FALL ’15
SeniorBlue PPO SeniorBlue HMO ®
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Medications What’s Your Health Score? Take the test!
Questions you should ask
New Incentives for Preventive Exams
Capital BlueCross is an Independent Licensee of the BlueCross BlueShield Association
Y0016_MK15_079 Accepted 09262015
ANNUAL ELECTION PERIOD and Much More!
Living Well is published as a service for SeniorBlue PPO and SeniorBlue HMO members. PO Box 779821 Harrisburg, PA 17177-9821 Fall 2015 Lisa W. Sackett, Editor SeniorBlue PPO Customer Service: 1-866-987-4213 SeniorBlue HMO Customer Service: 1-800-779-6962 TTY (both plans): 1-800-779-6961 (711 effective January 1, 2016) Monday through Friday: 8 a.m. – 8 p.m.
It’s time to lock in your choice for next year’s health care coverage. Capital BlueCross makes it easy to continue your SeniorBlue PPO or SeniorBlue HMO plan — no action is needed! Your coverage will automatically renew on January 1, 2016. The Medicare annual election period runs October 15 through December 7. If you have questions about your options, please call us for assistance. (See phone numbers on the left.) Speaking of next year, inside this edition of Living Well, we take a look at what’s new for 2016 including:
Copyright © 2015 by Capital BlueCross SeniorBlue® PPO is offered by Capital Advantage Insurance Company,® a Medicare Advantage organization with a Medicare contract. SeniorBlue® HMO is offered by Keystone Health Plan® Central, a Medicare Advantage organization with a Medicare contract. Enrollment in SeniorBlue PPO and SeniorBlue HMO depends on contract renewal. Dental and vision benefits are issued by Capital Advantage Assurance Company,® a subsidiary of Capital BlueCross. Capital BlueCross and its subsidiaries Capital Advantage Insurance Company, Capital Advantage Assurance Company and Keystone Health Plan Central are independent licensees of the BlueCross BlueShield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.
■ How you can earn a $25 gift card for getting your annual preventive exam ■ A new innovative approach to help members who have heart failure ■ An update on your prescription drug benefits and how you can best manage your medication needs All of this information applies to SeniorBlue PPO and SeniorBlue HMO plans. Enjoy this edition of Living Well. And have a happy and healthy rest of 2015!
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PERSONAL PROFILE
How it works
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Online coaching programs
Register or sign on to your secure member page at CapitalBlueMedicare.com. The Login button is at the top right of the page.
Our confidential and convenient digital coaching programs address many health conditions and lifestyle habits. Read about wellness strategies, learn how to change behaviors, and get advice on these topics:
Click on the Personal Profile link.
■ Back pain
Complete the Personal Profile. After you click Submit, you will receive your health score and a personalized wellness plan.
■ Blood pressure
■ Binge eating
■ Cholesterol ■ Chronic conditions ■ Chronic pain
Review the wellness plan to learn what lifestyle choices and health habits you can change to improve your health.
■ Depression ■ Diabetes ■ Insomnia
What’s your health score? We can help you improve it!
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Take recommended online coaching programs to receive guidance that can help you make the changes suggested in your wellness plan.
■ Nutrition ■ Physical activity ■ Smoking/tobacco cessation
Where does your health status fall on a scale from 1 to 100? By completing a Personal Profile, you can find out. Even better, you can learn how to improve your score and live healthier!
■ Stress management ■ Weight management
The Personal Profile is an online questionnaire* that evaluates your overall health based on answers to questions about weight, diet, physical activity, tobacco and alcohol use, stress, and other lifestyle behaviors. In addition to generating a score, completing the profile will provide you with a personalized wellness plan that includes ideas for healthy living and recommended online health coaching programs. *If you do not have internet access, call the number on your ID card and ask for a paper copy of the Personal Profile. Complete and mail it back for your health score and wellness plan. On behalf of Capital BlueCross, Johnson & Johnson Health and Wellness Solutions, Inc., an independent company, assists in the administration of health management programs.
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Your plan will include one of these formularies: Expanded Performance Formulary ■ Five tiers of copays, with generic drugs on Tiers 1 and 2, brand name drugs on Tier 3, brand name and select generic drugs on Tier 4, and specialty drugs on Tier 5 ■ Brand name drugs with generic equivalents are no longer included* Generic Standard Formulary ■ Five tiers of copays, with a mix of generic and brand name drugs on all five tiers ■ Some generic drugs will be covered at a higher tier with a higher cost share*
Your Prescription Drug Benefit Looking ahead to 2016 In September, Capital BlueCross mailed the 2016 formulary — a list of drugs covered by your plan — to SeniorBlue PPO and SeniorBlue HMO members. Please take time to find your prescribed drugs, as changes may affect how much you pay for them. You can find more information about your prescription drug coverage in your Evidence of Coverage.
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If you have questions about your prescription drug benefit, please call CVS/caremark™ at 1-800-861-1737 if you are a SeniorBlue PPO member, or 1-800-844-0719 if you are a SeniorBlue HMO member. (TTY: 1-866-236-1069; 711 effective January 1, 2016.) CVS/caremark is available to assist you 24 hours a day, seven days a week. Visit CapitalBlueMedicare.com and click on the Pharmacy Information link at the top to view the current and 2016 formularies and locate other helpful information about your pharmacy benefit.
*To reduce your out-of-pocket expenses, consider asking your doctor about alternative drugs you can take that are included in the formulary. On behalf of Capital BlueCross, CVS/caremarkTM assists in the administration of our prescription drug program. CVS/caremark is an independent pharmacy benefit manager.
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KNOW YOUR MEDS
For chronic conditions — health problems that are ongoing or last a long time — doctors commonly prescribe medications that help keep symptoms from getting worse. If not taken as directed, drugs may not work as expected.
Medication tips ■ Take medications at the same time every day unless your doctor directs otherwise – When is the best time for you to remember? Breakfast time? When you brush your teeth? Whatever time you decide, staying consistent will help you develop a routine. ■ Keep track of your medicines
You should always ask these questions about each drug your doctor prescribes: What is it? Why am I taking it? How and when should I take it? What happens if I don’t take it as prescribed? Ask your doctor or pharmacist for help understanding how to take your medications when you are unsure.
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– Use a pill box or calendar for easy access to daily reminders ■ Your pharmacy can help – Ask your pharmacy to alert you when a refill is needed; if you are using the network mail order delivery program, you can set up automatic refills by contacting CVS/caremark ■ Speak with your doctor about options if: – Your medication routine is too complicated — often the number of daily doses can be reduced so remembering to take pills is easier – You cannot afford your medications — there may be less costly, yet suitable alternatives – You think your medication is not helping — never stop taking any medication without your doctor’s guidance
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An extra hand from a pharmacist Have you received a letter or phone call explaining that you qualify for our Medication Therapy Management (MTM) program? A free and voluntary service, the MTM program is offered to members enrolled in a Medicare Part D drug plan who are managing long-term health conditions* to: ■ Reduce the risk of drug reactions and side effects ■ Help you use medications as effectively as possible Services, which are provided by a pharmacist, include: ■ Comprehensive Medication Review – Annual phone or face-to-face interview that takes
about 30 minutes
– You receive a Personal Medication List and
Medication Action Plan to take along to your
next doctor visit
■ Targeted Medication Reviews – Quarterly reviews of medications – Recommendations are provided directly to your
primary care physician
* Enrollment is automatic if you meet certain requirements, but you can decline to participate.
How will you know if the caller is a representative of the MTM program? MTM services may be provided by Mirixa Community Pharmacy Services, Town Total Health, or your local community pharmacy. If you are unsure about a letter or phone call you received, or would like more information, please call 1-800-861-1737 (SeniorBlue PPO) or 1-800-844-0719 (SeniorBlue HMO) (TTY: 1-866-236-1069; 711 effective January 1, 2016.)
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Statins Can Help Lower Cholesterol Ask your doctor if one is right for you High blood cholesterol (LDL) is a major risk factor for heart attack and stroke. For some people, changes to diet and activity level alone can help lower cholesterol. But for others, medication also is needed.
Did you know? Someone dies from a heart attack or stroke every 39 seconds. Reduce your risk by managing high cholesterol!
While plenty of medications can lower cholesterol, one group — called statins — is recommended for most people. Why? Because statins are the only cholesterollowering drug class directly associated with lowering the risk of heart attack and stroke.
National organizations — including American Heart Association, American College of Cardiology, and American Diabetes Association — recommend statins for some people with diabetes, high cholesterol, and certain forms of heart disease. If you have these conditions and are not taking a statin, ask your doctor about the risks and benefits and if one could be right for you. Statin or statin combination drugs available on one or both 2016 formularies: ■ Advicor®
■ Lescol® XL
■ Simcor®
■ Altoprev®
■ Liptruzet™
■ simvastatin*
■ atorvastatin*
■ Livalo®
■ Vytorin®
■ Crestor®
■ lovastatin*
■ fluvastatin*
■ pravastatin*
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New policy In the last edition of Living Well, we informed you of a new policy from the Centers for Medicare and Medicaid Services (CMS) for Part D prescribers. The policy requires all doctors — including dentists and ophthalmologists — who write prescriptions covered under the Medicare Part D benefit, to be enrolled in Medicare or have a valid opt-out status with Medicare. CMS has delayed the policy effective date to January 1, 2016, and will begin enforcing this requirement on June 1, 2016. CMS will allow Capital BlueCross to provide a one-time, three-month supply if a covered prescription is written by a health care provider who is not enrolled in Medicare or who has not opted out of Medicare. However, future prescriptions written by the provider will not be covered. You will receive a written notice from Capital BlueCross if that occurs.
What you should do *Generic medication
CVS/caremark PPO: 1-800-861-1737 HMO: 1-800-844-0719 TTY: 1-866-236-1069 (711 effective January 1, 2016)
To verify coverage of specific statins under your plan, call CVS/caremark or visit CapitalBlueMedicare.com.
Part D Prescriber Enrollment Requirement — Update
To avoid any financial impact or inconvenience, ask your doctor and other health care providers if they are enrolled in Medicare or have a valid opt-out status with Medicare in order for your prescription to be covered. You also can call the Customer Service number on your plan ID card if you have questions.
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Diabetic Retinal Eye Exams
Annual Wellness Visit
If you have diabetes, you know it is important to monitor your blood sugar. Poorly controlled diabetes can lead to complications of almost every organ of the body, including your eyes.
Kids get annual check-ups — why shouldn’t you?
Diabetic eye disease may begin with blurry or black spots in your vision and can lead to blindness. However, you can have diabetic eye disease even if you aren’t seeing black spots. An eye care provider can detect problems related to diabetes before you see changes in your vision. Get your annual diabetic retinal eye exam to ensure healthy eyes for many years to come. SeniorBlue PPO and SeniorBlue HMO plans cover a diabetic retinal eye exam with a medical provider or with an eye care specialist, ophthalmologist, or optometrist. Applicable copays or coinsurance are applied to the diabetic eye exam.
Having an annual wellness visit is key to staying healthy. An annual exam can help your doctor find problems before they start, and it gives you the chance to bring up health concerns you have. Your appointment allows time for you and your doctor to review medications, treatment plans, and topics such as exercise and diet, balance and fall prevention, bone health, and bladder control. No copay or deductible applies to this important benefit when provided by network providers. Cost sharing for SeniorBlue PPO members may vary when provided
by an out-of-network provider. SeniorBlue HMO members must visit in-network providers for most services, including the annual wellness visit.
Immunizations and Screenings to Keep You Healthy At your annual wellness visit — or the next time you see your doctor — remember to ask if your immunizations are up to date. Your doctor also can determine if any health screenings to detect disease are necessary. In most cases, immunizations and preventive health screenings* are covered.
*Capital BlueCross reviews standards and recommendations from nationally recognized organizations and the Centers for Medicare and Medicaid Services (CMS) to prepare preventive guidelines. Covered preventive services are subject to the age and frequency rules explained in our Health Maintenance Guidelines. Cost sharing may apply. For a complete schedule of preventive health services, visit CapitalBlueMedicare.com and click on Health and Wellness or call the Customer Service number on your plan ID card to request a copy.
GET PAID TO HAVE THESE IMPORTANT EXAMS! Living Well
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■ $25 GIFT CARD for members with diabetes who have a diabetic retinal eye exam with an eye care specialist, ophthalmologist, or optometrist ■ $25 GIFT CARD for members who have an annual wellness visit Eligibility is from January 1 through December 31, 2016, for SeniorBlue PPO and SeniorBlue HMO members. No special forms are needed. A gift card voucher will be mailed to your home within two weeks after your provider files the service claim with Capital BlueCross.
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New in 2016 Technology is rapidly changing the delivery of health care, and Capital BlueCross is leading the way with innovative use of technology to improve our members’ health.
Lab Services
Video Doctor Visits
Your benefits for lab services are changing in 2016. Currently, these services are covered at no cost to you.
Starting January 1, 2016, SeniorBlue PPO members will have the option to see a doctor by live, high-quality video using a smartphone, tablet, or computer.
In 2016, you can continue to have these services covered at no cost when you have them performed in an independent free standing lab such as Quest Diagnostics or Health Network Laboratories. However, you will pay 20% coinsurance when your lab services are performed in an outpatient setting such as a hospital.*
Televisits are an alternative when your doctor’s office is closed, when you are too sick or busy to go to your doctor’s office, or when you are traveling. During televisits, doctors can diagnose common conditions and even write prescriptions that are sent straight to your pharmacy. Read more about this exciting new benefit in your SeniorBlue PPO Annual Notice of Change and the Evidence of Coverage on CapitalBlueMedicare.com.
*SeniorBlue HMO exception: Cost sharing will not apply when lab work is performed at Milton S. Hershey Medical Center.
Telemonitoring Services If you have experienced heart complications, we may contact you
to participate in our new telemonitoring program that starts in 2016.
Telemonitoring involves the use of a small wearable monitor
that wirelessly transmits data to your doctor or care manager.
Our nurses will work with you and your doctor to assess your health
and decide if remote monitoring of your vital signs is a good fit for you.
It’s free and it’s easy. All health monitoring equipment is provided at no cost, and we will teach you how to use it. Your doctor will receive reports of daily measurements captured by the equipment and will have more data than ever to treat your condition and help you live healthier.
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Are You at Risk for Osteoporosis? Osteoporosis is a condition in which bones lose density and become weak and brittle. Many health factors and habits put you at risk for developing osteoporosis. The more that apply to you, the greater your chance is of developing osteoporosis. You cannot change certain risk factors because they result from genetics or other factors out of your control. These include: ■ Family history of broken bones or osteoporosis ■ Ethnic background (Caucasian and Asian are at highest risk)
Osteoporosis is called “the silent thief” because there are no symptoms as the bones weaken. A bone mineral density test is the only way to know if you have bone loss. The test is covered by SeniorBlue PPO and SeniorBlue HMO. For coverage requirements and additional information, refer to your Medical Benefits Chart in your Evidence of Coverage.
■ Being a small, thin woman ■ Drop in estrogen level due to menopause ■ Thyroid disease and other conditions requiring steroids and other medications that can cause bone density loss However, there are risk factors you can change, and it is possible to improve your bone health even if you already have bone loss. RISK FACTOR
WHAT YOU CAN DO ABOUT IT
Get the daily recommended amounts of each Low calcium and (varies by age and gender, so ask your doctor vitamin D intake or visit the websites noted below). Lack of physical activity
Move more and do weight-bearing, muscle-strengthening exercises.
Smoking
Quit today! Smoking has many negative effects on your body, including reduced absorption of calcium needed for healthy bones.
Excessive alcohol use
Limit how much you drink. Alcohol reduces calcium absorption and can make you unbalanced and prone to falls and bone breaks.
To learn more about preventing and treating osteoporosis, visit NIH Senior Health at nihseniorhealth.gov or the National Osteoporosis Foundation at nof.org.
Source: National Institutes of Health, Senior Health
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Getting More Value from Your Health Plan
New Medicare Updates
Shop before receiving services You shop for the best price when buying a car, TV, or appliance. You can do the same for your health care! We put you in the driver’s seat, with access to online tools and resources, like the Search & Save Center, that can help you find the best care at the best price.
Capital BlueCross is committed to providing coverage that is equal to or more generous than Original Medicare. To demonstrate this commitment, we post updates of any new coverage or change in coverage we receive from the Centers for Medicare and Medicaid Services (CMS) on our member websites within 30 days of their release. These periodic updates are called National Coverage Determinations (NCDs). NCDs are nationwide determinations of whether items or services are considered medically necessary under Medicare, and they pertain to procedures, drugs, and medical devices. The following new NCDs are posted to CapitalBlueMedicare.com. They are included here in case you have not had the opportunity to review them online. Please note coverage for these NCDs may be retroactive or coverage may have been implemented retroactively to the effective date.
Transcatheter Mitral Valve Repair (TMVR) Effective Date: August 7, 2014 Find a doctor or hospital.
Compare treatment costs.
Search our database of network doctors and facilities by name, specialty, and location.
From office visits to inpatient procedures, you can look up the most common costs of medical services.
Personalize it. Once you know where you want to go for care and how much it will cost, we can help you estimate how much you’ll spend out-of-pocket, based upon your benefits.
The Search & Save Center is just one of many health management resources available on our website at CapitalBlueMedicare.com. Click on Provider Directory to get started. You’ll find programs to help you live healthy, information about your benefits, and much more when you register for a secure member page.
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Implementation Date: April 6, 2015 Transcatheter Mitral Valve Repair (TMVR) is a less invasive way to repair one of the valves in the heart called the mitral valve (MV) if the valve does not close completely. When the valve doesn’t close, it allows blood to flow backward in the heart when the heart contracts. This condition is called mitral regurgitation (MR). When MR exists for an extended period of time, the top part of the heart begins to enlarge and does not function quite as well. Abbott’s MitraClip, the only FDA-approved TMVR device, clips together a portion of the mitral valve leaflets. While under general anesthesia, the device is put in place through a vein, using ultrasound or x-ray guidance. The procedure is typically performed in a cardiac catheterization lab. TMVR is covered to treat MR. When used for other reasons that have not been evaluated by the FDA, this treatment may be covered if performed within an approved clinical study which meets certain study question requirements. TMVR is performed by a specialist, typically a heart surgeon or cardiologist, trained to repair the heart valve using the MitraClip. Effective for dates of service on and after August 7, 2014, TMVR is covered under Coverage with Evidence Development (CED) when the
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treatment is furnished for the treatment of mitral regurgitation and according to an FDA-approved indication with an FDA-approved device, CED requires that each patient be entered into a qualified national registry. In addition, prior to receiving TMVR, face-to-face examinations of the patients are required by a cardiac surgeon and a cardiologist experienced in mitral valve surgery to evaluate the patient’s suitability for TMVR. TMVR is noncovered for the treatment of MR when not furnished under CED according to the above-noted criteria. TMVR used for the treatment of any non-MR indications are noncovered.
Single Chamber and Dual Chamber Permanent Cardiac Pacemakers Effective Date: July 13, 2013 Implementation Date: July 6, 2015 Permanent cardiac pacemakers refer to a group of self-contained, battery-operated, implanted devices that send electrical stimulation to the heart through one or more implanted leads. Single chamber pacemakers typically target either the right atrium or right ventricle. Dual chamber pacemakers stimulate both the right atrium and the right ventricle. The implantation procedure is typically performed under local anesthesia and requires only a brief hospitalization. A catheter is inserted into the chest and the pacemaker’s leads are threaded through the catheter to the appropriate chamber(s) of the heart. The surgeon then makes a small pocket in the pad of the flesh under the skin on the upper portion of the chest wall to hold the power source. The pocket is then closed with stitches. Effective for claims with dates of service on or after August 13, 2013, implanted permanent cardiac pacemakers are covered for the treatment of permanent bradycardia (pulse rate under 60 beats/ minute) that causes symptoms when it is caused by heart block and sinus node problems. Some common symptoms of bradycardia are fainting, seizures, congestive heart failure, dizziness, or confusion.
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Microvolt T-Wave Alternans (MTWA) Effective Date: January 13, 2015 Implementation Date: June 23, 2015 Microvolt T-wave Alternans (MTWA) testing is a non-invasive diagnostic test that looks at a portion of the electrocardiogram (ECG) heart rhythm strip known as the T-wave. The T-wave occurs when the lower part of the heart (the ventricle) is relaxing. During testing, a patient exercises (or takes medication) to increase the heart rate to 110 beats per minute during which time the ECG is recorded. The ECG is then reviewed to see how much the height of the T-wave changes with each heartbeat. Differences in the T-wave height are extremely small and not usually detectable with the naked eye. This testing may help to predict which patients are at a higher risk for abnormal heart rhythms that could result in sudden cardiac death (SCD). For patients who may be eligible for an implantable cardioverter defibrillator (ICD), a negative MTWA test may be helpful in identifying low-risk patients who are not likely to benefit from, or who may actually have worse outcomes from, ICD placement. Unchanged: Effective for claims with dates of service on and after March 21, 2006, MTWA diagnostic testing is covered for the evaluation of patients at risk for SCD, only when the spectral analysis (SA) method is used. Changed: Effective for claims with dates of service on and after January 21, 2015, Medicare Administrative Contractors (MACs) acting within their respective jurisdictions may determine coverage of MTWA diagnostic testing for the evaluation of patients at risk for SCD using all other methods. Contact Customer Service if you have questions about NCDs.
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Your Privacy is Important to Us At Capital BlueCross, we are committed to providing you with the highest quality health care products and services. An important part of this commitment is our pledge to protect your nonpublic personal financial information.
Our Privacy Pledge
Medical Identify Theft Medical identity theft is a serious crime. It occurs when someone uses your personal information — such as your name, health care identification number, or Social Security number — to get medical care, buy prescription drugs, or send false bills to your insurance company.
How to protect yourself ■ Treat your health insurance ID card as you would your credit card ■ Be suspicious if someone offers free medical supplies or services but requests insurance information — there’s no need for insurance information when supplies or services are free ■ Never allow others to use your health insurance ID card for themselves ■ Check your explanation of benefits against your credit card statements and bills — look for inconsistencies in provider names, service dates, and procedures performed
If you suspect medical identity theft or fraud, call the Capital BlueCross fraud hotline at 1-888-612-1277 or email
[email protected]. You also can contact the Capital BlueCross compliance hotline at 1-888-511-4036 or Medicare at 1-800-633-4227 (TTY 1-877-486-2048).
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Capital BlueCross does not sell customer information. We do not disclose your nonpublic personal financial information, except as permitted by law. We do not disclose this information, even when our customer relationships end, except as permitted by law.
Information We Collect We collect nonpublic personal financial information about you from: ■ Applications and other forms ■ Transactions (such as claims submissions and payments) with us, our affiliates, or others ■ Outside sources, such as health care providers, other insurance companies, and federal and state agencies
How We Protect Your Information Our policies restrict access of your information to employees who need it to provide you with our products and services, and as permitted by law. We maintain physical, electronic, and procedural safeguards that comply with legal requirements to protect your nonpublic personal financial information. Capital BlueCross also maintains a Notice of Privacy Practices, which you can access from your secure member page at CapitalBlueMedicare.com. If you have any questions about our privacy policy or want to receive a printed copy of our Notice of Privacy Practices, please call the Customer Service number on your plan ID card.
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®
SeniorBlue HMO
N39-69 (9/15)
Capital BlueCross is an Independent Licensee of the BlueCross BlueShield Association
The information in this newsletter is not a substitute for services performed by health care providers. Content is based on general medical guidelines. Only your doctor, and/or other health care providers can diagnose and treat your individual medical conditions. Capital BlueCross obtained and/or developed this content from outside resources. It believes these education resources provide useful information, but it does not assume any liability associated with the resources. If you have any concerns or questions about specific content that may affect your health, please contact your health care provider.
We are pleased to provide one newsletter per mailing address. Thank you for sharing this important information with others in your household.
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SeniorBlue PPO
Harrisburg, PA 17177-9821
PO Box 779821
