HealthSCOPE Benefits Whirlpool Lakeland Care 2010 Provider Tool Kit
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HealthSCOPE Benefits Whirlpool Lakeland Care 2010 Provider Tool Kit
Claims
and
Customer Service
HealthSCOPE Benefits / Whirlpool
Customer Care Tools
1-800-660-6212
www.healthscopebenefits.com
• Pre-certification/Pre-authorization
• Claim Status
• Eligibility
• Benefit Information
• Provider Network verification
• Copies of EOBs
• HSB offers Electronic Fund Transfer (EFT) payment options
HealthSCOPE Benefits Whirlpool
Customer Care Tools
www.healthscopebenefits.com
9Click on Provider
Check on:
9Claim Status
9Eligibility
9Benefit Information
9Provider Network verification
9Copies of EOBs
HealthSCOPE Benefits
Claim Submission Tools
• Sample ID Card-Active Members and
Pre-Medicare Retirees
• Lakeland Care and HealthSCPOPE Benefits
network locally
– Cofinity for rest of Michigan
– Lakeland Claims Submission
– EDI Payor ID 71063
– P.O. Box 619055 Dallas, TX 75261-9055
HealthSCOPE Benefits
Claim Submission Tools
•Sample ID Cards-Medicare Primary
Members
– Medicare Claims are received directly from
Medicare Payer
– If necessary, claims can be filed directly to
HealthSCOPE Benefits with Medicare
EOB to HealthSCOPE Benefits
P.O. Box 619055 Dallas, TX 75261-9055
HealthSCOPE Benefits
Electronic Payments
HealthSCOPE Benefits is pleased to offer an electronic
payment (ACH) option to participating providers.
Please complete the form included in this Tool Kit to
initiate your enrollment in this expedited payment option.
AGREEMENT FOR PROVIDER ELECTRONIC PAYMENTS
(via ACH)
HealthSCOPE Benefits is pleased to offer an electronic payment (ACH) option to
participating providers. Please complete the below to initiate your enrollment in
this expedited payment option.
Note: Payment detail will be provided via an 835 electronic transaction.
Provider Information:
Provider Name:
Federal Tax Identification Number:
Provider Contact: Phone:
Provider Address:
E-mail address for Payment Notification:
Provider Technical (for FTP setup of 835 retrieval)
Technical Contact: Phone:
Technical Contact E-mail:
Bank Information:
Bank Name:
Account Number
Routing Number
Bank City/State:
Bank Contact Name: Phone:
Bank Contact E-mail:
This authorization is to remain in full force and effect until HealthSCOPE Benefits has
received written notification of its termination in such a manner as to afford
HealthSCOPE Benefits and the depository financial institution a reasonable opportunity
to act on it.
Name (please print)
Date Authorized Signature
2010 Whirlpool Active Benefits • HealthSCOPE Benefits (HSB) selected to replace UnitedHealthcare • Two health plan options • Both plan options offer an opportunity for mem- bers to earn incentive dollars toward medical expenses • New $0 copay for certain prescription drugs • 100% coverage for certain value-based benefits for diabetic preventive visits, drugs and supplies • New and improved benefit design encourages use of proven medical treatments and preven- tive services
2010 HEALTHCARE HIGHLIGHTS
Main
Salaried Employees at: Hourly Employees at:
Amana Evansville Marion Benton Harbor Knoxville
Benton Harbor Findlay Newton Cleveland Marion
Cleveland Fort Smith Sales Clyde Newton
Clyde Greenville Tulsa Findlay Tulsa
Corporate Knoxville Greenville
Rewards Plan Savings Plan
Level 1 Level 2 out‐of‐network1 in‐network out‐of‐network1
Deductible
Employee $1,500 $500 $3,000 $2,000 $4,000
Employee + Spouse $3,000 $1,000 $6,000 $4,000 $8,000
Employee + Child(ren) $3,000 $1,000 $6,000 $4,000 $8,000
Family $3,000 $1,000 $6,000 $4,000 $8,000
Out‐of‐Pocket Limit
(does not include deductible)
Employee $8,500 $2,000 $17,000 $2,000 $8,500
Employee + Spouse $17,000 $4,000 $34,000 $4,000 $17,000
Employee + Child(ren) $17,000 $4,000 $34,000 $4,000 $17,000
Family $17,000 $4,000 $34,000 $4,000 $17,000
Benefit Description
Primary Care Physician (PCP)
60% * $15 copay 50% * 85% * 50% *
Office Visits
Specialist Office Visits 60% * 80% * 50% * 85% * 50% *
Hospital (Inpatient & Outpatient)2 60% * 80% * 50% * 85% * 50% *
Surgery (Inpatient & Outpatient) 2 60% * 80% * 50% * 85% * 50% *
Value‐Based Benefits for
100% ** 100% ** 50% * 100% ** 50% *
Diabetic Members 3
Adult Routine Wellness 4 100% ** 100% ** Not covered 100% ** 50% *
Well Woman Exam 100% ** 100% ** Not covered 100% ** 50% *
Mammograms 5 100% ** 100% ** Not covered 100% ** 50% *
Pap Smears 100% ** 100% ** Not covered 100% ** 50% *
Well Child Care 6 100% ** 100% ** Not covered 100% ** 50% *
60% * 80% * 80% * 85% * 85% *
Emergency Room
50% if non‐emergency 50% if non‐emergency
Mental and Nervous
60% * 80% * 50% * 85% * 50% *
(inpatient & outpatient)
60% * 80% * 50% * 85% * 50% *
Chiropractic Care limited to 20 visits per calendar year limited to 20 visits per calendar year
(combined limit) (combined limit)
60% * 80% * 50% * 85% * 50% *
Home Health Care limited to 120 visits per calendar year limited to 120 visits per calendar year
(combined limit) (combined limit)
Lifetime Maximum $2 million combined $2 million combined
* After Deductible
** No Deductible
September 2009 55‐021‐202‐00B2010 HEALTHCARE HIGHLIGHTS
Main (continued)
Prescription Benefit Highlights
(Rewards and Savings Plans) Tier 0 Tier 1 Tier 2 Tier 3 Tier 4
90% 80% 50%
$0 and
7,8,9 coinsurance Coinsurance coinsurance
Retail (30‐day Supply) 100% coinsurance 0% coinsurance
Min. $5 * Min. $20 * Min. $50 *
No deductible
Max. $12 * Max. $100 * Max. $250 *
90% 80% 50%
$0 and
7,8,9 coinsurance Coinsurance coinsurance
Mail Order (90‐day Supply) 100% coinsurance 0% coinsurance
Min. $12.50 * Min. $50 * Min. $125 *
No deductible
Max. $30 * Max. $250 * Max. $625 *
* after deductible
All plans administered by HealthSCOPE Benefits (HSB). If you have questions about any of these plan provisions, contact HSB
at 1‐800‐660‐6212 or visit www.healthscopebenefits.com, click MEMBER, then enter WHIRL under Company Name.
1. Out‐of‐network amounts subject to reasonable and customary (R&C) limits. Amounts over R&C limits do not count toward the
deductible or out‐of‐pocket limit.
2. All inpatient admissions and outpatient procedures and outpatient mental health services require pre‐certification. Please note that if
a member does not pre‐certify a procedure, there will be a $500 fee assessed when the claim is processed.
In 2010, members may elect to have selected surgeries performed using a minimally invasive procedure. If a member chooses to have
an open procedure, instead of the preferred minimally‐invasive surgery, the member would be responsible for an additional $1,000
toward the cost of surgery. If a physician states that the open procedure is clinically necessary for the member, the surcharge will be
waived after the physician submits supporting documentation to HealthSCOPE Benefits (HSB).
3. Services Include: Up to four physician office visits per year for diabetic related care; Hemoglobin A1C test (up to 4 per year); Lipid
profile test (up to 2 per year); Microalbumin test (1 per year); Annual flu shot; Pneumonia vaccine, once then every 5 years if physician
orders (up to age 65, then discontinued); Diabetes education covered up to 10 sessions in one year then up to 4 hours in each of 2
subsequent years); Podiatric visits as referred by MD/DO/NP, up to once every 6 months; Annual dilated eye exam (1 per year).
4. Adult routine wellness exams limited to one per calendar year. Tests must be age appropriate, physician‐ordered based on
patient/family history and submitted with “V” codes.
5. One baseline mammogram between ages 35 and 39, annually for ages 40 and above.
6. Well Child Care limited to six visits to age 1, three visits from age 1 to 2 and one office exam every year thereafter to age 19.
7. 50% coinsurance for drug classes that have over‐the‐counter (OTC) alternatives, e.g., Non‐Sedating Antihistamines (NSA) and Proton
Pump Inhibitors (PPI).
8. For Tier 1, Tier 2, and Tier 3 (retail and mail order):
Mandatory mail order for all plans after third retail refill: 50% coinsurance payment if member chooses to continue refilling at retail.
Plan members may not use the I‐account to pay 50% of the prescription cost. You must pay the additional 50% and it will not apply
toward your annual member responsibility.
9. For Tier 1, Tier 2, and Tier 3 (retail and mail order):
50% coinsurance for lifestyle drugs that treat weight loss, anti‐fungal and erectile dysfunction.
Tobacco cessation medications are also considered lifestyle drugs.
Over‐the‐Counter (OTC) Alternatives and Lifestyle Drugs: 50% coinsurance for Non‐Sedating Antihistamines (NSA) and Proton Pump
Inhibitors (PPI) drug classes when OTC available and 50% coinsurance for weight loss, anti‐fungal and erectile dysfunction drugs.
NOTE: This document serves as a Summary of Material Modifications to the Whirlpool Health Care Plan. While every effort
has been made to describe the highlights of your benefit plan accurately, this summary does not contain a full restatement of
all terms and provisions of the plan. If any conflicts exist between this summary and current plan documents, the current plan
documents will govern.
Please review your Personal Report carefully for details about your coverage costs. Some provisions may have changed.
September 2009 55‐021‐202‐00BThe Rewards Plan
CP
$15 P
!
Copay
• Two distinct levels of benefits
• Level 1 = Lowest level of benefits and highest out-of-
pocket costs (requires no action on member’s part)
• Level 2 = Highest level of benefits and lowest out-of-
pocket costs (requires quarterly participation)
• Member must complete (or have completed) a Health
Assessment (HA) to qualify for Level 2
• Completing four healthy behavior activities per year
(minimum of one per quarter) will make member eligible
for the higher Level 2 benefits
• Member must complete a minimum of one healthy be-
havior activity per quarter, but can work ahead and com-
plete more than one
• Member spouse/domestic partner can qualify for Level 2
benefits even if member does not (and vice versa)
• Children are always at Level 2Incentives For Rewards Plans • Employees and covered spouses/domestic partners can earn up to $400 each by completing healthy activities • Activities for incentives can be completed at any point during the year, but incentive dollars are not available for use until after the activity has been processed • I-account dollars will rollover each year
REWARDS PLAN & INCENTIVES
PUTTING IT ALL TOGETHER
ACTIVITY LEVEL 2 INCENTIVE VALUE
2010 Health Risk Assessment X $100
Wellness Exam X $100
Participate in a Disease Mgmt Program X $200
Participate in a Lifestyle Mgmt Program X $200
Participate in Case Mgmt X $100
Participate in On‐site Health Coaching X $100
Participating in the Maternity Mgmt Program X $100
Biometric Screening X $50
Mammogram X $50
PSA/DRE Exam X $50
Colonoscopy X $50
Participate in Employee Assistance Program (EAP) Counseling X $50
Get a Dental Cleaning X $50
Routine Vision Exam X $50
Participate in community wellness activity (such as 5K run/walk) $25
Participate in on‐site wellness activity $25
Flu shot $25
Participate in a fitness program (exercise class, etc.) $25
Participate in weight loss program (Weight Watchers, etc.) $25
Participate on a sports team $25
You must do at least four of these activities, and a minimum of one per quarter, during the calendar year in order to
have your benefits paid at Level 2.
As soon as you complete four, you will remain at Level 2 for the rest of the calendar year. There is a $400 maximum
for I-account per calendar year.The Savings Plan • The Savings Plan operates as a traditional Health Savings Account (HSA) • Works as a HDHP PPO. • Member contributions into their HSA fund are tax-free (up to $3,050 per employee or $6,150 per family) • HSA withdrawals are tax-free if used to pay for qualified medical expenses • Interest earned in account is tax-free • Individuals age 55 or older may contribute an extra $1,000 into your HSA above the annual limits • Unused HSA balances roll from year to year • It’s portable (it’s your money and it goes with member)
Incentives For Savings Plans • Employees and covered spouses/domestic part- ners can earn up to $1,000 each by completing healthy activities • Activities can be completed at any point during the year • HSA will be credited as activities are completed • Unused HSA dollars will rollover each year
Savings Plan Activity Chart
ACTIVITY WHIRLPOOL FUNDING
2010 Health Assessment $250
Wellness Exam $250
Participate in a Disease Mgmt Program $250
Participate in a Lifestyle Mgmt Program $250
Participate in Case Mgmt $250
Participate in Onsite Health Coaching $250
Participate in the Maternity Mgmt Program $250
Biometric Screening $100
Mammogram $100
PSA /DRE Exam $100
Colonoscopy $100
Participate in Employee Assistance Program (EAP) $100
Get a Dental Cleaning $100
Routine Vision Exam $100
Participate in a community wellness activity (such as a 5‐k run/walk) $50
Participate in an onsite wellness activity $50
Flu shot $50
Participate in a fitness program (exercise classes, etc) $50
Participate in a weight loss program (such as Weight Watchers) $50
Participate on a sports team (such as softball, golf, etc.) $50
$1,000 maximum available
for Employer Sponsored HSA
Contributions per calendar
year for each employee and
spouse/domestic partner cov‐
ered under the Savings Plan.
Funds will be available 30‐45
days after the completion of
the activity.2010 Whirlpool Retiree Benefits
NEW 2010 Retiree Medical Plan Options
REWARDS PLAN SAVINGS PLAN
1‐800‐660‐6212 1‐800‐660‐6212
www.healthscopebenefits.com www.healthscopebenefits.com
HealthSCOPE Benefits HealthSCOPE Benefits
Level 1 Level 2 out‐of‐network in‐network out‐of‐network
DEDUCTIBLE
Per Person $1,500 $500 $3,000 $2,000 $4,000
OUT‐OF‐POCKET LIMIT
(DOES NOT INCLUDE DEDUCTIBLE)
Per Person $8,500 $2,000 $17,000 $2,000 $8,500
Primary Care Physician (PCP) Office Visit 60% after deductible $15 copay 50% after deductible 85% after deductible 50% after deductible
Specialist Office Visit 60% after deductible 80% after deductible 50% after deductible 85% after deductible 50% after deductible
Hospital (Inpatient and Outpatient) 60% after deductible 80% after deductible 50% after deductible 85% after deductible 50% after deductible
Surgery (Inpatient and Outpatient) 60% after deductible 80% after deductible 50% after deductible 85% after deductible 50% after deductible
Value Based Diabetic 100% ‐ no deductible 100% ‐ no deductible 50% ‐ after deductible 100% ‐no deductible 50% ‐ after deductible
Adult Routine Wellness 100% ‐ no deductible 100% ‐ no deductible Not Covered 100% ‐ no deductible 50% ‐ after deductible
Well Child Care 100% ‐ no deductible 100% ‐ no deductible Not Covered 100% ‐ no deductible 50% ‐ after deductible
Emergency Room 60% after deductible/50% 80% after deducti‐ 80% after deductible/50% 85% after deductible/50% 85% after deductible/50%
if non emergency ble/50% if non emer‐ if non emergency if non emergency if non emergency
Life Time Maximum $1 million combined $1 million combined $1 million combined $1 million combined $1 million combined
RETIREE WELLNESS ACTIVITIES
2010 Health Risk Assessment
Wellness Exam
Biometric Screening
Mammogram
Prostate Exam
Colonoscopy
Participate in a Disease Mgmt Program
Participate in a Lifestyle Mgmt Program
Participate in Case Mgmt
Get a Dental Cleaning
Routine Vision ExamRETIREE MEDICAL PLAN OPTIONS FOR
MEMBERS WHO RETIRED PRIOR TO 2010
WHIRLPOOL Amounts
Annual Deductible Network and Non-Network
80/20 Plan: $500 per Covered Person per calendar year.
Out-of-Pocket Maximum Network and Non-Network
80/20 Plan: $3,500 per Covered Person per calendar
year. The Out-of-Pocket Maximum does not include the Annual De-
ductible.
Maximum Plan Benefit Network and Non-Network
80/20 Plan: $1,000,000 per Covered Person
WHIRLPOOL BASIC Amounts
Annual Deductible $500 per Covered Person per calendar year
(amount may vary for some plans:
for details regarding your specific coverage,
Out-of-Pocket Maximum None
Maximum Plan Benefit $100,000
Retired PRIOR
to 2010Whirlpool Wellness Benefits
Whirlpool Wellness Preventive Care Benefits
Adult Actives and Retirees
Well-adult care includes one routine office visit and ex-
Preventive amination each Plan Year after age 18 years and one
Care OB/GYN office visit and examination after age 18 years
of age each Plan Year.
Adults Included immunizations and screenings associated with
Actives & the above routine office visits are as follows:
• Immunizations
Retirees •Tetanus / Diphtheria (Td) Booster once every 10
years,
•Influenza Vaccination (flu shot), one shot each
• 100% no Plan Year,
•Pneumococcal Vaccination (Pneumovaz) one
deductible in dose for persons 65 years and over,
network! •Meningococcal conjugated vaccine (MCV4), one
dose for college freshmen living in dormitories
•• Screenings
• Bill with •Cholesterol screening including triglycerides, LDL,
HDL, or lipid panel once every 5 years beginning at
routine/ age 20 years
•Baseline Mammogram, one between 30 and 40
preventive years of age, and one Mammogram each Plan
V-code Year starting at age 40 years of age
•Pap Smear and Routine Pelvic Exam, one each
Plan Year beginning at age 18 years,
•Bone density test for osteoporosis every two years
for women age 50 years and over,
Colorectal Cancer Screenings,
Fecal occult blood test (FOBT) or Colonoscopy or
Double contrast barium enema
Digital rectal examination (DRE) and prostate specific
antigen (PSA) test.
• Pathologies, labs, chest x-rays, and EKGs that are or-
dered as part of your preventive care visit due to age
and/or family history, and are considered preventive care
by your Physician.Whirlpool Wellness Preventive Care Benefits
Children
Preventive Care Well-child care includes routine office visits and examination, as fol-
lows:
Children •Six visits 0 – 12 months,
•Three visits 12 – 24 months,
•Annual visits from 24 months through age 18 years of age,
• 100% no •GYN exam for children at age 18.
deductible in When associated with routine office visits, the following immuniza-
tions and screenings are covered:
network! • Immunizations o Two doses of Hepatitis A, Three doses of Hepatitis
B,
o Six doses of Diphtheria, Tetanus, Pertussis (DtaP), Four doses of
• Bill with routine/ Haemophilus Influenza type b, Four doses of Polio, Four doses
preventive of Pnuemococcal Conjugate, Two doses of Varicella, wo doses
of Measles, Mumps, Rubella,
V-code o One dose of Influenza vaccine (flu shot) one dose each Plan Year
for children over the age of 8 years; two doses (administered
separately by at least 4 weeks) each Plan Year for children up
through 8 years of age.
o Human papilloma virus (HPV) vaccine for girls ages 9 through 18
years of age at the following intervals:
One complete dosage per lifetime consisting of 3 shots given
within a 6 month timeframe.
Women over the age of 18 years but under the age of 26 years
who have not yet received the HPV may also receive the vac-
cine.
• Meningococcal conjugated vaccine (MCV4) at the following inter-
vals:
One dose between the ages of 11 and 12 years; or
One dose before high school entry or at age 15 years,
whichever occurs first, for children who have not
previously received the MCV4 vaccine.
• Screenings and Exams
Lead level testing, one between ages 9 to 12 months and one at 24
months or after,
Vision screening conducted as part of Well-child care visit at ages 3,
4, 5, 6, 8, 10, 12, 15, and 18 years,
Hearing screening conducted as part of Well-Child care Visit at ages
4, 5, 6, 8, 10, 12, 15, and 18 years,
Pap smear and routine pelvic exam, one each Plan Year beginning
at age 18 years or the onset of sexual activity, whichever comes
first
Pathologies, labs, chest x-rays, and EKGs that are ordered as part
of your preventive care visit and are considered preventive care
by your Physician.Wellness Resources
• Nurseline
• Health Coaches
• Healthy Pregnancy Program
• Chronic Condition Management
• Smoking Cessation Program
• Treatment Decision Support
Contact HealthSCOPE Benefits at
1‐ 800‐660‐62122010 Whirlpool Rx Benefits
NEW 2010 TIER 0 PHARMACY
•Certain medications will now be covered at 100%
•Included in Tool Kit:
– CD with Drug name & Tier Assigned
•Examples of these include medications (primarily
generics) for high cholesterol, high blood pressure,
kidney protection, heart failure, etc.R: Retail
2010 PHARMACY BENEFITS M: Mail Order
Tier 0: Tier 1: Tier 2: Tier
$0 or 0% Coinsur‐ 10% Coinsurance 20% Coinsurance
ance Min: $5 R, $12.50 M Min: $20 R, $50 M 3: 50% Tier 4:
Max: $12 R, $30 M Max: $100 R, $250 Coinsurance 100% Coinsur‐
M Min: $50 R , $125 M ance
Max $250 R, $625
M
Cholesterol Blood Pressure Cholesterol Cholesterol Cholesterol
Drugs: Drugs: Drugs: Drugs: Drugs:
Simvastatin Fosinopril Lipitor 10mg Crestor (all Vytorin
Pravastatin Moexipril Lipitor 20mg strengths)
Lovastatin Quinapril Lipitor 40mg Lescol Blood Pressure
Ramipril Lipitor 80mg Lescol XL Drugs:
Blood Pressure Trandolapril None
Drugs: Blood Pressure Blood Pressure
Enalapril Blood Pressure Drugs: Drugs: Blood Pressure
Captopril (combined w/ Cozaar Atacand, Avapro, (combined w/
Benazepril diaretic) Drugs: Benicar, Diovan, diaretic) Drugs:
Lisinopril Fosinopril/HCTZ Blood Pressure Micardis, Teveten None
Moexipril/HCTZ (combined w/
Blood Pressure Quinapril/HCTZ diaretic) Drugs: Blood Pressure
(combined w/ Hyzaar (combined w/
diaretic) Drugs: diaretic) Drugs:
Captopril/HCTZ Atacand HCT,
Benazepril/HCTZ Avalide, Benicar
Lisinopril/HCTZ HCT, Diovan HCT,
Enalapril Micardis HCT, Te‐
veten HCT
*Only an example. To access full formulary list, please go to www.healthscopebenefits.comWhirlpool Value Based Benefits
Value Based Benefits for Diabetics
Value Based for Diabetics are Covered at
100%
No Deductible!
• Up to 4 physician office visits per year for diabetic-related care
• Hemoglobin A1C test (up to 4 per year)
• Lipid profile test (up to 2 per year)
• Microalbumin test (1 per year)
• Annual flu shot
• Pneumonia vaccine (once then every 5 years if ordered by a physi-
cian, up to age 65)
• Diabetes education (up to 10 sessions in one year, up to 4 hours in
each of 2 subsequent years)
• Podiatric visits as referred by MD/DO/NP, up to once every 6 months
• Annual dilated eye exam (1 per year)
• Insulin or oral diabetic medications*
• Lipid controlling agents*
• Blood pressure control agents*
• Diabetic test strips*
* Covered drugs and supplies outlined in Tier 0Medications and Supplies Covered Under Tier 0 Benefit for Diabetics
Medications:
GLIMEPIRIDE TABLET 1MG Generic
GLIMEPIRIDE TABLET 2MG Generic
GLIMEPIRIDE TABLET 4MG Generic
GLIPIZIDE TABLET 10MG Generic
GLIPIZIDE TABLET 5MG Generic
GLIPIZIDE ER TABLET, EXTENDED RELEASE 24 HR (2) 10MG Generic
GLIPIZIDE ER TABLET, EXTENDED RELEASE 24 HR (2) 2.5MG Generic
GLIPIZIDE ER TABLET, EXTENDED RELEASE 24 HR (2) 5MG Generic
GLIPIZIDE XL TABLET, EXTENDED RELEASE 24 HR (2) 10MG Generic
GLIPIZIDE XL TABLET, EXTENDED RELEASE 24 HR (2) 2.5MG Generic
GLIPIZIDE XL TABLET, EXTENDED RELEASE 24 HR (2) 5MG Generic
GLYBURIDE TABLET 1.25MG Generic
GLYBURIDE TABLET 2.5MG Generic
GLYBURIDE TABLET 5MG Generic
GLYBURIDE MICRONIZED TABLET 1.5MG Generic
GLYBURIDE MICRONIZED TABLET 3MG Generic
GLYBURIDE MICRONIZED TABLET 6MG Generic
GLYBURIDE‐METFORMIN HCL TABLET 1.25‐250MG Generic
GLYBURIDE‐METFORMIN HCL TABLET 2.5‐500MG Generic
GLYBURIDE‐METFORMIN HCL TABLET 5MG‐500MG Generic
HUMULIN 50‐50 VIAL (SDV,MDV OR ADDITIVE) (ML) 50‐50 U/ML Brand
HUMULIN 70‐30 VIAL (SDV,MDV OR ADDITIVE) (ML) 70‐30 U/ML Brand
HUMULIN N VIAL (SDV,MDV OR ADDITIVE) (ML) 100 U/ML Brand
HUMULIN R VIAL (SDV,MDV OR ADDITIVE) (ML) 100 U/ML Brand
HUMULIN R VIAL (SDV,MDV OR ADDITIVE) (ML) 500 U/ML Brand
HYDROCHLOROTHIAZIDE TABLET 25MG Generic
HYDROCHLOROTHIAZIDE TABLET 50MG Generic
HYDROCHLOROTHIAZIDE TABLET 12.5 MG Generic
LANTUS VIAL (SDV,MDV OR ADDITIVE) (ML) 100 U/ML Brand
Supplies:
Accu-Chek Compact Plus Meter
Accu-Check Aviva Meter
One Touch UltraMini Meter
One Touch Ultra2 Meter
Accu-Chek Compact Test Strip
Accu-Chek Aviva Test Strip
One Touch Ultra Test Strip
One Touch Ultra Test Strip
All insulin syringesWhirlpool
Minimally Invasive
Procedures
and
Precertification
RequirementsMinimally Invasive Procedures
• For 2010, selected procedures must be performed using
MIP unless there is medical documentation that would re-
quire the surgery be done by traditional means.
• If a member chooses to have an open procedure, instead
of the preferred minimally invasive surgery, the member
would be responsible for an additional $1,000 toward the
cost of surgery.
•Colon Surgery
•Gall Bladder Surgery
•Breast Biopsy
•Hysterectomy
•Reflux / Gastrointestinal SurgeryMinimally Invasive Procedures What is a minimally invasive surgery (MIP)? Minimally invasive surgery is a type of surgery that utilizes smaller incisions and state-of-the-art technology. In traditional open surgeries, large incisions are made to expose the area of the body where the surgery is being performed. Using technol- ogy, such as a scope, a minimally invasive surgery requires much less (or no) cutting of the skin. The MIP surgical tech- nique is safe and is the standard of care recommended by the American College of Surgeons. Minimally invasive surgery re- quires less time in the operating room, less recovery time for the patient and results in fewer infections. Benefit Guideline: In 2010, members will be required to have the following surgical procedures performed minimally invasive. If a member chooses to have an open procedure, instead of the preferred minimally invasive surgery, a $1000 penalty will be assessed. If a physi- cian states that the procedure is not clinically indicated for the member, the requirement will be waived after the physician pro- vides supporting documentation to HealthSCOPE Benefits. • Colon Surgery • Gall Bladder Surgery • Breast Biopsy • Hysterectomy • Reflux/Gastrointestinal Surgery During the pre-certification process, members will be provided information on the benefit and the surgical treatment options available.
NEW PRE-CERTIFICATION PROCEDURES
• In 2010, all members, along with their providers, will be
required to pre-certify all:
–Non-emergency inpatient admissions
–Outpatient surgical procedures
–Outpatient mental health
• Contact HealthSCOPE Benefits for pre-certification at
1-800-660-6212
• Member ID card has reminder statement regarding pre-
certification
• It is the member’s responsibility to pre-certify these
procedures. If not pre-certified, a $500 fee will be
assessed to the member2010 Precert Requirements
MEMBERS:
In 2010, ALL non-emergency inpatient procedures, outpatient procedures and outpa-
tient mental health procedures will need to be pre-certified by MEMBER with
HealthSCOPE Benefits. If the member does not pre-certify a procedure, there will
be a $500 penalty.
Process for Member Pre-Certification
1. Member ID card to specify pre-certification requirements
2. Member to contact HealthSCOPE Benefits
3. HealthSCOPE to accept
5. Members will be given the opportunity to speak with a nurse during every pre-cert
call
PROVIDERS:
Healthcare providers will be required to pre-certify the following procedures with
HealthSCOPE Benefits in 2010.
1. Outpatient spinal procedures
2. Inpatient procedures (non-emergency)
3. Vein treatment
4. Potential cosmetic trunk/body procedures
5. Potential cosmetic breast procedures
6. Potential cosmetic eyes/nose procedures
7. Potential cosmetic head/ear procedures
8. Potential cosmetic skin procedures
9. Dental and jaw/face/TMJ procedures
10.Ear devices (i.e. cochlear implants)
11.Oral pharynx procedures
12.Breast biopsy—MIP
13.Chemotherapy
14.Dialysis
15.Inpatient procedures
16.Outpatient mental health
17.Colectomy—MIP
18.Hysterectomy-MIP
19.Esophagogastric fundoplasty-MIP
20.Cholecystectomy-MIP
21.MRIs & CTsYou can also read
