouse with you to a meeting or have your spouse on the telephone while such information is discussed. We may also disclose claim and payment information of family members to the subscriber in a family plan. If you are not capable of agreeing or objecting to these disclosures because of, for instance, an emergency situation, we will disclose protected health information (as we determine) in your best interest. After the emergency, we will give you the opportunity to object to future disclosures to family and friends.

Disclosures to Business Associates We contract with individuals and entities (business associates) to perform various functions on our behalf or provide certain types of services. To perform these functions or provide these services, our business associates will

receive, create, maintain, use or disclose protected health information. We require the business associates to agree in writing to contract terms to safeguard your information, consistent with federal and state law. For example, we may disclose your protected health information to a business associate to administer claims or provide service support, utilization management, subrogation or pharmacy benefit management.

Special Situations We may use or disclose health information about you without your permission for the following purposes, subject to all applicable legal requirements and limitations:

To Avert a Serious Threat to Health or Safety We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Required By Law We will disclose your health information when required to do so by federal, state or local law. Public Health Activities We may disclose your health information to a public health authority that is authorized by law to collect or receive such information for the purpose of preventing disease or injury.

For Research Under certain circumstances, and only after a special approval process, we may use and disclose your health information to help conduct research. To a Health Oversight Agency We may disclose your health information to a health oversight agency for oversight activities authorized by law. Judicial and Administrative Proceedings We may disclose your health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal. We may disclosure your health information in the course of any judicial or administrative proceeding in response to a subpoena, discovery request, or other lawful process if we receive satisfactory assurance that you have been given notice of the request or that there is a qualified protective order for the information. Workers’ Compensation We may release health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness. Law Enforcement We may release health information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar

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Effective September 1, 2013

Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. process, subject to all applicable legal requirements.

For Military, National Security, or Incarceration/Law Enforcement Custody If you are involved with the military, national security or intelligence activities, or you are in the custody of law enforcement officials or an inmate in a correctional institution, we may release your health information to the proper authorities so they may carry out their duties under the law. Information Not Personally Identifiable We may use or disclose health information about you in a way that does not personally identify you or reveal who you are.

Other Uses & Disclosures of Health Information We will not use or disclose your health information for any purpose other than those identified in the previous sections without your specific, written Authorization. If you give us Authorization to use or disclose health information about you, you may revoke that Authorization, in writing, at any time. If you revoke your Authorization, we will no longer use or disclose information about you for the reasons covered by your written Authorization, but we cannot take back any uses or disclosures already made with your permission.

66

Member Information

If we have HIV or substance abuse information about you, we cannot release that information without a special signed, written authorization from you. In order to disclose these types of records for purposes of treatment, payment or health care operations, we will have to have a special written Authorization that complies with the law governing HIV or substance abuse records. If we have psychotherapy notes, we will not use or disclose that information without authorization unless the use or disclosure is used to defend MCHCP in a legal action or other proceeding brought by you. MCHCP will not use or disclose your protected health information for marketing purposes without an authorization, except if the marketing communication is in the form of a faceto-face communication made by MCHCP to you or in the form of a promotional gift of nominal value provided by MCHCP. MCHCP will not sell your protected health information without your authorization.

Your Rights Regarding Health Information About You You have the following rights regarding health information we maintain about you:

Right to Inspect and Copy You have the right to inspect and copy your health information, such

as enrollment, eligibility and billing records. You must submit a written request to MCHCP’s Privacy Officer in order to inspect and/or copy your health information. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other associated supplies. We may deny your request to inspect and/or copy in certain limited circumstances. If you are denied access to your health information, you may ask that the denial be reviewed. If such a review is required by law, we will select a licensed health care professional to review your request and our denial. The person conducting the review will not be the person who denied your request, and we will comply with the outcome of the review.

Right to Amend Incorrect or Incomplete PHI If you believe health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment as long as the information is kept by this office. To request an amendment, complete and submit a Member Record Amendment/ Correction Form to MCHCP’s Privacy Officer. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

Effective September 1, 2013

Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Complaints If you believe your privacy rights have been violated, you may file a complaint with our office or with the federal office of the Secretary of the Department of Health and Human Services - Office of Civil Rights. To file a complaint with our office, contact MCHCP’s Privacy Officer at 573-751-8881 or toll free 800-701-8881. You will not be penalized or retaliated against for filing a complaint. You may contact the Department of Health and Human Service on your rights under HIPAA at:

Office for Civil Rights, DHHS 601 East 12th St. – Room 248 Kansas City, MO 64106 (816) 426-7277 (816) 426-7065 (TDD) www.hhs.gov

1. We did not create, unless the person or entity that created the information is no longer available to make the amendment; 2. Is not part of the health information that we keep; 3. You would not be permitted to inspect and copy; or 4. Is accurate and complete. Right to an Accounting of Certain Disclosures You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of medical information about you for purposes other than treatment, payment and health care operations. To obtain this list, you must submit your request in writing to MCHCP’s Privacy Officer. It must state a time period, which may not go back more than six years from the date of the request. Your request should indicate in what form you want the list (for example, on paper or electronically). We may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. Right to Request Restrictions You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is

involved in your care or the payment for it, like a family member or friend. For example, you could ask that we not use or disclose information about a particular health care treatment you received.

We are Not Required to Agree to Your Request We are not required to agree to your request for restrictions. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. If your request restricts us from using or disclosing information for purposes of treatment, payment or health care operations, we have the right to discontinue providing you with health care treatment and services. Request Restrictions To request restrictions, you may complete and submit the Request for Restriction on Use/Disclosure of Health Care Information to MCHCP’s Privacy Officer. Right to Request Confidential Communications You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you may complete and submit the Request for Restriction on Use and Disclosure of Health Care Information and/or Confidential Communication to MCHCP’s Privacy Officer. We will not ask

you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive it electronically, you are still entitled to a paper copy. To obtain such a copy, contact MCHCP’s Privacy Officer.

Changes to This Notice MCHCP is required to abide by the terms of the notice currently in effect. We reserve the right to change this notice, and to make the revised or changed notice effective for medical information we already have about you, as well as any information we receive in the future. We will post the revised notice to our website prior to the effective date of the change, and we will distribute any amended notice or information about the change and how to obtain a revised notice in the next annual communication to members, either by mail or electronically if you have agreed to receive communications in that manner. Please note that the amended notice may be part of another mailing from MCHCP. In addition, we will post the current notice in our office and on www.mchcp. org with its effective date directly under the heading. You are entitled to a copy of the notice currently in effect. 2016 Benefit Guide

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Appeal Procedures Claim Submissions and Initial Denials You must use the claims and administrative procedures established by the health plan administering the particular service for which coverage, authorization or payment is sought.

Pre-Service Claims Pre-service claims are requests made to the health plan before getting medical care, such as prior authorization or a decision on whether a treatment or procedure is medically necessary. Preservice claims must be decided no later than 15 days from the date the health plan receives the request. If the health plan requires more time for reasons beyond its control, it must notify you before the end of the first 15-day period, explain the reason for the delay and request any additional information. If more information is requested, you have at least 45 days to provide the information. The health plan must decide the claim no later than 15 days after receiving the additional information or after the period allowed to supply it ends, whichever is first. Urgent Care Claims Urgent care claims are a special type of pre-service claim that require a quicker decision because waiting the standard time could seriously jeopardize you or your family member’s life, health or ability to regain maximum function. A request for an urgent care claim must be submitted verbally or in writing and will be decided within 72 hours and followed by a written confirmation of the decision. Concurrent Claims Concurrent claims are claims related to

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Member Information

an ongoing course of previously approved treatment. If the health plan approved ongoing treatment over a period of time or number of treatments and later reduces or terminates the course of treatment, it will be treated as a benefit denial. The health plan must notify you in writing before reducing or ending a previously approved course of treatment, in sufficient time to allow you to appeal and obtain a determination before the benefit is reduced or terminated.

Post-Service Claims Post-service claims are all other claims for services, including claims after services have been provided, such as requests for reimbursement or payment of the costs of services. Post-service claims must be decided no later than 30 days from the date the health plan receives the claim. If the health plan requires more time for reasons beyond its control, it must notify you before the end of the first 15-day period, explain the reason for the delay and request any additional information. If more information is requested, you have at least 45 days to provide the information. The health plan must decide the claim no later than 15 days after receiving the additional information or after the period allowed to supply it ends, whichever is first. Claim Filing Deadline • Claims must be filed by the provider or you to the health plan as soon as reasonably possible. Claims filed more than one year after charges are incurred will not be honored.

Initial Denial Notice If you, your provider or your authorized representative submits a request for

coverage or claim for services that is denied, in whole or in part, you will receive an initial denial notice with the following information:

1. Reason for denial 2. Reference to plan provisions, regulation, statute, clinical criteria or guideline on which the denial was based, and directions on how you can obtain access to this information free of charge 3. If documentation or information is missing, a description of the documentation or information necessary for you to provide, and an explanation as to why it is necessary 4. Information as to the steps you can take to submit an appeal of the denial

Adverse Benefit Determinations You have the right to appeal adverse benefit determinations. Adverse benefit determinations include the following: • Denial, reduction, termination of, or failure to provide or make payment for a benefit based on an individual’s eligibility to participate in the plan • Denial, reduction, termination of, or failure to provide or make payment for a benefit based on utilization review or failure to cover a service because it is determined to be experimental, investigational, or not medically necessary or appropriate • Rescission of coverage after an individual has been covered under the plan Appeals of adverse benefit determinations must be submitted in writing to the health plan that issued the original determination giving rise to the appeal.

Appeal Procedures Medical Appeals First-Level Appeal A first-level appeal of an adverse benefit determination for medical services must be submitted in writing within 180 days of the date on the original claim decision notice. Include any additional information or documentation to support the reason the original claim decision should be overturned. The health plan will have someone review the appeal who was not involved in the original decision, and will consult with a qualified medical professional if a medical judgment is involved. The health plan must respond to you in writing within 30 days for postservice claims and 15 days for pre-service claims from the date the health plan received the first-level appeal request. Submit the first-level appeal in writing to the medical plan:

UMR Pre-service/Concurrent claim appeals UMR Appeals PO Box 400046 San Antonio, TX 78229 Fax: 888-615-6584

Post-service claim appeals UMR Claims Appeal Unit PO Box 30546 Salt Lake City, UT 84130-0546 Fax: 877-291-3248

Aetna Appeals Resolution Team PO Box 14463 Lexington, KY 40512 Fax: 859-425-3379

Second-Level Appeal A second-level appeal for medical services must be submitted in writing within 60 days of the date of the first-level appeal decision letter that upholds the original decision. Include any additional information or documentation to support the reason the first-level appeal decision should be overturned. The health plan will have someone review the appeal who was not involved in the original decision or first-level appeal, and will consult with a qualified medical professional if a medical judgment is involved. The health plan must respond in writing within 30 days for post-service claims and within 15 days for pre-service claims from the date the health plan received the second-level appeal request. Submit the second-level appeal in writing to the medical plan:

UMR Pre-service/Concurrent claim appeals UMR Appeals PO Box 400046 San Antonio, TX 78229 Fax: 888-615-6584

Post-service claim appeals UMR Claims Appeal Unit PO Box 30546 Salt Lake City, UT 84130-0546 Fax: 877-291-3248

Aetna Appeals Resolution Team PO Box 14463 Lexington, KY 40512 Fax: 859-425-3379

Pharmacy Appeals The pharmacy benefit manager will have someone review the appeal who was not involved in the original decision, and will consult with a qualified medical professional if a medical judgment is involved. The pharmacy benefit manager must respond in writing within 60 days for post-service claims and within 30 days for pre-service claims from the date the pharmacy benefit manager received the appeal request.

Non-Medicare Prescription Drug Plan Appeals An appeal of an adverse benefit determination for pharmacy services must be submitted in writing within 180 days of the date on the original claim decision notice. Include the date you attempted to fill the prescription, the prescribing physician’s name, the drug name and quantity, the cost of the prescription, if applicable, the reason you believe the claim should be paid, and any additional information or documentation to support your belief that the original decision should be overturned. Submit the appeal to the pharmacy benefit manager: Express Scripts P.O. Box 66588 St. Louis, MO 63166-6588 Attn: Clinical Appeals Department Phone: 800-753-2851

Medicare Prescription Drug Plan Appeals Appeals involving services from the Medicare Prescription Drug Plan must 2016 Benefit Guide

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Appeal Procedures be submitted directly to Express Scripts Medicare. Medicare Part D drugs will follow the Centers for Medicare and Medicaid Services (CMS) appeal procedures listed in the Express Scripts Medicare Welcome Kit. Non-Part D and Part B drugs will follow the NonMedicare Prescription Drug Plan appeal procedures in this guide.

Expedited Appeals An expedited appeal may be requested when a decision is related to a pre-service claim for urgent care. The health plan or pharmacy benefit manager will have someone review the appeal who was not involved in the original decision, and will consult with a qualified medical professional if a medical judgment is involved. The health plan or pharmacy benefit manager must respond verbally within 72 hours of receiving a request for an expedited review, with written confirmation of the decision within three working days of providing notification of the determination. Submit the expedited appeal to the health plan or pharmacy benefit manager by telephone or fax:

UMR Phone: 800-808-4424, ext. 15227 Fax: 888-615-6584 Attn: Appeals Unit

Aetna Phone: 800-245-0618 Fax: 859-425-3379 Attn: Appeals Resolution Team

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Member Information

Express Scripts

Dental and Vision Appeals

Phone (Non-Medicare): 800-753-2851 Phone (Medicare): 800-935-6103

Appeals involving services from the dental and vision plans must be submitted to the dental and vision plans.

External Review After completion of the internal appeals process for medical or pharmacy services, an external review is available for covered medical and pharmacy benefits through the U.S. Office of Personnel Management (OPM) and the U.S. Department of Health and Human Services (HHS).

Delta Dental

Members may file a written request for external review within four months of receiving a final internal adverse benefit determination. The request should be sent to:

Attn: Appeals Committee 12399 Gravois Road St. Louis, MO 63127

MAXIMUS Federal Services, INC. MAXIMUS Federal Services 3750 Monroe Ave Suite 705 Pittsford, NY 14534 Fax: 888-866-6190 www.externalappeal.com

Contact MAXIMUS Federal Services at 888-866-6205 if you have any questions or concerns during the external review process. A decision will be made within 45 days of the request. You may file an expedited review if the standard review time frame would seriously jeopardize your life or health, or your ability to regain maximum function, or if the final internal adverse benefit determination involves admission, availability of care, continued stay, or an item or service for which you received services but have not been discharged from the facility.

First-Level Appeal Attn: Customer Service 12399 Gravois Road St. Louis, MO 63127

Second-Level Appeal

National Vision Administrators National Vision Administrators, L.L.C. Attn: Complaints, Grievances, Appeals PO Box 2187 Clifton, NJ 07015

Administrative Appeals Administrative appeals involve issues regarding MCHCP eligibility, plan effective dates, premium payments, Partnership Incentive, TobaccoFree Incentive and plan choices. Administrative appeals must be submitted in writing within 180 days of the date of the notice of administrative decision or written denial of your administrative request. All administrative appeals should be addressed to:

Missouri Consolidated Health Care Plan Attn: Appeal PO Box 104355 Jefferson City, MO 65110-4355

Section 4

Premiums

Active Employee Premiums Leave of Absence Subscriber Premiums COBRA Subscriber Premiums Retiree and Survivor without Medicare Total Premiums Retiree and Survivor with Medicare Total Premiums Long-Term Disability Subscriber without Medicare Premiums Long-Term Disability Subscriber with Medicare Premiums Terminated Vested Subscriber without Medicare Premiums Terminated Vested Subscriber with Medicare Premiums Level B Foster Parent Premiums Dental, Vision and TRICARE Premiums

Active Employee Premiums With Tobacco-Free Incentive Level of Coverage

HSA Plan

PPO 600 Plan

PPO 300 Plan

Partnership Standard Premium Premium

Partnership Standard Premium Premium

Partnership Standard Premium Premium

Employee Only

 $0

$25

$41

$66

$70

$95

Employee and Spouse1

 73

 98

241

266

314

339

Employee and One Child

 12

 37

 69

 94

110

135

Employee and Two Children

 18

 43

 89

114

141

166

Employee and Three Children

 23

 48

109

134

172

197

Employee and Four Children

 31

 56

129

154

204

229

Employee and Five or more Children

 32

 57

149

174

240

265

Employee, Spouse and One Child1

102

127

311

336

394

419

Employee, Spouse and Two Children1

110

135

331

356

426

451

Employee, Spouse and Three Children1

116

141

351

376

457

482

Employee, Spouse and Four Children1

121

146

371

396

488

513

Employee, Spouse and Five or more Children1

124

149

391

416

525

550

1. The premium listed for “Employee and Spouse” and “Employee, Spouse and Child(ren)” assumes that both the employee and spouse are in the Tobacco-Free Incentive. If only one is in the Tobacco-Free Incentive, $40 will be added to the listed premium.

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Premiums

Active Employee Premiums Without Tobacco-Free Incentive Level of Coverage

HSA Plan

PPO 600 Plan

PPO 300 Plan

Partnership Premium

Standard Premium

Partnership Premium

Standard Premium

Partnership Premium

Standard Premium

Employee Only

$40

$65

$81

$106

$110

$135

Employee and Spouse1

153

178

321

 346

 394

 419

Employee and One Child

 52

 77

109

 134

 150

 175

Employee and Two Children

  58

  83

129

  154

  181 

 206

Employee and Three Children

 63

 88

149

 174

 212

 237

Employee and Four Children

 71

 96

169

 194

 244

 269

Employee and Five or more Children

 72

 97

189

 214

 280

 305

Employee, Spouse and One Child1

182

207

391

 416

 474

 499

Employee, Spouse and Two Children1

190

215

411

 436

 506

 531

Employee, Spouse and Three Children1

196

221

431

 456

 537

 562

Employee, Spouse and Four Children1

201

226

451

 476

 568

 593

Employee, Spouse and Five or more Children1

204

229

471

 496

 605

 630

1. The premium listed for “Employee and Spouse” and “Employee, Spouse and Child(ren)” assumes that both the employee and spouse are not in the Tobacco-Free Incentive. If one is in the Tobacco-Free Incentive, $40 will be subtracted from the listed premium.

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Leave of Absence Subscriber Premiums With Tobacco-Free Incentive Level of Coverage

HSA Plan Partnership Premium

Standard Premium

PPO 600 Plan

PPO 300 Plan

Partnership Premium

Partnership Premium

Standard Premium

Standard Premium

Subscriber Only

$481

$506

$562

$587

$589

$614

Subscriber and Spouse1

1,168

1,193

1,376

1,401

1,440

1,465

Subscriber and One Child

  684

  709

  772

  797

  808

 833

Subscriber and Two Children

  862

  887

  981

1,006

1,028

1,053

Subscriber and Three Children

1,040

1,065

1,191

1,216

1,248

1,273

Subscriber and Four Children

1,218

1,243

1,400

1,425

1,467

1,492

Subscriber and Five or more Children

1,474

1,499

1,701

1,726

1,782

1,807

Subscriber, Spouse and One Child1

1,346

1,371

1,585

1,610

1,659

1,684

Subscriber, Spouse and Two Children1

1,524

1,549

1,795

1,820

1,879

1,904

Subscriber, Spouse and Three Children1

1,702

1,727

2,004

2,029

2,099

2,124

Subscriber, Spouse and Four Children1

1,880

1,905

2,214

2,239

2,318

2,343

Subscriber, Spouse and Five or more Children1

2,136

2,161

2,514

2,539

2,634

2,659

1. The premium listed for “Subscriber and Spouse” and “Subscriber, Spouse and Child(ren)” assumes that both the subscriber and spouse are in the Tobacco-Free Incentive. If only one is in the Tobacco-Free Incentive, $40 will be added to the listed premium.

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Premiums

Leave of Absence Subscriber Premiums Without Tobacco-Free Incentive Level of Coverage

HSA Plan Partnership Premium

Standard Premium

PPO 600 Plan

PPO 300 Plan

Partnership Premium

Partnership Premium

Standard Premium

Standard Premium

Subscriber Only

$521

$546

$602

$627

$629

$654

Subscriber and Spouse1

1,248

1,273

1,456

1,481

1,520

1,545

Subscriber and One Child

  724

  749

  812

  837

  848

  873

Subscriber and Two Children

  902

  927

1,021

1,046

1,068

1,093

Subscriber and Three Children

1,080

1,105

1,231

1,256

1,288

1,313

Subscriber and Four Children

1,258

1,283

1,440

1,465

1,507

1,532

Subscriber and Five or more Children

1,514

1,539

1,741

1,766

1,822

1,847

Subscriber, Spouse and One Child1

1,426

1,451

1,665

1,690

1,739

1,764

Subscriber, Spouse and Two Children1

1,604

1,629

1,875

1,900

1,959

1,984

Subscriber, Spouse and Three Children1

1,782

1,807

2,084

2,109

2,179

2,204

Subscriber, Spouse and Four Children1

1,960

1,985

2,294

2,319

2,398

2,423

Subscriber, Spouse and Five or more Children1

2,216

2,241

2,594

2,619

2,714

2,739

1. The premium listed for “Subscriber and Spouse” and “Subscriber, Spouse and Child(ren)” assumes that both the subscriber and spouse are not in the Tobacco-Free Incentive. If one is in the Tobacco-Free Incentive, $40 will be subtracted from the listed premium.

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COBRA Subscriber Premiums With Tobacco-Free Incentive Level of Coverage

HSA Plan Partnership Premium

Standard Premium

PPO 600 Plan

PPO 300 Plan

Partnership Premium

Partnership Premium

Standard Premium

Standard Premium

Subscriber Only

$466

$491

$574

$599

$600

$625

Subscriber and Spouse1

1,141

1,166

1,403

1,428

1,469

1,494

Subscriber and One Child

  647

  672

  787

  812

  824

  849

Subscriber and Two Children

  829

  854

1,001

1,026

1,048

1,073

Subscriber and Three Children

1,010

1,035

1,215

1,240

1,272

1,297

Subscriber and Four Children

1,192

1,217

1,428

1,453

1,497

1,522

Subscriber and Five or more Children

1,452

1,477

1,735

1,760

1,818

1,843

Subscriber, Spouse and One Child1

1,322

1,347

1,617

1,642

1,693

1,718

Subscriber, Spouse and Two Children1

1,504

1,529

1,830

1,855

1,917

1,942

Subscriber, Spouse and Three Children1

1,685

1,710

2,044

2,069

2,141

2,166

Subscriber, Spouse and Four Children1

1,867

1,892

2,258

2,283

2,365

2,390

Subscriber, Spouse and Five or more Children1

2,127

2,152

2,564

2,589

2,686

2,711

Child Only

  182

  182

  214

  214

  224

  224

Spousal Continuation without Medicare

  466

  491

  574

  599

  600

  625

Spousal Continuation with Medicare

Not Available

  322

  322

  344

  344

1. The premium listed for “Subscriber and Spouse” and “Subscriber, Spouse and Child(ren)” assumes that both the subscriber and spouse are in the Tobacco-Free Incentive. If only one is in the Tobacco-Free Incentive, $40 will be added to the listed premium.

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Premiums

COBRA Subscriber Premiums Without Tobacco-Free Incentive Level of Coverage

HSA Plan

PPO 600 Plan

PPO 300 Plan

Partnership Standard Premium Premium

Partnership Standard Premium Premium

Partnership Standard Premium Premium

Subscriber Only

$506

$531

$614

$639

$640

$665

Subscriber and Spouse1

1,221

1,246

1,483

1,508

1,549

1,574

Subscriber and One Child

  687

  712

  827

  852

  864

889

Subscriber and Two Children

  869

  894

1,041

1,066

1,088

1,113

Subscriber and Three Children

1,050

1,075

1,255

1,280

1,312

1,337

Subscriber and Four Children

1,232

1,257

1,468

1,493

1,537

1,562

Subscriber and Five or more Children

1,492

1,517

1,775

1,800

1,858

1,883

Subscriber, Spouse and One Child1

1,402

1,427

1,697

1,722

1,773

1,798

Subscriber, Spouse and Two Children1

1,584

1,609

1,910

1,935

1,997

2,022

Subscriber, Spouse and Three Children1

1,765

1,790

2,124

2,149

2,221

2,246

Subscriber, Spouse and Four Children1

1,947

1,972

2,338

2,363

2,445

2,470

Subscriber, Spouse and Five or more Children1

2,207

2,232

2,644

2,669

2,766

2,791

Child Only

  182

  182

  214

  214

  224

  224

Spousal Continuation without Medicare

  506

  531

  614

  639

  640

  665

Spousal Continuation with Medicare

Not Available

  322

  322

  344

  344

1. The premium listed for “Subscriber and Spouse” and “Subscriber, Spouse and Child(ren)” assumes that both the subscriber and spouse are not in the Tobacco-Free Incentive. If one is in the Tobacco-Free Incentive, $40 will be subtracted from the listed premium.

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Retiree & Survivor without Medicare Total Premiums Level of Coverage

HSA Plan Partnership Premium

Retiree only without Medicare

Standard Premium

With Tobacco-Free Incentive

PPO 600 Plan

PPO 300 Plan

Partnership Premium

Partnership Premium

Standard Premium

Standard Premium

$768

$793

$938

$963

$956

$981

1,536

1,561

1,876

1,901

1,912

1,937

1,752

1,777

2,135

2,160

2,176

2,201

1,967

1,992

2,393

2,418

2,440

2,465

Retiree, Spouse without Medicare and Three Children

2,182

2,207

2,652

2,677

2,703

2,728

Retiree, Spouse without Medicare and Four Children1

2,397

2,422

2,910

2,935

2,967

2,992

Retiree, Spouse without Medicare and Five or more Children1

2,704

2,729

3,280

3,305

3,343

3,368

Retiree without Medicare, Spouse with Medicare

Not Available

1,260

1,285

1,300

1,325

Retiree, Spouse with Medicare and One Child

Not Available

1,518

1,543

1,564

1,589

Retiree, Spouse with Medicare and Two Children

Not Available

1,777

1,802

1,827

1,852

Retiree, Spouse with Medicare and Three Children

Not Available

2,036

2,061

2,091

2,116

Retiree, Spouse with Medicare and Four Children

Not Available

2,294

2,319

2,355

2,380

Retiree, Spouse with Medicare and Five or more Children

Not Available

2,663

2,688

2,731

2,756

Retiree and Spouse without Medicare1 Retiree, Spouse without Medicare and One Child

1

Retiree, Spouse without Medicare and Two Children1 1

Retiree and One Child

983

1,008

1,197

1,222

1,220

1,245

Retiree and Two Children

1,198

1,223

1,455

1,480

1,484

1,509

Retiree and Three Children

1,414

1,439

1,714

1,739

1,747

1,772

Retiree and Four Children

1,629

1,654

1,972

1,997

2,011

2,036

Retiree and Five or more Children

1,936

1,961

2,342

2,367

2,387

2,412

215

215

259

259

264

264

Surviving Child

*  If you are a retiree or survivor, you will receive a letter from MCHCP, stating the amount MCHCP will contribute in 2016. This figure is based on the level of coverage you had in 2015. Subtract that contribution amount from the premium cost, listed above, to determine your monthly premium. Members who choose a different level of coverage or become a retiree/survivor in 2016 will need to use the premium calculator on MCHCP’s website to find out the amount MCHCP will contribute to the total premium. 1. The premium listed for “Subscriber and Spouse” and “Subscriber, Spouse and Child(ren)” assumes that both the subscriber and spouse are in the Tobacco-Free Incentive. If only one is in the Tobacco-Free Incentive, $40 will be added to the listed premium.

78

Premiums

Retiree & Survivor without Medicare Total Premiums Level of Coverage

Retiree only without Medicare

Without Tobacco-Free Incentive

HSA Plan

PPO 600 Plan

PPO 300 Plan

Partnership Standard Premium Premium

Partnership Standard Premium Premium

Partnership Standard Premium Premium

$808

$833

$978

$1,003

$996

$1,021

1,616

1,641

1,956

1,981

1,992

2,017

1,832

1,857

2,215

2,240

2,256

2,281

2,047

2,072

2,473

2,498

2,520

2,545

2,262

2,287

2,732

2,757

2,783

2,808

2,477

2,502

2,990

3,015

3,047

3,072

Retiree, Spouse without Medicare and Five or more Children

2,784

2,809

3,360

3,385

3,423

3,448

Retiree without Medicare, Spouse with Medicare

Not Available

1,300

1,325

1,340

1,365

Retiree, Spouse with Medicare and One Child

Not Available

1,558

1,583

1,604

1,629

Retiree, Spouse with Medicare and Two Children

Not Available

1,817

1,842

1,867

1,892

Retiree, Spouse with Medicare and Three Children

Not Available

2,076

2,101

2,131

2,156

Retiree, Spouse with Medicare and Four Children

Not Available

2,334

2,359

2,395

2,420

Retiree, Spouse with Medicare and Five or more Children

Not Available

2,703

2,728

2,771

2,796

Retiree and One Child

1,023

1,048

1,237

1,262

1,260

1,285

Retiree and Two Children

1,238

1,263

1,495

1,520

1,524

1,549

Retiree and Three Children

1,454

1,479

1,754

1,779

1,787

1,812

Retiree and Four Children

1,669

1,694

2,012

2,037

2,051

2,076

Retiree and Five or more Children

1,976

2,001

2,382

2,407

2,427

2,452

215

215

259

259

264

264

Retiree and Spouse without Medicare1 Retiree, Spouse without Medicare and One Child

1

Retiree, Spouse without Medicare and Two Children1 Retiree, Spouse without Medicare and Three Children

1

Retiree, Spouse without Medicare and Four Children1 1

Surviving Child

*  If you are a retiree or survivor, you will receive a letter from MCHCP, stating the amount MCHCP will contribute in 2016. This figure is based on the level of coverage you had in 2015. Subtract that contribution amount from the premium cost, listed above, to determine your monthly premium. Members who choose a different level of coverage or become a retiree/survivor in 2016 will need to use the premium calculator on MCHCP’s website to find out the amount MCHCP will contribute to the total premium. 1. The premium listed for “Subscriber and Spouse” and “Subscriber, Spouse and Child(ren)” assumes that both the subscriber and spouse are not in the Tobacco-Free Incentive. If one is in the Tobacco-Free Incentive, $40 will be subtracted from the listed premium.

2016 Benefit Guide

State Members

79

Retiree & Survivor with Medicare Total Premiums Level of Coverage

PPO 600 Plan

PPO 300 Plan

Medicare Prescription Drug Only Plan (All covered members must have Medicare)

Retiree only with Medicare

$322

$344

$185

Retiree and Spouse without Medicare

1,260

1,300

Not Available

Retiree, Spouse without Medicare and One Child

1,518

1,564

Not Available

Retiree, Spouse without Medicare and Two Children

1,777

1,827

Not Available

Retiree, Spouse without Medicare and Three Children

2,036

2,091

Not Available

Retiree, Spouse without Medicare and Four Children

2,294

2,355

Not Available

Retiree, Spouse without Medicare and Five or more Children

2,663

2,731

Not Available

Retiree and Spouse with Medicare

643

688

 370

Retiree, Spouse with Medicare and One Child

902

952

422

Retiree, Spouse with Medicare and Two Children

1,161

1,215

474

Retiree, Spouse with Medicare and Three Children

1,419

1,479

526

Retiree, Spouse with Medicare and Four Children

1,678

1,743

578

Retiree, Spouse with Medicare and Five or more Children

2,047

2,119

652

Retiree and One Child

580

608

237

Retiree and Two Children

839

871

289

Retiree and Three Children

1,098

1,135

341

Retiree and Four Children

1,356

1,399

393

Retiree and Five or more Children

1,725

1,775

467

259

264

52

Surviving Child

*  If you are a retiree or survivor, you will receive a letter from MCHCP, stating the amount MCHCP will contribute in 2016. This figure is based on the level of coverage you had in 2015. Subtract that contribution amount from the premium cost, listed above, to determine your monthly premium. Members who choose a different level of coverage or become a retiree/survivor in 2016 will need to use the premium calculator on MCHCP’s website to find out the amount MCHCP will contribute to the total premium.

80

Premiums

Long-Term Disability Subscriber without Medicare Premiums Level of Coverage

With Tobacco-Free Incentive

HSA Plan

PPO 600 Plan

PPO 300 Plan

Partnership Standard Premium Premium

Partnership Standard Premium Premium

Partnership Standard Premium Premium

Subscriber only without Medicare

$541

$566

$711

$736

$729

$754

Subscriber and Spouse without Medicare1

1,123

1,148

1,462

1,487

1,499

1,524

Subscriber, Spouse without Medicare and One Child1

1,227

1,252

1,610

1,635

1,651

1,676

Subscriber, Spouse without Medicare and Two Children1

1,442

1,467

1,868

1,893

1,915

1,940

Subscriber, Spouse without Medicare and Three Children1

1,657

1,682

2,127

2,152

2,178

2,203

Subscriber, Spouse without Medicare and Four Children1

1,872

1,897

2,385

2,410

2,442

2,467

Subscriber, Spouse without Medicare and Five or more Children1

2,179

2,204

2,755

2,780

2,818

2,843

Subscriber without Medicare, Spouse with Medicare

Not Available

950

975

991

1,016

Subscriber, Spouse with Medicare and One Child

Not Available

1,099

1,124

1,144

1,169

Subscriber, Spouse with Medicare and Two Children

Not Available

1,357

1,382

1,408

1,433

Subscriber, Spouse with Medicare and Three Children

Not Available

1,616

1,641

1,672

1,697

Subscriber, Spouse with Medicare and Four Children

Not Available

1,875

1,900

1,935

1,960

Subscriber, Spouse with Medicare and Five or more Children

Not Available

2,244

2,269

2,312

2,337

Subscriber and One Child

647

672

860

885

884

909

Subscriber and Two Children

862

887

1,119

1,144

1,147

1,172

Subscriber and Three Children

1,077

1,102

1,378

1,403

1,411

1,436

Subscriber and Four Children

1,292

1,317

1,636

1,661

1,675

1,700

Subscriber and Five or more Children

1,600

1,625

2,005

2,030

2,051

2,076

1. The premium listed for “Subscriber and Spouse” and “Subscriber, Spouse and Child(ren)” assumes that both the subscriber and spouse are in the Tobacco-Free Incentive. If only one is in the Tobacco-Free Incentive, $40 will be added to the listed premium.

2016 Benefit Guide

State Members

81

Long-Term Disability Subscriber without Medicare Premiums Level of Coverage

HSA Plan Partnership Premium

Standard Premium

Without Tobacco-Free Incentive

PPO 600 Plan

PPO 300 Plan

Partnership Premium

Partnership Premium

Standard Premium

Standard Premium

Subscriber only without Medicare

$581

$606

$751

$776

$769

$794

Subscriber and Spouse without Medicare1

1,203

1,228

1,542

1,567

1,579

1,604

Subscriber, Spouse without Medicare and One Child1

1,307

1,332

1,690

1,715

1,731

1,756

Subscriber, Spouse without Medicare and Two Children1

1,522

1,547

1,948

1,973

1,995

2,020

Subscriber, Spouse without Medicare and Three Children1

1,737

1,762

2,207

2,232

2,258

2,283

Subscriber, Spouse without Medicare and Four Children1

1,952

1,977

2,465

2,490

2,522

2,547

Subscriber, Spouse without Medicare and Five or more Children1

2,259

2,284

2,835

2,860

2,898

2,923

Subscriber without Medicare, Spouse with Medicare

Not Available

990

1,015

1,031

1,056

Subscriber, Spouse with Medicare and One Child

Not Available

1,139

1,164

1,184

1,209

Subscriber, Spouse with Medicare and Two Children

Not Available

1,397

1,422

1,448

1,473

Subscriber, Spouse with Medicare and Three Children

Not Available

1,656

1,681

1,712

1,737

Subscriber, Spouse with Medicare and Four Children

Not Available

1,915

1,940

1,975

2,000

Subscriber, Spouse with Medicare and Five or more Children

Not Available

2,284

2,309

2,352

2,377

Subscriber and One Child

687

712

900

925

924

949

Subscriber and Two Children

902

927

1,159

1,184

1,187

1,212

Subscriber and Three Children

1,117

1,142

1,418

1,443

1,451

1,476

Subscriber and Four Children

1,332

1,357

1,676

1,701

1,715

1,740

Subscriber and Five or more Children

1,640

1,665

2,045

2,070

2,091

2,116

1. The premium listed for “Subscriber and Spouse” and “Subscriber, Spouse and Child(ren)” assumes that both the subscriber and spouse are not in the Tobacco-Free Incentive. If one is in the Tobacco-Free Incentive, $40 will be subtracted from the listed premium.

82

Premiums

Long-Term Disability Subscriber with Medicare Premiums Level of Coverage

PPO 600 Plan

PPO 300 Plan

Medicare Prescription Drug Only Plan (All covered members must have Medicare)

Subscriber only with Medicare

$204

$226

$118

923

963

Not Available

Subscriber, Spouse without Medicare and One Child

1,069

1,114

Not Available

Subscriber, Spouse without Medicare and Two Children

1,327

1,378

Not Available

Subscriber, Spouse without Medicare and Three Children

1,586

1,641

Not Available

Subscriber, Spouse without Medicare and Four Children

1,845

1,905

Not Available

Subscriber, Spouse without Medicare and Five or more Children

2,214

2,282

Not Available

Subscriber and Spouse with Medicare

410

455

237

Subscriber, Spouse with Medicare and One Child

555

604

224

Subscriber, Spouse with Medicare and Two Children

813

868

276

Subscriber, Spouse with Medicare and Three Children

1,072

1,132

328

Subscriber, Spouse with Medicare and Four Children

1,331

1,395

380

Subscriber, Spouse with Medicare and Five or more Children

1,700

1,772

454

Subscriber and One Child

351

378

106

Subscriber and Two Children

610

642

158

Subscriber and Three Children

868

906

210

Subscriber and Four Children

1,127

1,169

262

Subscriber and Five or more Children

1,496

1,546

337

Subscriber and Spouse without Medicare

2016 Benefit Guide

State Members

83

Terminated Vested Subscriber without Medicare Premiums Level of Coverage

HSA Plan Partnership Premium

Standard Premium

With Tobacco-Free Incentive

PPO 600 Plan

PPO 300 Plan

Partnership Premium

Partnership Premium

Standard Premium

Standard Premium

Subscriber only without Medicare

$631

$656

$754

$779

$768

$793

Subscriber and Spouse without Medicare1

1,262

1,287

1,508

1,533

1,537

1,562

Subscriber, Spouse without Medicare and One Child1

1,439

1,464

1,716

1,741

1,749

1,774

Subscriber, Spouse without Medicare and Two Children1

1,616

1,641

1,923

1,948

1,961

1,986

Subscriber, Spouse without Medicare and Three Children1

1,793

1,818

2,131

2,156

2,172

2,197

Subscriber, Spouse without Medicare and Four Children1

1,969

1,994

2,339

2,364

2,384

2,409

Subscriber, Spouse without Medicare & Five or more Children1

2,222

2,247

2,636

2,661

2,687

2,712

Subscriber without Medicare, Spouse with Medicare

Not Available

1,075

1,100

1,112

1,137

Subscriber, Spouse with Medicare and One Child

Not Available

1,283

1,308

1,324

1,349

Subscriber, Spouse with Medicare and Two Children

Not Available

1,491

1,516

1,536

1,561

Subscriber, Spouse with Medicare and Three Children

Not Available

1,699

1,724

1,748

1,773

Subscriber, Spouse with Medicare and Four Children

Not Available

1,907

1,932

1,960

1,985

Subscriber, Spouse with Medicare and Five or more Children

Not Available

2,204

2,229

2,262

2,287

Subscriber and One Child

808

833

962

987

980

1,005

Subscriber and Two Children

985

1,010

1,170

1,195

1,192

1,217

Subscriber and Three Children

1,161

1,186

1,377

1,402

1,404

1,429

Subscriber and Four Children

1,338

1,363

1,585

1,610

1,616

1,641

Subscriber and Five or more Children

1,591

1,616

1,882

1,907

1,919

1,944

1. The premium listed for “Subscriber and Spouse” and “Subscriber, Spouse and Child(ren)” assumes that both the subscriber and spouse are in the Tobacco-Free Incentive. If only one is in the Tobacco-Free Incentive, $40 will be added to the listed premium.

84

Premiums

Terminated Vested Subscriber without Medicare Premiums Level of Coverage

HSA Plan Partnership Premium

Standard Premium

Without Tobacco-Free Incentive

PPO 600 Plan

PPO 300 Plan

Partnership Premium

Partnership Premium

Standard Premium

Standard Premium

Subscriber only without Medicare

$671

$696

$794

$819

$808

$833

Subscriber and Spouse without Medicare1

1,342

1,367

1,588

1,613

1,617

1,642

Subscriber, Spouse without Medicare and One Child1

1,519

1,544

1,796

1,821

1,829

1,854

Subscriber, Spouse without Medicare and Two Children1

1,696

1,721

2,003

2,028

2,041

2,066

Subscriber, Spouse without Medicare and Three Children1

1,873

1,898

2,211

2,236

2,252

2,277

Subscriber, Spouse without Medicare and Four Children1

2,049

2,074

2,419

2,444

2,464

2,489

Subscriber, Spouse without Medicare and Five or more Children1

2,302

2,327

2,716

2,741

2,767

2,792

Subscriber without Medicare, Spouse with Medicare

Not Available

1,115

1,140

1,152

1,177

Subscriber, Spouse with Medicare and One Child

Not Available

1,323

1,348

1,364

1,389

Subscriber, Spouse with Medicare and Two Children

Not Available

1,531

1,556

1,576

1,601

Subscriber, Spouse with Medicare and Three Children

Not Available

1,739

1,764

1,788

1,813

Subscriber, Spouse with Medicare and Four Children

Not Available

1,947

1,972

2,000

2,025

Subscriber, Spouse with Medicare and Five or more Children

Not Available

2,244

2,269

2,302

2,327

Subscriber and One Child

848

873

1,002

1,027

1,020

1,045

Subscriber and Two Children

1,025

1,050

1,210

1,235

1,232

1,257

Subscriber and Three Children

1,201

1,226

1,417

1,442

1,444

1,469

Subscriber and Four Children

1,378

1,403

1,625

1,650

1,656

1,681

Subscriber and Five or more Children

1,631

1,656

1,922

1,947

1,959

1,984

1. The premium listed for “Subscriber and Spouse” and “Subscriber, Spouse and Child(ren)” assumes that both the subscriber and spouse are not in the Tobacco-Free Incentive. If one is in the Tobacco-Free Incentive, $40 will be subtracted from the listed premium.

2016 Benefit Guide

State Members

85

Terminated Vested Subscriber with Medicare Premiums Level of Coverage

PPO 600 Plan

PPO 300 Plan

Medicare Prescription Drug Only Plan (All covered members must have Medicare)

Subscriber only with Medicare

$322

$344

$185

Subscriber and Spouse without Medicare

1,075

1,112

  Not Available

Subscriber, Spouse without Medicare and One Child

1,334

1,376

  Not Available

Subscriber, Spouse without Medicare and Two Children

1,593

1,640

  Not Available

Subscriber, Spouse without Medicare and Three Children

1,851

1,903

  Not Available

Subscriber, Spouse without Medicare and Four Children

2,110

2,167

  Not Available

Subscriber, Spouse without Medicare and Five or more Children

2,479

2,543

  Not Available

Subscriber and Spouse with Medicare

643

688

370

Subscriber, Spouse with Medicare and One Child

902

952

422

Subscriber, Spouse with Medicare and Two Children

1,161

1,215

474

Subscriber, Spouse with Medicare and Three Children

1,419

1,479

526

Subscriber, Spouse with Medicare and Four Children

1,678

1,743

578

Subscriber, Spouse with Medicare and Five or more Children

2,047

2,119

652

Subscriber and One Child

580

608

237

Subscriber and Two Children

839

871

289

Subscriber and Three Children

1,098

1,135

341

Subscriber and Four Children

1,356

1,399

393

Subscriber and Five or more Children

1,725

1,775

467

86

Premiums

Level B Foster Parent Premiums With Tobacco-Free Incentive Level of Coverage

HSA Plan

PPO 600 Plan

PPO 300 Plan

Partnership Standard Premium Premium

Partnership Standard Premium Premium

Partnership Standard Premium Premium

Subscriber Only

$481

$506

$562

$587

$589

$614

Subscriber and Spouse1

1,168

1,193

1,376

1,401

1,440

1,465

Subscriber and One Child

684

709

772

797

808

833

Subscriber and Two Children

862

887

981

1,006

1,028

1,053

Subscriber and Three Children

1,040

1,065

1,191

1,216

1,248

1,273

Subscriber and Four Children

1,218

1,243

1,400

1,425

1,467

1,492

Subscriber and Five or more Children

1,474

1,499

1,701

1,726

1,782

1,807

Subscriber, Spouse and One Child1

1,346

1,371

1,585

1,610

1,659

1,684

Subscriber, Spouse and Two Children1

1,524

1,549

1,795

1,820

1,879

1,904

Subscriber, Spouse and Three Children1

1,702

1,727

2,004

2,029

2,099

2,124

Subscriber, Spouse and Four Children1

1,880

1,905

2,214

2,239

2,318

2,343

Subscriber, Spouse and Five or more Children1

2,136

2,161

2,514

2,539

2,634

2,659

1. The premium listed for “Subscriber and Spouse” and “Subscriber, Spouse and Child(ren)” assumes that both the subscriber and spouse are in the Tobacco-Free Incentive. If only one is in the Tobacco-Free Incentive, $40 will be added to the listed premium.

2016 Benefit Guide

State Members

87

Level B Foster Parent Premiums Without Tobacco-Free Incentive Level of Coverage

HSA Plan Partnership Premium

Standard Premium

PPO 600 Plan

PPO 300 Plan

Partnership Premium

Partnership Premium

Standard Premium

Standard Premium

Subscriber Only

$521

$546

$602

$627

$629

$654

Subscriber and Spouse1

1,248

1,273

1,456

1,481

1,520

1,545

Subscriber and One Child

724

749

812

837

848

873

Subscriber and Two Children

902

927

1,021

1,046

1,068

1,093

Subscriber and Three Children

1,080

1,105

1,231

1,256

1,288

1,313

Subscriber and Four Children

1,258

1,283

1,440

1,465

1,507

1,532

Subscriber and Five or more Children

1,514

1,539

1,741

1,766

1,822

1,847

Subscriber, Spouse and One Child1

1,426

1,451

1,665

1,690

1,739

1,764

Subscriber, Spouse and Two Children1

1,604

1,629

1,875

1,900

1,959

1,984

Subscriber, Spouse and Three Children1

1,782

1,807

2,084

2,109

2,179

2,204

Subscriber, Spouse and Four Children1

1,960

1,985

2,294

2,319

2,398

2,423

Subscriber, Spouse and Five or more Children1

2,216

2,241

2,594

2,619

2,714

2,739

1. The premium listed for “Subscriber and Spouse” and “Subscriber, Spouse and Child(ren)” assumes that both the subscriber and spouse are not in the Tobacco-Free Incentive. If one is in the Tobacco-Free Incentive, $40 will be subtracted from the listed premium.

88

Premiums

Dental, Vision, and TRICARE Premiums Dental Premiums Subscriber Only

Subscriber and Spouse

Subscriber and Child(ren)

Subscriber and Family

COBRA Child(ren)

Active Employee

$25.36

$50.50

$52.42

$87.88

Not Available

Leave of Absence

$25.36

$50.50

$52.42

$87.88

Not Available

COBRA Subscriber

$25.86

$51.51

$53.47

$89.64

$27.61

Retiree, Long-Term Disability, Terminated Vested and Survivor

$25.36

$50.50

$52.42

$87.88

Not Available

Subscriber Only

Subscriber and Spouse

Subscriber and Child(ren)

Subscriber and Family

COBRA Child(ren)

Basic Plan

Premium Plan

Basic Plan

Premium Plan

Basic Plan

Premium Plan

Basic Plan

Premium Plan

Basic Plan

Active Employee

$3.84

$4.84

$7.68

$9.66

$11.06

$13.96

$15.78

$19.90

Not Available

Leave of Absence

$3.84

$4.84

$7.68

$9.66

$11.06

$13.96

$15.78

$19.90

Not Available

COBRA Subscriber

$3.91

$4.94

$7.82

$9.85

$11.28

$14.23

$16.10

$20.30

$7.37

Retiree, Long-Term Disability, Terminated Vested and Survivor

$4.00

$5.05

$8.01

$10.09

$11.55

$14.57

$16.48

$20.79

Not Available

Vision Premiums

Premium Plan

$9.29

TRICARE Supplement Premiums Employee Only

 $60.50

Employee and Spouse

$119.50

Employee and Child(ren)

$119.50

Employee and Family

$160.50

2016 Benefit Guide

State Members

89

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Section 5

Contact

Contact Information

Who to Contact Your plan for: Claim questions ID cards Specific benefit questions Appeal information

MCHCP for: General benefit questions Eligibility questions Enrollment questions Address changes or forms MCHCPid requests HIPAA forms and questions

Contact Information Medical Plan UMR

Non-Medicare Prescription Drug Plan Express Scripts, Inc. (ESI)

HSA Plan, PPO 600, and PPO 300 www.umr.com 888-200-1167

www.express-scripts.com 800-797-5754 TTY: 866-707-1862

Claims Address PO Box 30787 Salt Lake City, UT 84130-0787

Home Delivery Pharmacy Service PO Box 66773 St. Louis, MO 63166-6773

Appeals Addresses Pre-service and Concurrent Claims UMR Appeals PO Box 400046 San Antonio, TX 78229

Appeals Address Express Scripts PO Box 66588 St. Louis, MO 63166-6588 Attn: Clinical Appeals Department 800-753-2851

Post-service Claims UMR Claims Appeal Unit PO Box 30546 Salt Lake City, UT 84130-0546

Medical Plan Aetna

Medicare Prescription Drug Plan Express Scripts Medicare www.express-scripts.com 866-544-6963 TTY: 800-716-3231

HSA Plan, PPO 600, and PPO 300 www.aetna.com 800-245-0618

Medicare Home Delivery Pharmacy Service PO Box 66577 St. Louis, MO 63166-9843

Claims Address PO Box 14079 Lexington, KY 40512-4079

Appeals Address Express Scripts PO Box 66588 St. Louis, MO 63166-6588 Attn: Medicare Clinical Appeals 800-935-6103

Appeals Address Appeals Resolution Team PO Box 14463 Lexington, KY 40512

Accredo Specialty Pharmacy 800-803-2523 TTY: 877-804-9222

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Contact

Contact Information Dental Plan Delta Dental

www.deltadentalmo.com/stateofmo 866-737-9802 PO Box 8690 St. Louis, MO 63126-0690

Disease Management Program

TRICARE Supplement Plan

www.my.mchcp.org 844-246-2427 (844-24MCHCP)

800-638-2610

Alere

Claims Address PO Box 8690 St. Louis, MO 63126-0690

Quit Tobacco Health Coaching

Appeals Addresses First-Level Appeals Address Attn: Customer Service 12399 Gravois Road St. Louis, MO 63127

www.my.mchcp.org 844-246-2427 (844-24MCHCP)

Second-Level Appeals Address Attn: Appeals Committee 12399 Gravois Road St. Louis, MO 63127

Vision Plan

National Vision Administrators, L.L.C. (NVA) www.e-nva.com User Name: mchcp Password: vision1 877-300-6641 Claims Address Attn: Claims PO Box 2187 Clifton, NJ 07015

Alere

Selman & Company

www.selmantricareresource.com/MCHCP

Employee Assistance Program ComPsych®

www.guidanceresources.com Web ID: MCHCP 800-808-2261

Strive for Wellness® Program

Nurse Call Lines

www.mchcp.org

If you’re unsure whether to go to the doctor for an illness or just want more information about a treatment or condition, registered nurses are on hand all day, every day to help.

Quit Tobacco and Weight Management Programs

Attn: Wellness Department 832 Weathered Rock Court Jefferson City, MO 65110 Member Services: 573-751-0771 Toll-free: 800-487-0771

Strive for Wellness® Health Center www.my.mchcp.org 301 W. High St. Jefferson City, MO 573-526-3175

All MCHCP medical plan members have access to 24-hour nurse call lines for health-related questions.

Helpful Tips Websites Plan websites are provided as a convenience to our members. The inclusion of other websites does not mean MCHCP endorses or is responsible for those websites. Provider Directories Participating providers may change during the year. Contact the plan or the provider to verify participation. Contact UMR or Aetna for a list of network providers. Benefit Information This guide provides a summary of your benefits. More detailed information is available at www.mchcp.org or from the plans.

To use this service, call your medical plan:

UMR NurseLine 888-200-1167

Aetna – Informed Health Line 800-556-1555

Appeals Address Attn: Complaints, Grievances & Appeals PO Box 2187 Clifton, NJ 07015

2016 Benefit Guide

State Members

93

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About Us Website

Missouri Consolidated Health Care Plan

www.mchcp.org

Hours 8:30 a.m.– 4:30 p.m. Monday – Friday

Phone 800-487-0771 or 573-751-0771

Fax 866-346-8785

Address 832 Weathered Rock Court PO Box 104355 Jefferson City, MO 65110-4355

Our vision is to be recognized and valued by our members as their advocate in providing affordable, accessible, quality health care options.

Who We Are

MCHCP’s Mission

MCHCP provides coverage to employees and retirees of most state agencies as well as public entities that have joined MCHCP. Nearly 100,000 state and public entity members are covered by MCHCP.

To provide access to quality and affordable health insurance to state and local government employees. We will accomplish this by:

MCHCP is a separate, stand-alone state entity created by statute and organized under the direction of a 13-member board of trustees.

• Consolidating purchasing power and administration to achieve benefits not available to individual employer members • Creating collaborations to ensure the needs of individual members are understood and met

• Ensuring fiscal responsibility • Developing innovative delivery options and incentives • Identifying and contracting with high-value plans • Maintaining a high-quality and knowledgeable work force

2016 Benefit Guide

State Members

95

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832 Weathered Rock Court Jefferson City, MO 65101 800-487-0771 573-751-0771

www.mchcp.org myMCHCP