PLAN YEAR 2014-2015

Transcription

PLAN YEAR 2014-2015

PLAN YEAR 2014-2015
PROVIDER ACCESS PROVIDER INFORMATION
TOOL GUIDE
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IEBP Quality Improvement and Management Program
IEBP Member Rights and Responsibilities Statement
IEBP Information
Website Services for Providers
Provider Network Assistance: Primary, Secondary Networks,
Centers of Excellence
Identification of the Covered Individual:
Sample Medical/Prescription ID Card
Public/Private Alliance Provider Solution
United Healthcare Choice Plus Provider Network Information
Transplant and Obesity Designated Centers of Excellence and
Choice Plus Network Providers
IEBP Medication Therapy Management Program
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Provider Clinical Practice Guideline Resources
Provider Coding Guidelines
Prompt Pay Adjudication
Sample Explanation of Benefits (EOB)
Electronic Fund Transfer PayPlus Information
Sample Explanation of Payment (EOP)
How Benefits are Paid
Non-Duplication of Benefits
Healthy Initiatives
Medical Intelligence
After Hours and/or Weekend Medical and Mental Health Care Services
Dedicated to Services Measuring the Patient Healthcare Experience by
Managing the Integrity of the Healthcare Dollar Optimized by Efficient Performance Based Outcome
Resource
TML MultiState Intergovernmental Employee Benefits Pool (IEBP)
Customer Care Helpline:
Secured Customer Care E-mail:
Contact Information
1821 Rutherford Lane, Suite 300 | Austin, Texas 78754
PO Box 149190 | Austin, Texas 78714-9190
(800) 282-5385
Visit www.iebp.org | click on the “Login” button | click on
“Online Customer Care” under the “My Tools” menu
www.iebp.org
(800) 847-1213
(888) 818-2822
TML MultiState IEBP Internet Website:
Medical Notifications:
Professional Health Coaches: Professional Health Coaches will answer
basic health and medication questions and assist Covered Individuals with
the Healthy Initiatives Incentive Program. Covered Individuals may enroll
in professional health coaching.
Spanish Line:
(800) 385-9952
Where to Mail Paper Medical Claims:
TML MultiState IEBP | PO Box 149190 | Austin, Texas
78714-9190
After Hours and/or Weekend Medical and Mental Healthcare
Call 911 or immediately go to the emergency department.
Emergencies:
Page 1 of 62 | TML MultiState IEBP
Accessible Hours
8:30 AM - 5:00 PM Central
Twenty-four (24) hours
or Scheduled Appointment
(Rev 5.6.15)
Provider Access Provider Information Tool Guide
TABLE OF CONTENTS
Welcome ..................................................................................................................................................... 4
IEBP Quality Improvement and Management Program ................................................................................ 4
IEBP Member Rights and Responsibilities Statement .................................................................................... 5
IEBP Information ......................................................................................................................................... 6
Website Services for Providers..................................................................................................................... 6
IEBP Provider Portal ............................................................................................................................................................ 6
Phone/Fax/Web Services for Providers .............................................................................................................................. 6
Provider Network Assistance ....................................................................................................................... 6
Identification of the Covered Individual ....................................................................................................... 7
Sample Medical/Prescription ID Card ................................................................................................................................. 7
Public/Private Alliance Provider Solution ..................................................................................................... 8
United Healthcare Choice Plus Provider Network Information ...................................................................... 9
Secondary Network Services for United Options and Choice Plus PPO............................................................................ 10
Professional Negotiation Service ...................................................................................................................................... 10
Patient Advocacy Services................................................................................................................................................. 10
Prompt Pay Provider Claims Tracking and Handling ......................................................................................................... 10
Transplant Benefit ............................................................................................................................................................. 10
OptumHealth Care Solutions Centers of Excellence Transplant Centers (formerly URN) ................................................ 12
Transplant and Obesity Designated Centers of Excellence and Choice Plus Network Providers ..................................... 12
TML MultiState IEBP Medication Therapy Management Program ............................................................... 14
Medication Therapy Management Alliance Partners ....................................................................................................... 14
Retail and Mail Order Covered Individual Copayments .................................................................................................... 14
Biosimilar FDA Approval Standards .................................................................................................................................. 15
Step Therapy ..................................................................................................................................................................... 16
Clinical Prior Authorization ............................................................................................................................................... 17
Cost Share Copay Drugs .................................................................................................................................................... 18
Prescription Benefits ......................................................................................................................................................... 20
Mac A Rx Plan.................................................................................................................................................................... 20
Mac C Rx Plan .................................................................................................................................................................... 20
High Deductible Health Savings Account Plans................................................................................................................. 20
Authorized Generics.......................................................................................................................................................... 20
Covered and Non-Covered Drugs ..................................................................................................................................... 21
OptumRx Specialty/Biotech Prescriptions ........................................................................................................................ 22
High Deductible H.S.A. Wellness Drug List ........................................................................................................................ 24
OptumRx Mobile Friendly Website ................................................................................................................................... 28
Provider Clinical Practice Guideline Resources ........................................................................................... 29
Provider Coding Guidelines ........................................................................................................................ 32
Prompt Statute - Article 3.70.3, Texas Insurance Code .................................................................................................... 32
Additional Information Requests ...................................................................................................................................... 32
(Rev 5.6.15)
Prompt Pay Adjudication ........................................................................................................................... 35
Sample Explanation of Benefits (EOB) ........................................................................................................ 36
Electronic Fund Transfer Pay-Plus Information ........................................................................................... 38
Sample Explanation of Payment (EOP) ....................................................................................................... 39
How Benefits are Paid ............................................................................................................................... 40
Claims ................................................................................................................................................................................ 40
Right to Receive and Release Necessary Information ...................................................................................................... 41
No Replacement for Workers’ Compensation .................................................................................................................. 41
Assignments ...................................................................................................................................................................... 41
Legal Actions ..................................................................................................................................................................... 41
Appeals .............................................................................................................................................................................. 41
Privacy of Your Health Information................................................................................................................................... 43
Security of Your Health Information ................................................................................................................................. 44
Non-Duplication of Benefits ....................................................................................................................... 44
Integration of Benefits ...................................................................................................................................................... 44
Application ........................................................................................................................................................................ 44
Definitions for the purpose of Integration of Benefits ..................................................................................................... 44
Special Rules...................................................................................................................................................................... 45
Other Party Liability .......................................................................................................................................................... 47
Overpayment Provisions ................................................................................................................................................... 48
Integration with Medicare ................................................................................................................................................ 49
Healthy Initiatives ..................................................................................................................................... 50
Preventive/Routine Care Benefit (Calendar Year) ............................................................................................................ 50
Immunizations................................................................................................................................................................... 50
Medical Intelligence Care Management Features w/Disclaimer .................................................................. 51
How the Notification Process Works ................................................................................................................................ 51
Notification Requirements ................................................................................................................................................ 52
Continued Stay Review ..................................................................................................................................................... 54
Medical Intensive Care Management ............................................................................................................................... 54
Population Health Engagement ........................................................................................................................................ 54
After Hours and/or Weekend Medical and Mental Health Care .................................................................. 58
Primary Care...................................................................................................................................................................... 58
Telemedicine ..................................................................................................................................................................... 58
In-store Clinic .................................................................................................................................................................... 62
Urgent Care Center ........................................................................................................................................................... 62
Emergency Department .................................................................................................................................................... 62
(Rev 5.6.15)
WELCOME
The TML MultiState Intergovernmental Employee Benefits Pool’s (IEBP) objective is to provide employees, qualified dependents,
qualified retirees, and qualified elected officials of political subdivisions, benefit plans and provider networks that are equal to or
improved in comparison to those commonly provided in the private industry. By achieving this objective, the political subdivisions will
be able to attract and retain competent, able employees and to recognize their faithful service and dedication to their employer.
The Preferred Provider Plan provides incentive to the Members to utilize the Preferred Provider Network for their medical care. The
covered individual has the responsibility to cooperate with the preferred network guidelines that have been designed to manage their
health care cost.
IEBP developed this guide to assist you in working with our member groups and to make your job as easy as possible. We continually
strive to improve the health care services that are managed and offered to our Member groups.
IEBP also strives to improve the services we offer to providers. Over the past year, we have made many enhancements to our website,
including the addition of the “Providers Only” section. The “Providers Only” section of IEBP’s web site contains valuable information,
which can be accessed from the convenience of your computer. Visit www.iebp.org and click the “Providers Only” link on the
navigation bar. After entering your tax identification number, you will gain access to an online version of our HealthX eligibility and
claim status verification system. Also, you can submit address changes and browse the Provider Access Provider Information Tool
Guide online.
We would like to thank you in advance for participating in our network and look forward to working with you in a cooperative spirit.
IEBP QUALITY IMPROVEMENT AND MANAGEMENT PROGRAM
The Quality Improvement and Management Program at IEBP is a comprehensive program under the leadership of the Executive
Director and Medical Director.
The Quality Improvement program consists of the following components:
 Quality of clinical care
 Quality of service
 Availability and accessibility of services
 Safety of clinical care and protected health information
 Objectives for serving a culturally and linguistically diverse membership
 Serving individuals with complex healthcare needs
 Improvement of behavioral healthcare
The Quality Improvement and Management Program consist of a Quality Improvement (QI) Committee that meets on a quarterly basis
and oversees the Quality Management Plan of the organization. The QI Committee is comprised of IEBP Functional Area Managers,
the Medical Director, and a Behavioral Healthcare Practitioner, PhD.
The role of the committee is to ensure quality service performance is based on medical initiatives and patient safety services are
monitored.
The roles of Medical Director and Behavioral Healthcare Practitioner are to evaluate and monitor guidelines within the Healthplan
benefits. The subject matter experts will advise the committee members on subject matters pertaining to patient safety and education,
complex health and behavioral healthcare program needs and access to benefit plan resources.
Additional information on IEBP's Quality Improvement and Management Program is available upon request.
IEBP does not use incentives to encourage barriers to care and service; and does not make decisions about hiring, promoting or
terminating providers or other staff based on the likelihood, or on the perceived likelihood, that the provider or staff member
supports, or tends to support, denial of benefits.
(Rev 5.6.15)
IEBP MEMBER RIGHTS AND RESPONSIBILITIES STATEMENT
TML MultiState Intergovernmental Employee Benefits Pool's mission is:
To provide excellent service offering competitive health benefits and administrative services to eligible
municipalities and other governmental entities in Texas and other states by utilizing innovative, viable,
affordable alternatives while maintaining financial integrity.
TML MultiState Intergovernmental Employee Benefits Pool (IEBP) is committed to respecting the right of the covered
individuals and ensuring the membership is aware of their rights and responsibilities.
The Covered Individual has the Right to:
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Be treated with respect and dignity by IEBP personnel and healthcare professionals
Privacy and confidentiality regarding the healthcare services received
Voice concerns regarding any service you have received under the benefit plan
File complaints and appeals concerning the healthcare benefit plan or the services you have received from the
provider
Receive a prompt response to your concerns and/or appeals
Be provided with appropriate access to the provider community
Be actively involved with the providers making decisions regarding your healthcare needs
Be educated regarding the benefit plan and eligible and ineligible benefits
Be educated about the covered individual's right to refuse treatment and access an Advance Directive to designate
the kind of care you desire if you should become unable to express your wishes
Participate in a conversation with your provider regarding your treatment plan regardless if the services are eligible
or ineligible under your medical benefit plan
Request information from IEBP regarding their healthcare information, the organization, its services, the provider
network
Be educated regarding medically necessary treatment options for the medical condition, regardless of cost or
benefit coverage
Receive affirmation regarding the distribution of incentive payments
Provide IEBP information and/or recommendations to update the Member Rights and Responsibilities Statement
The Covered Individual has the Responsibility to:
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Ensure their eligibility information was received and processed by IEBP
Contact and access care from healthcare professionals when a medical need occurs
Access emergent and immediate care services
Maintain scheduled appointments
Receive healthcare information regarding the care being received
Participate in understanding your treatment plan and mutually agree upon treatment goals and maintain treatment
compliance
 Timely notify your employer of demographic and family status changes and ensure the health plan has been updated
with the correct information
 Visit the IEBP website or contact customer care with any questions or concerns
 Communicate with IEBP regarding the member’s rights and responsibility statement
IEBP does not use incentives to encourage barriers to care and service; and does not make decisions about hiring,
promoting or terminating providers or other staff based on the likelihood, or on the perceived likelihood, that the
provider or staff member supports, or tends to support, denial of benefits.
(Rev 5.6.15)
IEBP INFORMATION
Each Member group participating in the Pool selects the benefit plan that best suits his/her needs. Due to a wide variation in member
group plans, specific benefit plan information cannot be provided in this manual. For eligibility, benefit verification or claim status,
please contact the automated HealthX service at (800) 282-6186.
Please note that when multiple providers bill with the same Federal ID number for the same patient on the same date of service,
HealthX may not be able to identify the actual claim in question.
For further information, please contact a Member Service Representative between the hours of 8:30 A.M. and 5:00 P.M., Central
Standard Time. Please call (800) 282-5385.
 Submission of bills
 Questions regarding claims payment
WEBSITE SERVICES FOR PROVIDERS
IEBP Provider Portal
IEBP, through a partnership with HealthX, offers a Provider Web portal that allows providers to access Claim Status information,
Eligibility information and Online Customer Care tools. To access the Provider Web portal, you will need a User ID and Password.
Once you have registered, you will be able to access claims and eligibility information for IEBP covered individuals as well as
individuals covered by other payors who have partnered with HealthX.
Registration is simple. Go to www.iebp.org and click the “Sign Up Now” link found in the Healthcare Providers login section. After
registration, you will gain immediate access to Claim Status and Eligibility information.
In addition to Claim Status and Eligibility providers can send questions to IEBP Member Service representatives through a secure
messaging system. After logging in, click the “Online Customer Service” link found in the “Working With IEBP” menu.
Phone/Fax/Web Services for Providers
Providers may also access Claim Status and Eligibility information over the phone through IEBP’s automated Phone IT system. This
system combines Interactive Voice Response features with a Fax back option. This automated phone system provides claim status
and eligibility information over the phone and gives providers the option to receive this status information by fax.
 Phone/Fax information call: (800) 282-6186
 WebIT: www.iebp.org - Login as a Provider
PROVIDER NETWORK ASSISTANCE
IEBP Provider Network Representatives assist the preferred provider network in delivering health care efficiently and effectively. You
may contact a provider representative at the address below.
TML MultiState IEBP
P.O. Box 149190
Austin, TX 78714-9190
(800) 282-5385
www.iebp.org
The Provider Network Representative is available to help as necessary.
(Rev 5.6.15)
IDENTIFICATION OF THE COVERED INDIVIDUAL
Provider recognition of a covered individual’s membership in the Intergovernmental Employee Benefits Pool is important for the
efficient and effective operation of the Provider Network Program.
The easiest method of identifying an IEBP member is by the IEBP Medical/Prescription Identification Card. A sample
Medical/Prescription ID Card is included for your review.
Sample Medical/Prescription ID Card
(Rev 5.6.15)
PUBLIC/PRIVATE ALLIANCE PROVIDER SOLUTION
• Direct Interface with Political Subdivision
• Risk and Non-Risk Benefit and Claim
Adjudication Services
• Plan Management Administrative
Services
• Customer Services: Phone, E-Mail, Patient
Advocacy
• Prompt Pay Proactive Correspondence
• Benefit Plan Set-Up
• NCQA Accreditation Quality Management
• HealthX Relationship: Online Claim Look
Up/Electronic EOB/ID Card, Electronic
Fund Transfers Pay Plus: ACH/Virtual Card
• OptumInsight Clinical Data Analytics
• Medical Intelligence
• Underwriting
• Medication Therapy Management
Program (MTMP) delegate to OptumRx,
Restat/Catamaran and RxResults/Rx
Reportal
• Billing and Eligibility/Online System
• ID Card/Electronic EOB Vendor Update
• Internal Audits and Education Program
• Network Hierarchy Audit Access
• Legal/Legislative/Regulatory Support
• Internet Services
• Consumer Driven Debit Card
Relationship; Tiered Card
Access/Alegeus/WealthCare
• Reinsurance Interface
• Right of Recovery Services
• Electronic Data Interchange Services:
Mail, Scan, Pre/Post Duplicate Audit,
OnBase/Electronic Workflow
Management
• Public Employees Benefit Alliance
Services (PEBA)/Benefit Purchasing
Cooperative
• IEBP Business Continuity Plan
• Cost Estimator/Price Transparency
• MyBenefits on Demand
• MyIEBP Mobile App
• Delegate Telemedicine Service to Teladoc
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TELA Data Entry Relationship
QicLink 5.0 Alliance
Validata audit of Eligibility Audit
Repricing transmission to United
Healthcare
SAS 70 Audit
Claim Adjudication Platform
ClinicLogic Claim Audit
Claim Adjudication Service Team
Marketing Synergy
Claim Adjudication Business
Continuity Support
Health Information Technology
UMR Business Continuity
Security Guidelines
Provider/Member Appeals
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Options PPO Network
Options PPO Primary Network
Three Tiered Secondary Network
IEBP Direct Contract Support
Premium Network Identification
Repricing Software
System Audit/iCES
Provider Network Disruption Review
Provider Credentialing
TransReview Designated Transplant
Services
Designated Bariatric Centers
Provider Network Website
Marketing Synergy
Choice Plus Network
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Choice Plus Primary Network
Three Tiered Secondary Network
Premium Network Identification
Repricing Software
System Audit/iCES
Provider Network Disruption Review
Provider Credentialing
TransReview Designated Transplant
Services
Designated Bariatric Centers
Provider Network Website
Marketing Synergy
ICD-9 to ICD-10 mapping
NCQA Delegated Network
Distribution Model
(Rev 5.6.15)
UNITED HEALTHCARE CHOICE PLUS PROVIDER NETWORK INFORMATION
The Alliance Makes the Difference!
IEBP offers the Options PPO Network to their fully funded Pool members in East Texas that prefer an employer specific East Texas
Medical Center Facility network in Tyler and in the rural East Texas market. OptumInsight, Inc. offers IEBP Designated Centers of
Excellence for Transplant and Surgical Obesity treatment.
TML MultiState IEBP United Healthcare Choice Plus Network
Risk Membership
(Rev 5.6.15)
Secondary Network Services for United Options and Choice Plus PPO
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First Health (logo required) - secondary network
Multi-Plan - secondary network
TC3 - secondary network
Ingenix - professional negotiations
Ethicare
Out-of-Network claims are repriced if Out of Network Providers participate in the Multi-Plan Supplemental Network. The discount
amount will not be balance billed to the covered individual and the claim will be adjudicated at the out of network benefit
percentage. The secondary networks include: First Health (logo required), Multi-Plan - secondary network, TC3 - secondary network,
Ingenix - professional negotiations, and Ethicare for Reasonable and Customary audits.
Professional Negotiation Service
Claims are reviewed against normative data ICD-9, CPT codes, and charges by revenue center to ensure that the ratios are
appropriate and reasonable and are compared against a proprietary database. The cases are reviewed on an individual basis and
the patient cannot be balance billed for the adjusted amount on the bill.
If Professional Negotiations cannot be provided, the out of network claim will be paid per the usual, reasonable & customary fee
schedule and the covered individual may need to contact the Patient Advocacy program for balance billing assistance.
Patient Advocacy Services
IEBP’s Member Service Representatives are educated to provide patient advocacy services for appropriate covered individuals' out
of network or ineligible out of pocket expenses. The IEBP patient advocate determines whether the claim is eligible for patient
advocacy services. The Covered Individual’s out of network or individual expenses need to be a minimum of $300.00 per charge.
Prompt Pay Provider Claims Tracking and Handling
A Prompt Pay Tracking report tracks claims and related documentation belonging to the Prompt Pay provider. This tracking report
is programmed utilizing the Tax ID numbers associated with that provider and accounts for non-completed claims processing activity,
as well as claims denied for additional information. Claims denied for additional information may require different tracking rules
depending upon from whom the additional information is being requested.
Management or designated staffs are responsible to review the report daily for claims or claim referrals. Customer Service staff will
focus on claims denied for additional information and will pro-actively contact covered individuals and providers to expedite receipt
of the requested additional information.
Transplant Benefit
Transplant benefits provided at an OptumHealth/Centers of Excellence/Designated Transplant Center differ from those provided at
a Non-Designated Transplant Center. At least ten (10) working days prior to any pre-transplant evaluation, the Covered Individual
or a family member must provide Notification to Medical Intelligence Care Management; failure to do so will result in a Late
Notification Penalty of $400 or a reduction in benefits.
If the Covered Individual’s treatment plan changes, the Healthcare Provider must provide Notification to Medical Intelligence Care
Management at (800) 847-1213. Medical Intelligence Care Management will obtain an update on the treatment plan and will
conduct a concurrent review regarding additional length of stay and any new treatments/procedures.
Eligible Transplant expenses incurred in connection with any organ or tissue transplant will be covered subject to Medical
Intelligence Care Management approval and Plan limitations. Under this provision, the term Transplant includes the pre-transplant
evaluation, procurement, the transplant itself and one (1) year of post transplant follow-up care, excluding outpatient prescription
drugs covered elsewhere under the Plan.
Transplant benefits are paid at the benefit percentage on the Summary of Benefits and Coverage as long as services are provided at
an OptumHealth/Centers of Excellence/Designated Transplant Center and approved by Medical Intelligence Care Management.
(Rev 5.6.15)
Non-Designated Transplant Center
If the organ transplant is performed at a Non-Designated OptumHealth/Centers of Excellence Transplant Center or Medical
Intelligence Care Management is refused, the pre-transplant, transplant and post transplant care will not be covered.
Benefits will not be paid if the procedure is an Unproven Medical Procedure or a Phase I and/or II clinical trial as defined in this
booklet or if it involves an artificial (mechanical) organ or non-human tissue. A Cornea transplant is not covered as a transplant
benefit, but will be covered as any other Major Medical Benefit.
Transplant Center
The transplant services must be performed at an OptumHealth Centers of Excellence Centers. A list of OptumHealth Transplant
Centers of Excellence may be obtained from Medical Intelligence Care Management.
This benefit will cover charges resulting from organ transplantation for:
1.
travel (if more than two hundred (200) miles one way to hospital or facility from place of employment);
a.
Private vehicle use will be reimbursed at the maximum allowable amount determined by the Internal Revenue Service
and reimbursement is limited to travel between home and the Transplant Center. Airfare will be reimbursed at cost.
b.
The Plan provides for ground or air transportation of the Covered Individual to and from the pre-transplant evaluation,
organ transplantation and any other Eligible Benefit or follow-up appointment.
c.
The Plan provides for ground or air transportation of each eligible companion to and from the pre-transplant
evaluation, organ transplantation and any other eligible provider services or follow-up appointment.
d.
Receipts will be required for reimbursement and submitted on an Expense Activity Report.
2.
organ transportation;
3.
donor medical benefits not covered under the donor’s plan of benefits;
4.
locating and preserving the tissue for the transplant procedure;
5.
fees for maintenance on an organ transplant waiting list;
6.
food for the Covered Individual and eligible companion to a maximum of thirty-five dollars ($35) each per day (if more than
two hundred (200) miles one way to the designated transplant facility from place of employment); and
a.
The Plan will pay for the Covered Individual and eligible companion’s (age eighteen years of age or older) food during
transplant-related outpatient treatment that is an Eligible Benefit and the eligible companion’s food during transplantrelated inpatient.
b.
Maximum food reimbursement rate of thirty-five dollars ($35) each per day.
c.
Receipts will be required for reimbursement and submitted on an Expense Activity Report.
7.
lodging (if more than two hundred (200) miles one way to the designated transplant facility from place of employment).
a.
The Plan will pay for the covered individual’s and the eligible companion’s eligible lodging when the patient is not
confined to eligible facility.
b.
The Plan will pay for the eligible companion’s lodging when the patient is confined to an eligible facility.
c.
Receipts will be required for reimbursement.
The maximum travel, food and lodging benefit for the Covered Individual is $10,000 and $5,000 for an eligible companion (per the
medical network Summary of Benefits and Coverage percentage). Eligible companion is a person of the Covered Individual's choice.
(Rev 5.6.15)
OptumHealth Care Solutions Centers of Excellence Transplant Centers (formerly URN)
The Transplant and Designated Facility Network is updated frequently. Please call Medical Care Management for Center of
Excellence Network Information.
Texas OptumHealth Adult Transplant Centers of Excellence Network
Texas
Baylor All Saints
Fort Worth [Kidney, Kidney/Liver, Liver]
Baylor University Medical Center
Dallas [Blood/Marrow, Heart, Kidney,
Kidney/Liver, Liver]
CHI St. Luke's Health Baylor College of Medicine
Medical Center
Houston [Heart, Kidney, Kidney/Liver, Liver]
Houston Methodist Hospital
Houston [Blood/Marrow, Heart, Heart/Lung, Kidney,
Kidney/Liver, Kidney/Pancreas, Liver, Lung, Pancreas]
Medical City Dallas Hospital
Dallas [Blood/Marrow, Heart]
Memorial Hermann Texas Medical Center
Houston [Liver]
Methodist Hospital of Dallas
Dallas [Kidney, Kidney/Liver, Liver]
Methodist Specialty & Transplant Hospital
San Antonio [Blood/Marrow, Heart, Kidney,
Kidney/Liver, Liver]
University Health System-San Antonio
San Antonio [Kidney, Kidney/Liver, Liver, Lung]
University of Texas M.D. Anderson Cancer Center
Houston [Blood/Marrow]
UT Southwestern St. Paul Hospital
Dallas [Blood/Marrow, Heart, Heart/Lung, Lung]
Oklahoma
Integris Baptist Medical Center
Oklahoma City [Heart, Kidney, Kidney/Liver, Liver]
Pediatric Transplant Centers of Excellence Network
Texas
Children's Medical Center of Dallas
Dallas [Blood/Marrow, Heart, Kidney, Kidney/Liver, Liver]
Cook Children's Medical Center
Fort Worth [Blood/Marrow]
Medical City Dallas Hospital
Dallas [Blood/Marrow]
Methodist Specialty & Transplant Hospital
San Antonio [Blood/Marrow]
Texas Children's Hospital
Houston [Blood/Marrow, Heart, Heart/Lung, Kidney,
Liver, Lung]
University Health System-San Antonio
San Antonio [Kidney]
University of Texas M.D. Anderson Cancer Center
Houston [Blood/Marrow]
Transplant and Obesity Designated Centers of Excellence and Choice Plus Network Providers
Texas
City
Austin
Amarillo
Beaumont
Bryan
Carrollton
Cedar park
Cypress
Dallas
Decatur
Provider Name
Seton Medical Center
St David's Medical Center
Baptist St Anthony's Health System
Northwest Texas Healthcare System
Christus (Dubuis) St. Elizabeth Hospital
The Physician Centre Hospital
Baylor Medical Center at Carrollton
Cedar Park Regional Medical Center
North Cypress Medical Center
Doctors Hospital at White Rock Lake
Forest Park Medical Center
Methodist Health Systems
Texas Health Presbyterian Hospital Dallas
UT Southwestern Medical Center
Baylor University Medical Center Weight
Loss Surgery Program
Columbia Hospital at Medical City Dallas
(Medical City Dallas in network)
Wise Regional Health System
Provider Address
1201 West 38th Street
Austin TX 78705
919 East 32nd Street
Austin TX 78705
1600 Wallace Blvd
Amarillo TX 79106
1501 S Coulter
Amarillo TX 79106
2830 Calder St
Beaumont, TX 77702
3131 University Dr East
Bryan TX 77802
4343 N Josey Lane
Carrollton, TX 75010
1401 Medical Parkway
Cedar Park, TX 78613
21214 Northwest Fwy
Cypress, TX 77429
9440 Poppy Drive
Dallas TX 75218
11990 N Central Expy
Dallas TX 75243
1441 N Beckley Ave
Dallas TX 75203
8200 Walnut Hill Ln
Dallas TX 75231
5909 Harry Hines Blvd
Dallas TX 75235
3500 Gaston Ave
Dallas TX 75246
Phone Number
(512) 324-3404
(512) 544-5433
(806) 212-2000
(806) 354-1000
(409) 892-7171
(979) 731-3100
n/a
(512) 528-7000
(832) 912-3500
(214) 324-6127
(972) 234-1900
(214) 947-1761
(214) 345-6789
(214) 645-5555
(214) 820-7528
UHC
Options
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
UHC
Choice
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
TML
Direct
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
7777 Forest Lane, Suite 240A
Dallas TX 75230
(972) 566-6349
Y
Y
N
609 Medical Center Dr
Decatur TX 76234
(940) 627-5921
Y
Y
N
(Rev 5.6.15)
City
Denton
Denison
Provider Name
Texas Health Presbyterian Hosp Denton
Texoma Medical Center
Edinburg
DBA Day Surgery at Renaissance
(also known as Doctors Hospital)
Providence Memorial Hospital
Plaza Medical Center at Fort Worth
Baylor Medical Center at Frisco
UTMB at Galveston - TIN 746000949
Baylor Regional Medical Center At
Grapevine
Cypress Fairbanks Medical Center Hosp
Houston Northwest Medical Center
The Methodist Hospital
Memorial Hermann Memorial City Hosp
Memorial Hermann Southeast
Memorial Hermann Hospital
Park Plaza Hospital
West Houston Medical Center
University General Hospital
Laredo Medical Center
Doctors Hospital of Laredo
High Plains Surgery Center
McAllen Heart Hospital, DBA South Texas
Health Sys
Rio Grande Regional Hospital
Medical Center Hospital
Bayshore Medical Center
Baylor Medical Center at Plano
Texas Health Presbyterian Hosp of Plano
Texas Health Presbyterian Rockwall
Methodist Spec Trans Hospital
Methodist Texsan Hospital
Nix Hospital
Northeast Baptist Hospital
Southwest General Hosp
Metropolitan Methodist Hospital
Wadley Regional Medical Center
Scott and White (Memorial) Hospital
Baylor Medical Center at Trophy Club /
Trophy Medical Center
Mother Frances Hospital
Citizens Bariatric Center / Citizens Medical
Center
Providence Health Center
United Regional Health Care Systems
El Paso
Fort worth
Frisco
Galveston
Grapevine
Houston
Laredo
Lubbock
McAllen
Odessa
Pasadena
Plano
Rockwall
San Antonio
Texarkana
Temple
Trophy Club
Tyler
Victoria
Waco
Wichita Falls
Provider Address
3000 I-35 North
Denton TX 76201
619 W Main St
Denison TX 75020
5016 S US Highway 75
Denison TX 75020
5501 S McColl Rd
Edinburg, TX 78539
Phone Number
(940) 898-7000
(903) 416-5555
(903) 416-4000
(956) 362-5610
UHC
Options
Y
Y
Y
Y
UHC
Choice
Y
Y
Y
Y
TML
Direct
N
N
N
N
2001 N Oregon ST
900 8th Ave
5601 Warren Parkway
301 University Blvd
1650 W College St
El Paso, TX 79902
Fort Worth TX 76104
Frisco TX 75034
Galveston TX 77555
Grapevine, TX 76051
(915) 577-7939
(817) 87PLAZA
(214) 407-5006
(409) 772-1011
(817) 488-7546
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
10655 Steepletop Dr
710 FM RD W
6565 Fannin St
921 Gessner Road
11800 Astroia Blvd
6400-6411 Fannin
1313 Hermann Drive
12141 Richmond Ave
7501 Fannin St
1700 E Saunders St
10700 McPherson Rd
3610 22nd St
1900 South D St
Houston, TX 77065
Houston, TX 77090
Houston TX 77030
Houston TX 77024
Houston TX 77089
Houston TX, 77030
Houston TX 77004
Houston, TX 77082
Houston, TX 77054
Laredo, TX 78041
Laredo, TX 78045
Lubbock, TX 79410
McAllen TX 78503
(281) 890-4285
(281) 440-1000
(713) 790-3311
(713) 242-4290
(281) 929-4389
(713) 704-4000
(713) 527-5127
(281) 558-344
(713) 375-7000
(956) 796-2662
(956) 388-2000
(806) 776-4772
(956) 664-1616
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
101 E Ridge Road
500 W 4th St
4000 Spencer Highway
3901 W 15th St.
6200 W Parker Rd, 7C Tower
3150 Horizon Rd
8026 Floyd Curl DR
6700 IH 10 West
414 Navarro Street
8811 Village Dr
7400 Bartlite Blvd
1310 McCullough Avenue
1000 Pine Street
2401 S 31st
2850 E Hwy 114
McAllen TX 78503
Odessa, TX 79761
Pasadena TX 77504
Plano TX 75075
Plano TX 75093
Rockwall TX 75032
San Antonio, TX
San Antonio TX 78201
Texarkana TX 75501
Temple TX 76508
Trophy Club, TX 76262
(956) 661-3560
(432) 640 3551
(713) 359-1664
(972) 596-6800
(972) 981-3861
(469) 698-1000
(210) 575-8110
(210) 736-8460
(210) 846-2935
(210) 297-2034
(210) 921-2000
(210) 365 7561
(903) 798-8872
(254) 724-2111
(817) 837 3046
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
800 East Dawson
2701 Hospital Dr
Tyler TX 75701
Victoria TX 77901
(903) 593-8441
(361) 574-1738
Y
Y
Y
Y
N
N
6901 Medical Pkwy
1600 11th Street
Waco, TX 76712
Wichita Falls TX 76301
(254) 751-4000
(940) 764-7000
Y
Y
Y
Y
N
N
Oklahoma
City
Norman
Oklahoma City
Owasso
Provider Name
Norman Regional Health System
Integris Baptist Medical Center
Bailey Medical Center, LLC
Provider Address
901 N Porter Ave
Norman OK 73071
3300 NW Expressway
Oklahoma City OK 73112
10502 N 110th East Ave
Owasso OK 74055
Phone Number
405-307-1000
405-949-3011
918-376-8000
UHC
Options
N
N
N
UHC
Choice
Y
Y
Y
TML
Direct
N
N
N
(Rev 5.6.15)
TML MULTISTATE IEBP MEDICATION THERAPY MANAGEMENT PROGRAM
How to get the most out of your IEBP Medication Therapy Management Program
Medication Therapy Management Alliance Partners






Pharmacy Benefit Manager Network: OptumRx Membership: (888) 543-1369 | www.optumrx.com | 24 hours a day/7 days a
week
» OptumRx Online Pharmacy Locator Tool: Members can locate a Value Network pharmacy near them by using the OptumRx
Online Pharmacy Locator Tool at www.optumrx.com.
OptumRx Pharmacy Help Desk: (800) 788-7871
OptumRx Mail Service Program: (800) 797-9791 (TTY 711) | www.optumrx.com
OptumRx Specialty Pharmacy: (866) 218-5445 | Fax: (800) 491-7997
Submit OptumRx Paper Prescription Claims to: OptumRx | PO Box 29044 | Hot Springs, AR 71903
Evidence-Based Medication Review: RxResults | Toll Free: (855) 892-0936 | Local: (501) 686-7463 | Fax: (877) 540-9036
Retail and Mail Order Covered Individual Copayments
MAC A Plan: If a brand name drug is dispensed and a generic alternate drug exists, the Covered Individual pays the difference
between the brand name and generic price in addition to the appropriate copayment for the brand name. The cost difference
between the brand name and generic price does not apply to any individual deductibles or out of pocket amounts. The MAC
differential applies to all prescriptions purchased through this program when a generic alternate is available.
MAC C Plan: If a brand name drug is dispensed and a generic alternate drug exists, the Covered Individual pays the appropriate
brand copay.
Covered Individual Out of Pocket (OOP)
Retail:
Prescribed (Doctor Ordered)
(up to 34 day supply max
Over the Counter Alternates and Prescription Networks
unless noted otherwise)
 Smoking Cessation (Nicorette Gum), Quantity Limit - 3 months per plan year
 Aspirin, Folic Acid, Fluoride Chemoprevention Supplements, Iron Deficiency
$0.00
Supplements, and Vitamin D supplementation to prevent falls in community-dwelling
adults age 65 years and older who are at an increased risk for falls; per prescription
Network Retail: 34 day Non-Cost Share most Generic Dispensement
$0.00 (up to 34 day supply)
Network Retail: 90 day Non-Cost Share most Generic Dispensement
$9.00 (35 up to 90 day supply)
OptumRx Network Non-Cost Share Best Brand/Formulary List
$38.00
OptumRx Network Non-Cost Share Non-Best Brand/Non-Formulary List
$60.00
OptumRx Network Cost Share
$120.00
OptumRx Specialty/Biotech Prescriptions
N/A
OptumRx Biosimilar Generic Prescriptions
N/A
Prescription Refill Control Standards
75%
Mail/Maintenance:
(up to 90 day
dispensement)
SpecialtyRx/Biotech/Biosimilar:
(up to 34 day dispensement)
N/A
N/A
N/A
$25.00
$95.00
$150.00
$300.00
N/A
N/A
70%
N/A
Women's Preventive Health Services Covered Individual Out of Pocket (OOP)
Benefit
Retail Rx Medical Plan
Oral Contraceptives Generic (no cost share)
IUD Device (no cost share)
X
Implant Device (no cost share)
X
Permanent Implantable Contraceptive Coil (subject to the appropriate deductible and benefit percentages)
X
Insertion and/or Removal of Devices (no cost share)
X
Sonogram to Detect Placement of Device (no cost share)
X
Injectable Contraceptives (no cost share)
X
Injectable Administration Fee (no cost share)
X
Diaphragm (cervical), Hormone Vaginal Ring, Hormone Patch, Cervical Cap, Spermicides, Sponges (no cost share)
Diaphragm Instruction and Fitting Fee (no cost share)
X
Emergency Birth Control
Over-The-Counter (OTC) Birth Control
Contraceptive Management (no cost share)
X
Female Condoms (no cost share)
Medications for risk reduction of breast cancer in women who are at increased risk for breast cancer and at low risk for
adverse medication effects: Tamoxifen or Raloxifene
Prescription Plan
X
X
X
Plan Ineligible
X
X
X
X
X
X
(Rev 5.6.15)
Biosimilar FDA Approval Standards
The FDA typically approves small molecule generics on the basis of pharmaceutical equivalence. Pharmaceutical equivalence
suggests that the generic contains the same active ingredient at the same strength as the brand (including the particular salt if
relevant).
We do not believe that the FDA will insist that a biosimilar be exactly the same as the innovator product (brand); rather it will employ
a more flexible standard of sameness. Such a standard would partly depend on some structure-function understanding of the
innovator product. For relatively small proteins, we expect that these will be required to exhibit an identical amino acid sequence.
This standard may be more flexible for larger molecules, such as antibodies. The agency will also likely consider the impact of
posttranslational protein modifications, such as glycosylation.
Given that structural identity is unlikely for biosimilars, the FDA is also likely to require demonstration that the biological activity of
the biosimilar is very close to the reference (innovator) molecule. In the case of Lovenox, this could be demonstrated with a straight
forward predictive in vitro bioassay. While such a standard could be employed in a few instances, for example in agents used to
treat clotting disorders, such as hemophilia, we believe that some clinical data will be necessary for most applications.
Although clinical data will be needed for most applications, the data requirements are likely to be different from the registrational
studies for the reference product. A key element, in our view, is the ability to demonstrate that the biosimilar is reliably producing
a biological effect that is the same as the reference product. We believe that a combination of data utilizing reliable clinical
measures, and data showing clear biological response would be sufficient. For example, extensive characterization of in vitro
biological activity of an oncology drug, such as receptor activity, combined with demonstration of equivalent response rates in
patients, could be viewed as sufficient, without the need to undergo a lengthy clinical trial with “hard” endpoints, such as survival.
(Rev 5.6.15)
Save on Generics at OptumRx Pharmacies!
Step 1: Check the Cost
Go to OptumRx.com and Log In to check the cost
of your prescription.
Please keep in mind that drug prices may change
frequently, and can vary by pharmacy.
Most generics are $0 at OptumRx Network Pharmacies. Find a Network Pharmacy near you by
going to: www.optumrx.com
Save on Over the Counter Equivalents!
The following over the counter (OTC) equivalents are $0 with a prescription:
Doctor Ordered:
 Smoking Cessation (Nicorette Gum), Quantity Limit - 3 months per plan year
 Aspirin, Folic Acid, Fluoride Chemoprevention Supplements, Iron Deficiency Supplements,
and Vitamin D supplementation to prevent falls in community-dwelling adults age 65 years
and older who are at an increased risk for falls; per prescription
Step 2: Step Therapy, Prior Authorization & Cost Share
You should check the attached Step Therapy, Prior Authorization and Cost Share prescription sheets to find out if your prescription must be
pre-authorized.
Important Information
 IEBP Billing & Eligibility: (800) 282-5385
 IEBP Website: www.iebp.org
If your prescription is on a step therapy or prior authorization list, please have your doctor/prescription prescribing provider contact
RxResults toll free: (855) 892-0936 or local: (501) 686-7463.
Step Therapy
Prior Authorization
Cost Share
Note:
RxResults is the IEBP contracted Evidence-Based Prescription Pharmacy Review Organization. RxResults should be contacted for the Prior
Authorization Services identified below. The RxResults (Doctor/Prescription Prescribers Only) number is toll free: (855) 892-0936 or local: (501) 6867463. All clinical programs (Clinical Prior Authorization, Step Therapy, Cost Share Drugs, etc.) are subject to change without notice to accommodate
new drug entries to the marketplace and adjustments in established medical and pharmacy practice guidelines.
Step Therapy
For Clinical Authorization, doctor/prescription prescribers should call RxResults toll free: (855) 892-0936 or local: (501) 686-7463.
Your doctor/prescription prescriber will be asked a series of questions and RxResults will then approve or deny the authorization
request.

Sample of what will occur at pharmacy:
Claim is processing for Advair® & the following message will alert the pharmacist: Step Therapy after inhaled steroid 1st or
Prior Authorization call toll free: (855) 892-0936 or local: (501) 686-7463.
Asthma
Required for members <40 years of age who have not demonstrated adherence to an inhaled corticosteroid (ICS) (90 days of
therapy in the past 120 days).
Category A
 Inhaled corticosteroid (ICS) - Member must demonstrate adherence to an inhaled steroid and/or satisfy specific clinical
criteria as determined by RxResults prior to obtaining a Category B medication.
(Rev 5.6.15)
Category B (Only after failure with a Category A medication)




Advair®
Brovana®
Dulera®
Foradil®
 Perforomist®
 Serevent®
 Symbicort®
Treatment Plan Adherence is required for authorization to be approved.
Note:
All clinical programs (Clinical Prior Authorization, Step Therapy, Cost Share Drugs, etc.) are subject to change without notice
to accommodate new drug entries to the marketplace and adjustments in established medical and pharmacy practice
guidelines.
Important Information
» IEBP Billing & Eligibility: (800) 282-5385
» RxResults (Doctor/Prescription Prescribers Only): Toll Free: (855) 892-0936 | Local: (501) 686-7463
» IEBP Website: www.iebp.org
Clinical Prior Authorization
The list of conditions below may change as appropriate for the plan. For prior authorization requests, please have your
doctor/prescription prescriber call RxResults toll free: (855) 892-0936 or local: (501) 686-7463. Your doctor/prescription prescriber
will be asked a series of questions and RxResults will then approve or deny the authorization request. A Prior Authorization is active
for one year. If the covered individual has consistently taken the medication, (no lapse in medication greater than 100 days) the
prescribing provider will be required to resubmit clinical information to maintain the ongoing Prior Authorization Approval.
Antibiotics
 Zyvox®
General
These medications may be reimbursed following satisfaction of clinical criteria as determined by prior authorization review.
 Attention Deficit Disorder ADHD (For individuals 17 years of age or older)
 Narcolepsy Medications including Xyrem® (For individuals 17 years of age or older)
Major Biotech Prescription Categories
 Blood Cell Deficiency
 Crohn’s Disease
 Cystic Fibrosis
 Pulmonary Arterial Hypertension
 Rheumatoid Arthritis
 Multiple Sclerosis
 Oncology Oral
 Psoriasis
 Osteoarthritis
 Hemophilia
 Renal Disease
 HIV/Immune Deficiency Medications
 Hepatitis C
 Others
Testosterone - All Products
Two separate morning lab results defining the testosterone level will be required. The lab report will indicate whether the level is low or within
normal ranges.
 Injectable Only (topical and buccal testosterone products are not covered)
Diabetes
These medications may be reimbursed following satisfaction of clinical criteria as determined by prior authorization review.
 Bydureon®  Byetta®
 Januvia®/Janumet®, Janumet XR® (covered for diabetes only)
 Jentadueto®
 Juvisync®
 Kazano®
 Kombiglyze®
 Nesina®
 Onglyza®
 Oseni®
 Symlin®
 Tradjenta®
 Victoza®
(Rev 5.6.15)
Lipid-Lowering Agents (Statins)
 Crestor® (Prior authorization required for 40mg strength only. Other strengths considered Cost Share Copay drugs.)
Note:
All clinical programs (Clinical Prior Authorization, Step Therapy, Cost Share Drugs, etc.) are subject to change without
notice to accommodate new drug entries to the marketplace and adjustments in established medical and pharmacy
practice guidelines.
Cost Share Copay Drugs
IEBP has implemented a clinical evidence-based approach to its prescription plan for groups adopting 2014-2015 Plan Year benefits.
As such, IEBP will impose a higher patient copayment for drugs for which there is no clinical evidence to show that non-preferred
“Cost Share Drugs” perform any better than therapeutic doses of less costly preferred “Alternative Drugs”.
ADHD/CNS Stimulants
 Impacts utilization on: Immediate Release Amphetamine Products: Adderall®, Dexedrine®; Immediate Release Methylphenidate Products:
Ritalin® (brand only), Focalin®; Extended Release Amphetamine Products: Adderall XR®, Amphetamine ER, Dexedrine CR®, dextroamphetamine
ER; Extended Release Methylphenidate Products: Concerta®, Daytrana®, Focalin XR®, Metadate CD®, methylphenidate ER, Ritalin LA®, Intuniv®,
Kapvay®, Nuvigil®, Provigil® (brand only); Alternate Drugs: Generic: methylphenidate®, amphetamine, guanfacine immediate release (for
Intuniv®), clonidine (for Kapvay®), modafinil (for Provigil®, Nuvigil®); Brand: Strattera®, Vyvanse®
Analgesics/Anti-Inflammatory/Pain Agents
 Impacts utilization on: Lazanda®, Subsys®; Alternative Drugs: Generic: fentanyl patch, fentanyl lozenge
 Impacts utilization on: Celebrex®, Naprelan®, Flector patch®, Solaraze®, Pennsaid®, Zipsor®; Alternative Drugs: Generic: naproxen, diclofenac
 Impacts utilization on: Conzip®, Rybix®, Ryzolt®, tramadol ER, Ultracet®, Ultram®, Ultram ER®; Alternative Drug: Generic: tramadol
Antibiotics: Anti-Infective Agents
 Impacts utilization on: Adoxa®, Doryx®, Dynacin®, minocycline ER, Monodox®, Moxatag®, Periostat®, Solodyn®, Oraxyl®, Oracea®; Alternative
Drugs: Generic: amoxicillin (for Moxatag), capsule minocycline (for Dynacin®, Solodyn®), doxycycline (for Adoxa®, Doryx®, Monodox®, Periostat®,
Oracea®, Oraxyl®)
Anticonvulsants
 Impacts utilization on: Gralise®, Lamictal XR®, lamotrigine ER, Lyrica®, Neurontin®; Alternative Drugs: Generic: gabapentin (for Gralise®,
Lyrica®, Neurontin®), lamotrigine (for Lamictal XR®, lamotrigine ER)
Antidepressants/Fibromyalgia
 Impacts utilization on: Cymbalta®, duloxetine, Effexor XR, Pristiq, Savella®, Viibryd®; Alternate Drugs: Generic: bupropion, citalopram,
escitalopram, fluoxetine, paroxetine, sertraline, venlafaxine, venlafaxine ER (capsules only)
Antihypertensive Agents
 Impacts utilization on: Amturnide®, Atacand®/Atacand HCT®, Avapro®/Avalide®, Azor®, Benicar®/Benicar HCT®, Cozaar®/Hyzaar® (brand only),
Diovan®/Diovan HCT® (brand only), Edarbi®/Edarbyclor®, Exforge®/Exforge HCT® (brand only), Micardis®/Micardis HCT®, Tekamlo®,
Tekturna®/Tekturna HCT®, Teveten®/Teveten HCT®, Tribenzor®, Twynsta®, Valturna®; Alternate Drugs: Generic: metroprololhydrochlorothiazide (for Dutoprol®), any generic ACE Inhibitor, losartan/losartan HCTZ (for Cozaar®/Hyzaar®), irbesartan/irbesartan HCTZ (for
Avapro®/Avalide®), eprosartan/eprosartan HCTZ (for Teveten®/Teveten HCT®), valsartan/valsartan HCTZ (for Diovan®/Diovan HCT®)
Central Nervous System: Sedative Hypnotics
 Impacts utilization on: Ambien®, Ambien CR®, Edluar®, Lunesta®, Rozerem®, Sonata®, zolpidem ER®, Intermezzo®, Silenor®, Zolpimist®; Alternate
Drugs: Generic: zolpidem immediate release (generic for Ambien®), zaleplon (generic for Sonata®), doxepin (for Silenor®), zolpidem (for
Intermezzo®, Zolpimist®)
Lipid-Lowering Agents (Statins)
 Impacts utilization on: Advicor®, Altoprev®, amlodipine/atorvastatin combination, Caduet®, Crestor® (except 40mg strength), Lescol®, Lescol
XL®, Lipitor®, Livalo®, Mevacor®, Pravachol®, Simcor®, Vytorin®, Zocor®, Zetia®; Alternate Drugs: atorvastatin (generic for Lipitor®), lovastatin
(generic for Mevacor®), pravastatin (generic for Pravachol®), simvastatin (generic for Zocor®)
(Rev 5.6.15)
Lipid-Lowering Agents (Fibric Acid Derivatives)
 Impacts utilization on: Antara®, fenofibric acid, Fenoglide®, Fibricor®, Lipofen®, Lofibra®, Lopid®, Tricor®, Triglide®, Trilipix®, fenofibrate 43, 130
and 145mg; Alternate Drugs: fenofibrate (generic for Tricor® and various other brands), gemfibrozil (generic for Lopid®)
Migraine Headaches
 Impacts utilization on: Amerge®, Axert®, Frova®, Imitrex® (brand), Maxalt®, Relpax®, Treximet®, zolmitriptan, Zomig®, Zomig ZMT®; Alternate
Drugs: Generic: sumatriptan (for Imitrex®), naratriptan (for Amerge®), rizatriptan (for Maxalt®)
Nasal Steroids
 Impacts utilization on: Beconase AQ®, Dymista®, Flonase® (brand), Nasacort AQ®, Nasonex®, Omnaris®, Rhinocort AQ®, Veramyst®, QNASL®,
triamcinolone, Zetonna®; Alternate Drugs: Generic: fluticasone (for Flonase®) and flunisolide
Osteoporosis Drugs
 Impacts utilization on: Actonel®, Actonel® w/Calcium, Alendronate® (brand), Atelvia®, Binosto®, Boniva®, Fosamax®, Fosamax-D®, ibandronate
(generic for Boniva®); Alternate Drug: Generic: alendronate
Otic Products
 Impacts utilization on: Auralgan®; Alternate Drug: Generic: benzocaine-antipyrine
Overactive Bladder Drugs
 Impacts utilization on: Detrol®, Detrol LA®, Ditropan XL®, Gelnique®, Myrbetriq®, Enablex®, oxybutynin ER®, Oxytrol® patches, Sanctura®,
Sanctura XR®, tolterodine, Toviaz®, trospium CL, trospium CL ER, Vesicare®; Alternate Drugs: Generic: oxybutynin immediate release
Respiratory/Allergy/Asthma: Antihistamines
 Impacts utilization on: Clarinex®, levocetirizine, Xyzal®; Alternate Drugs: Over-the-Counter (OTC) versions of Allegra (fexofenadine), Claritin
(loratadine), and Zyrtec (cetirizine) are available at member’s out of pocket cost.
Respiratory/Allergy/Asthma: Antihistamines – Decongestant
 Impacts utilization on: Clarinex-D®; Alternate Drugs: Over-the-Counter (OTC) versions of Allegra-D (fexofenadine-D), Claritin-D (loratadine-D),
and Zyrtec-D (cetirizine-D) are available at member’s out of pocket cost.
Skeletal Muscle Relaxants
 Impacts utilization on: Amrix®, Carisoprodol® 250mg (brand), cyclobenzaprine ER, Fexmid®, Flexeril®, Lorzone®, metaxalone (generic for
Skelaxin®), Norflex® (including its generic orphenadrine injection), Parafon Forte®, Robaxin®, Skelaxin®, Soma®, Soma® Compound, Soma®
Compound w/Codeine, Zanaflex®; Alternate Drug: Generic: carisoprodol, chlorzoxazone, cyclobenzaprine, methocarbamol, tizanidine
Stomach Ulcer/Reflux Drugs/Gastrointestinal/Stomach: Proton Pump Inhibitors
 Impacts utilization on: Aciphex®, Dexilant®, Duexis®, lansoprazole, Nexium® (prescription strength), Prevacid® (prescription strength), Prilosec®
(prescription strength), Protonix®, Vimovo®, Zegerid capsules (prescription strength – including generic omeprazole/bicarbonate); Alternate
Drugs: Generic: omeprazole, pantoprazole, ibuprofen, and famotidine separately (for Duexis®); Over-the Counter (OTC) versions of Nexium 24
HR (esomeprazole), Priolosec® (omeprazole), Prevacid® (lansoprazole), and Zegerid® (omeprazole/sodium bicarbonate) are available at
member’s out of pocket cost.
Topical Antifungal Agents
 Impacts utilization on: Pedipirox-4®; Alternate Drug: Generic: ciclopirox
Cost Share Copays
 Network Retail Copay – up to 34 day supply - $120 or cost of drug (whichever is less)
 Mail Order Copay – 35 up to 90 days supply - $300 or cost of drug (whichever is less)
(Rev 5.6.15)
Prescription Benefits
Coverage for eligible biotech and biosimilar prescriptions that are available through the Pharmacy Benefit Manager or from Network
Providers will be paid per the Medication Therapy Management Guide.
For eligible prescriptions purchased outside of the Pharmacy Benefit Manager or the Network Providers, the plan will pay at the out
of network benefit percentage and will not, at any time, pay at 100%.
Mac A Rx Plan
If a brand name drug is dispensed and a generic alternate drug exists, the Covered Individual pays the difference between the
brand name and generic price in addition to the appropriate copayment for the brand name. The cost difference between the
brand name and generic price does not apply to any individual deductibles or out of pocket amounts. The MAC differential applies
to all prescriptions purchased through this program when a generic alternate is available.
Mac C Rx Plan
Covered individual will pay the appropriate copayment amount of the prescription.
High Deductible Health Savings Account Plans
The wellness/preventive medication list may be accessed at the copay out of pocket cost. The high deductible will have to be met
prior to non-wellness/preventive medications being accessed at the copay out of pocket cost.
Authorized Generics
The use of authorized generics undermines the Hatch-Waxman Act by devaluing the 180 day exclusive patent period incentive.
Ultimately, consumers pay the prices as brand companies keep drug prices high and access to affordable alternative medicine is
delayed. Once a generic (single or multi source) medication alternative is allowed on the market the generic copay will be applied.
The generic company that is first to successfully challenge a questionable brand patent, file an abbreviated new drug application
with the FDA and receive approval to market that drug is awarded 180 days exclusivity. During the 180 day period, that generic
company alone is permitted to compete with the brand company, allowing the generic company to bring affordable medicines to
consumers faster.
Patents are generally good for 20 years from the date of filing. The abbreviated new drug application approval allows manufacturers
to bring generic competitors to market which allows the generic to challenge the current patent on the brand medication.
Authorized generics are generally coded as brand drugs by Medispan and First Databank due to single source classification and
manufactured by the brand name manufacturer. This brand coding is what causes the higher dollar out of pocket cost.
(Rev 5.6.15)
Covered and Non-Covered Drugs
Drugs Covered Under This Benefit
Drugs Not Covered Under This Benefit
1.
2.
3.
1.
2.
3.
4.
5.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Legend Drugs;
Insulin or oral diabetic prescription;
Disposable insulin needles/syringes and physician prescribed
needles/syringes;
Disposable blood/urine/glucose/acetone testing agents (e.g.
Acetest Tablets, Clinitest Tablets, Glucometer (one per calendar
year), Lancets, Diastix Strips, Tes-Tape and Chemstrips;
Diabetic supplies will be purchased with order for oral diabetic
prescription. The plan will allow needles, syringes, lancets and
testing strips at no charge if ordered within 30 days of a
prescription at the same pharmacy;
Tretinoin all dosage forms (e.g. Retin-A, Differin, Tazorac) for
Individuals through the age of 25 years;
Compound medication of which at least one ingredient is a
legend drug to maximum $200.00 per prescription payment;
Any other drug which under the applicable State Law may only
be dispensed upon the written prescription of a physician or
other lawful prescriber;
Contraceptives: Oral, Brand Extended cycle (mail order only),
Generic Extended cycle (Network at 90 days copay),
Transdermal patches, Contraceptive devices, Levonorgestrel
(Norplant), Prescription Strength Only;
Depo Provera;
Central Nervous System Stimulants (e.g. Adderall, Adderall XR,
Focalin, Focalin XR, Ritalin, Dexedrine, etc) will be covered for
individuals through age 16. (Individuals 17 years and older will
require prior authorization through RxResults.)
Prescribed smoking deterrent medications containing nicotine
or any other smoking cessation aids, all dosage forms;
Growth hormones through age 15;
Extended Release anti-depressive agents: Wellbutrin XL, Effexor
XR;
Extended Release migraine prophylactic agents: Depakote ER;
Single entity legend vitamins.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
Dietary supplements, vitamins or formulas;
Growth hormones after age 15;
Immunization agents, biological sera blood or blood plasma;
Male pattern baldness medications; hair growth stimulants;
Tretinoin, all dosage forms (e.g. Retin-A, Differin, Tazorac) for
individuals 26 years of age or older; cosmetic agents including
anti-wrinkle, Botox and skin depigmenting agents;
Vitamins individually or in combination;
Therapeutic devices or appliances, including support garments
and other non-medicinal substances, regardless of intended
use;
Charges for the administration or injection of any drug;
Drugs labeled “Caution - limited by Federal Law to
investigational use” or experimental drugs even though a
charge is made to the individual;
Medications which are to be taken by or administered to an
individual, in whole or in part, while he or she is a patient in a
licensed hospital, rest home, sanitarium, extended care facility,
convalescent hospital, nursing home or similar premises which
operates on its premises or allows to be operated on its
premises, a facility for dispensing pharmaceuticals;
Emergency contraceptives;
Fertility medications;
Any prescription refilled in excess of the number specified by
the physician or any refill dispensed after one year from the
physician’s original order;
Prescription which an eligible individual is entitled to receive
without charges from any Workers’ Compensation Laws or
which is prescribed for an injury or illness which is excluded
from any medical coverage which is provided in conjunction
with this prescription benefit;
Anti-obesity medications;
Prescribed prenatal vitamins are not covered under the
prescription card. Claims for prescribed prenatal vitamins with
a pregnancy diagnosis may be submitted to IEBP for payment
consideration;
Cholesterol/Triglyceride-Lowering Agents: Lovaza, Niaspan and
niacin ER
Non-legend drugs other than those listed above;
Lifestyle convenience prescriptions (ie: erectile dysfunction
prescriptions and topical and buccal testosterone products);
Nutritional Supplements (i.e. Deplin, Metanx);
SGLT2 Antidiabetics: Invokana, Farxiga, and Jardiance.
(Rev 5.6.15)
OptumRx Specialty/Biotech Prescriptions


You can order directly from OptumRx Specialty Pharmacy by calling (866) 218-5445.
For Prior Authorization: Prescriber Call RxResults Toll Free: (855) 892-0936 | Local: (501) 686-7463
Alpha-1
Glassia
Ammonia
Detoxi ants
c
Ravicti
Androgens
Testopel
Anti Seizure
Sabril
Antiemedic
Aloxi
Emend
Granisetron
Antilipemic Agents
Juxtapid
Kynamro
Antiviral
Actimmune
Adefov Dipiv *
Alferon N
Baraclude *
Copegus
Hepsera
Incivek
Infergen
Intron-A (Onc Inj)
Olysio *
Pegasys *
Peg-Intron
Rebetol
Ribapak
Ribasphere *
Ribatab *
Ribavirin *
Sovaldi *
Synagis
Tyzeka
Victrelis
Asthma
Xolair
Birth Control
Implanon
Mirena
Nexplanon
Cancer
Abraxane
Adcetris (Onc Inj)
Adriamyc
Adriamycin
Adrucil
Afinitor
Afinitor Dis
Alimta
Alkeran
Amifostine
Arranon
Arzerra
Avastin
Azacitidine (Onc Inj)
Bexxar
Bexxar 131 I
Bicnu
Bleomycin
Bosulif
Busulfex
Camptosar
Capecitabine
Caprelsa
Carboplatin
Cerubidine
Cisplatin
Cladribine
Clolar
Cometriq
Cosmegen
Cyclophosph
Cyclophospha
Cytarabine
Dacarbazine
Dacogen (Onc Inj)
Dactinomycin
Daunorubicin
Daunoxome
Decitabine (Onc Inj)
Dexrazoxane
Docefrez
Docetaxel
Doxil
Doxorubicin
Eligard
Ellence
Eloxatin
Elspar
Epirubicin
Erbitux
Erivedge
Erwinaze (Onc Inj)
Ethyol
Etopophos
Etoposide
Faslodex
Firmagon
Floxuridine
Fludara
Fludarabine
Fluorouracil
Folotyn
Fusilev
Gablofen
Gemcitabine
Gemzar
Gilotrif
Gleevec *
Halaven
Herceptin
Hycamtin (oral) (Onc Inj)
Iclusig
Idamycin PFS
Idarubicin
Ifex
Ifosfamide
Inlyta
Irinotecan
Istodax
Ixempra Kit
Jakafi
Jevtana
Kadcyla
Kepivance
Kyprolis
Leuprolide (Onc Inj)
Lipodox
Lipodox 50
Lupaneta Kit
Lupr Dep-Ped *
Lupron Depot *
Marqibo (Onc Inj)
Matulane *
Mekinist
Melphalan
Mercaptopuri
Mesna
Mesnex
Mitomycin
Mitomycin C
Mitoxantron (Onc Inj)
Mustargen
Navelbine
Nexavar *
Nipent
Oncaspar
Oxaliplatin
Paclitaxel
Pamidronate
Pentostatin
Perjeta (Onc Inj)
Photofrin
Pomalyst
Proleukin (Onc Inj)
Provenge
Revlimid
Rituxan (Onc Inj)
Sprycel
Stivarga
Supprelin LA
Sutent
Sylatron (Onc Inj)
Synribo (Onc Inj)
Tafinlar
Tarceva
Targretin *
Tasigna *
Taxotere
Temodar (Onc Inj)
Temozolomide *(Onc Inj)
Teniposide
Thalomid
Theracys
Thiotepa
Tice Bcg
Toposar
Topotecan
Torisel (Onc Inj)
Totect
Treanda (Onc Inj)
Trelstar Dep (Onc Inj)
Trelstar LA (Onc Inj)
Trelstar Mix
Tretinoin *
Trisenox
Tykerb *
Vantas (Onc Inj)
Vectibix
Velcade (Onc Inj)
Vidaza (Onc Inj)
Vinblastine
Vincasar PFS
Vincristine
Vinorelbine
Voraxaze
Votrient
Xalkori
Xeloda *
Xgeva (Onc Inj)
Xofigo * (Onc Inj)
Xtandi
Yervoy
Zaltrap (Onc Inj)
Zanosar
Zelboraf
Zevalin
Zinecard
Zoladex * (Onc Inj)
Zolinza
Zytiga
Coagulation Therapy
Arixtra
Enoxaparin
Fondaparinux
Fragmin
Lovenox
Enzyme Therapy
Adagen
Aldurazyme
Aralast NP
Cerezyme
Elaprase
Elelyso
Fabrazyme
Kuvan
Kuvan Powder
Lumizyme
Myozyme
Naglazyme
Procysbi
Prolastin-C
Vimizim Inj
Vpriv
Zavesca
Zemaira
Gastrointestinal
Agents
Gattex
Relistor
Solesta *
Sucraid
Gonadotropins
Chorionic
Growth Hormone
Genotropin
Humatrope
Increlex
Norditropin
Nutropin *
Nutropin AQ *
Omnitrope
Saizen *
Serostim
Tev-Tropin *
Zorbtive
Hematological
Agents
Activase
Advate
Alphanate
Alphanine SD
Aranesp * (Blood Mod)
Bebulin
Bebulin VH
Benefix
Berinert
Cathflo Acti
Cinryze
Corifact
Cyklokapron
Epogen (Blood Mod)
Feiba NF
Feiba VH
Firazyr
Helixate FS
Hemofil M
Humate-P
Kalbitor
Koate-DVI
Kogenate FS
Leukine
Monoclate-P
Mononine
Mozobil
Neulasta * (Blood Mod)
Neumega
Neupogen * (Blood Mod)
Novoseven RT
Nplate
Omontys
Procrit * (Blood Mod)
Profilnine
Promacta
Recombinate
Riastap
Rixubis
Tranex Acid
Tretten Inj
Wilate
(Rev 5.6.15)
Xyntha
Xyntha Solof
HIV/AIDS
Abacavir *
Aptivus *
Atripla *
Combivir
Complera *
Crixivan *
Didanosine *
Edurant *
Egrifta
Emtriva *
Epivir *
Epivir HBV *
Epzicom *
Fuzeon
Intelence *
Invirase *
Isentress *
Kaletra *
Lamivud/Zido *
Lamivudine *
Lexiva *
Nevirapine *
Norvir *
Prezista *
Rescriptor *
Retrovir
Reyataz *
Selzentry *
Stavudine *
Stribild *
Sustiva *
Tivicay *
Trizivir *
Truvada *
Videx *
Videx EC
Viracept *
Viramune
Viramune XR *
Viread *
Zerit
Ziagen *
Zidovudine *
Hormones and
Hormone Modifiers
Acthar HP
Acthrel
Krystexxa
Octreotide
Samsca
Sandostatin
Sensipar
Signifor
Somatuline
Somavert
Thyrogen
Zemplar
Huntington’s Disease
Xenazine
Immune Globulin
Atgam
Bivigam
Carimune NF
Cytogam
Flebogamma
Gamastan S/D
Gammagard
Gammagard SD
Gammaked
Gammaplex
Gamunex-C
Hizentra
Hyperrab S/D
Hyperrho S/D
Hypertet S/D
Imogam Rabie
Micrhogam PL
Octagam
Privigen
Rhogam Plus
Rhophylac
Soliris
Winrho SDF
Immunomodulator
Benlysta
Infertility
Bravelle
Cetrotide
Chor Gonadot
Follistim AQ *
Ganirelix AC
Gonal-f *
Gonal-f RFF *
Makena *
Menopur
Novarel
Ovidrel
Pregnyl *
Repronex
Inflammatory
Conditions
Actemra
Arcalyst
Cimzia
Cimzia Prefl
Enbrel *
Enbrel Srclk *
Humira *
Humira Pen *
Ilaris
Kineret
Orencia
Otrexup Injection
Remicade
Simponi
Simponi Aria
Stelara
Xeljanz
Iron Overload
Exjade
Ferriprox
Miscellaneous
Amyvid
Carbaglu *
Onfi
Orfadin
Vivitrol
Multiple Sclerosis
Ampyra *
Aubagio
Avonex *
Avonex Pen *
Avonex Prefl *
Betaseron *
Copaxone *
Extavia
Gilenya *(Tier 3)
Rebif
Rebif Rebido
Rebif Titrtn
Tecfidera *
Tysabri
Musculoskeletal
Agents
Botox
Botox Cosmet
Dysport
Myobloc
Xeomin
Xiaflex
Zoledronic (Onc Inj)
Zometa (Onc Inj)
Narcolepsy
Xyrem
Ophthalmic Agents
Cystaran
Eylea
Jetrea
Lucentis
Macugen
Ozurdex
Retisert
Visudyne
Osteoarthritis
Euflexxa *
Gel-One
Hyalgan
Orthovisc
Supartz
Synvisc *
Synvisc One *
Osteoporosis
Boniva
Forteo
Miacalcin
Prolia
Reclast
Pain Management
Lioresal Int
Prialt
Qutenza
Parkinson’s Disease
Apokyn
Pregnancy
Makena
Pulmonary
Hypertension
Adcirca *
Epoprostenol
Flolan
Letairis *
Opsumit
Remodulin
Revatio
Sildenafil
Tracleer *
Tyvaso
Tyvaso Refil
Tyvaso Start
Veletri
Ventavis
Respiratory Agents
Bethkis Neb
Cayston
Kalydeco
Pulmozyme
Tobi ST
Tobi Podhalr ST
Tobramycin Neb
Transplant
Astagraf XL
Cellcept *
Cellcept IV
Cyclosporine *
Gengraf *
Hecoria
Mycophenolate *
Myfortic
Neoral
Nulojix
Prograf
Rapamune
Sandimmune *
Sirolimus Tabs
Tacrolimus
Zortress
ST - Step Therapy • * - Preferred
This Specialty/Biotech Pharmacy Drug List may not be a complete representation of all available specialty/biotech drugs; this list is subject to
change at any time without prior notice. Non-specialty alternatives may be a recommended first-line therapy to treat your condition. Please
consult your physician.
(Rev 5.6.15)
High Deductible H.S.A. Wellness Drug List
OTC, PPACA No Cost Share Mandates
In addition to a healthy lifestyle, preventive medications can help people avoid many illnesses and conditions. Preventive medications are defined
as those prescribed to prevent the occurrence of a chronic disease or condition for those individuals with risk factors, or to prevent the recurrence
of a disease or condition. Some examples of the medications listed are for high blood pressure, high cholesterol, diabetes, asthma, osteoporosis,
and heart disease. This list provides examples of your preventive medications by drug category/therapeutic classification. Medications may be
added to or removed from the list, depending on different factors, including the intended purpose of the medication and new medications.
ANTIHYPERTENSIVES
(Blood Pressure)
Adrenergic Antagonists
Cardura
Catapres
Catapres-TTS
clonidine
Demser
doxazosin
guanfacine
Hemangeol
methyldopa
Minipress
Nexiclon XR
prazosin
prazosin HCL
reserpine
Tenex
terazosin
Angiotensin Converting Enzyme
Inhibitors
Accupril
Aceon
Altace
benazepril
captopril
enalapril
Epaned
fosinopril
lisinopril
Lotensin
Mavik
moexipril
perindopril
Prinivil
quinapril
ramipril
trandolapril
Univasc
Vasotec
Zestril
Renin Inhibitor
Avapro
Benicar
candesartan
Cozaar
Diovan
Edarbi
eprosartan
irbesartan
losartan
Micardis
Teveten
Vasodilators
BiDil
hydralazine
minoxidil tablet
Diuretics
Aldactazide
Aldactone
amiloride
bumetanide
chlorothiazide
chlorthalidone
Demadex
Diuril
Dyazide
Dyrenium
Edecrin
eplerenone
ezide
furosemide
hydrochlorothiazide
indapamide
Inspra
Lasix
Maxzide
methyclothiazide
metolazone
Microzide
Spironolactone
Spironolactone/HCTZ
torsemide
triamterene/hctz
Zaroxolyn
Tekturna
Angiotensin II Receptor Blockers
Atacand
Calcium Channel Blockers
Adalat CC
afeditab CR
amlodipine
Calan
Calan SR
Cardene SR
Cardizem CD
Cardizem LA
Cardizem
cartia XT
Covera-HS
Dilacor XR
dilt-CD
dilt-XR
diltiazem
diltiazem CD
diltiazem ER
diltzac
felodipine ER
Isoptin SR
isradipine
matzim LA
nicardipine
nifediac CC
nifedical XL
nifedipine
nifedipine ER
nimodipine
nisoldipine
nisoldipine ER
Norvasc
Nymalize
Procardia
Procardia XL
Sular
taztia XT
Tiazac
verapamil
verapamil ER
verapamil SR
Verelan
Verelan PM
Beta Blockers
acebutolol
atenolol
Betapace
Betapace AF
betaxolol
bisoprolol
(Rev 5.6.15)
Bystolic
carvedilol
Coreg
Coreg CR
Corgard
Inderal XL
Inderal LA
InnoPran XL
Kerlone
labetalol
Levatol
Lopressor
metoprolol
metoprolol ER
nadolol
pindolol
propranolol
propranolol ER
Sectral
sotalol
sotalol AF
Tenormin
timolol
Toprol XL
Trandate
Zebeta
Combination Antihypertensives
Accuretic
amiloride / hctz
amlodipine / atorvastatin B
amlodipine / benazepril
Amturnide
Atacand HCT
atenolol/chlorthalidone
Avalide
Azor
benazepril / hctz
Benicar HCT
bisoprolol / hctz
Caduet
candesartan / hctz
captopril / hctz
Clorpres
Corzide
Diovan HCT
Dutoprol
Edarbyclor
enalapril / hctz
Exforge
Exforge HCT
fosinopril / hctz
Hyzaar
irbesartan / hctz
lisinopril / hctz
Lopressor HCT
losartan / hctz
Lotensin HCT
Lotrel
methyldopa / hctz
metoprolol / hctz
Micardis HCT
Moexipril / hctz
nadolol / bendroflumethiazide
propranolol / hctz
quinapril / hctz
telmisartan
telmisartan / hctz
Tarka
Tekamlo
Tekturna HCT
Tenoretic
Teveten HCT
Tribenzor
Twynsta
Uniretic
valsartan
valsartan / hctz
Valturna
Vaseretic
Zestoretic
Ziac
Misc. Antihypertensives Agents
Vecamyl
Advair Diskus & HFA
Atrovent HFA
Breo Ellipta
Combivent Respimat
cromolyn nebulizer solution
Daliresp
Dulera
Duoneb
ipratropium / albuterol
montelukast
Singulair
Spiriva
Symbicort
Tudorza Pressair
zafirlukast
Zyflo
Zyflo CR
Oral Beta-Agonists
albuterol
metaproterenol
terbutaline
Vospire ER
ASTHMA AND COPD
(Chronic Obstructive Pulmonary Disease)
Inhaled Beta-Agonists
AccuNeb
Aerospan
albuterol
albuterol ER
Anoro Ellipta
Asmanex
Brovana
Foradil
ipratropium inhalation solution
isoproterenol
levalbuterol neb
Perforomist Neb
Pro-Air HFA
Proventil HFA
Serevent Diskus
Striverdi Respimat
Theo-24 CR / ER
terbutaline sulfate
theochron CR
theophylline CR
theophylline ER
Ventolin HFA
Xopenex HFA
Xopenex Solution
zafirlukast
Inhaled Corticosteriods
Alvesco
budesonide suspension
Flovent Diskus & HFA
Pulmicort
QVAR
Misc. Pulmonary Agents
Accolate
Xanthines
Elixophyllin
Lufyllin
Theo-24
theophylline
LIPID/CHOLESTEROL LOWERING
AGENTS
(Heart Attack and Heart Disease
Prevention)
Bile Acid Sequestrants
cholestyramine
cholestyramine lite
Colestid
colestipol
prevalite
Questran
Questran Lite
WelChol
Niacin Products
niacin ER (Rx)
niacor
Niaspan ER
Simcor
Combination Products
Advicor
Liptruzet
Vytorin
Fibric Acid Derivatives
Antara
fenofibrate
fenofibric acid
fenofibric acid DR
Fenoglide
Fibricor
(Rev 5.6.15)
gemfibrozil
Lipofen
Lofibra
Lopid
Tricor
Triglide
TriLipix
Statins
Altoprev
atorvastatin
Crestor
fluvastatin
Lescol
Lescol XL
Lipitor
Livalo
lovastatin
Mevacor
Pravachol
pravastatin
simvastatin
Zocor
Other
Juxtapid SP
Kynamro SP
Lovaza
omega-3-acid (Rx)
Vascepa
Zetia
DIABETES THERAPY
Non-Insulin Hypoglycemic Agents
acarbose
Actoplus Met
Actoplusmet XR
Actos
Amaryl
Avandamet
Avandaryl
Avandia
Bydureon
Byetta
chlorpropamide
Cycloset
Diabeta
Duetact
Fortamet
glimepiride
glipizide
glipizide ER
glipizide XL
glipizide/metformin
Glucophage
Glucophage XR
Glucotrol
Glucotrol XL
Glucovance
Glumetza
glyburide
glyburide micronized
glyburide/metformin
Glynase
Glyset
Invokana
Janumet
Janumet XR
Januvia
Jardiance
Jentadueto
Kazano
Kombiglyze
Kombiglyze XR
metformin
metformin ER
nateglinide
Nesina
Onglyza
Oseni
pioglitazone
pioglitazone / glimepiride
pioglitazone /metformin
Prandin
Prandimet
Precose
repaglinide
Riomet
Starlix
Symlin
Tanzeum
tolazamide
tolbutamide
Tradjenta
Victoza
Combination Products
Juvisync
Testing Supplies
Control Solution — for Diabetic Meters
Diabetic Test Strips
Diabetic Testing — Lancets
Insulin Pen Needles and Needles /
Syringes
Insulins
Apidra
Farxiga
Humalog
Humalog Mix
Humulin
Lantus
Lantus Solostar
Levemir
Novolin
Novolin Relion
Novolog (all)
Antipsychotic Drugs
Abilify
Adasuve
chlorpromazine
clozapine
Clozaril
Compazine
Equetro
Fanapt
Fazaclo
fluphenazine
Geodon
haloperidol
Invega
Latuda
loxapine
Loxitane
olanzapine
olanzapine-fluoxetine
perphenazine
prochlorperazine
quetiapine
Risperdal
risperidone
Saphris
Seroquel
Seroquel XR
Symbyax
thioridazine
thiothixene
trifluoperazine
Versacloz
ziprasidone
Zyprexa
OSTEOPOROSIS THERAPY
(Healthy Bones)
Bisphosphonates
Actonel
alendronate
Atelvia
Binosto
Boniva
didronel
etidronate
Fosamax
Fosamax + D
ibandronate
risedronate
Skelid
Other
calcitonin spray
Forteo SP
Fortical
Miacalcin spray
ANTI-ESTROGEN
(Breast Cancer Prevention)
anastrozole
Arimidex
Aromasin SP
Evista
exemestane SP
Fareston
Femara SP
letrozole SP
raloxifene
Soltamox
(Rev 5.6.15)
tamoxifen
ANTICOAGULANTS
(Heart Attack, Blood Clot and Stroke
Prevention)
Aggrenox
Arixtra
Brilinta
cilostazol
clopidogrel
Coumadin
dipyridamole
Effient
Eliquis
enoxaparin
fondaparinux
Fragmin
heparin
Jantoven
Lovenox
Persantine
Plavix
Pletal
Pradaxa
ticlopidine
warfarin
Xarelto
Zontivity
IMMUNOSUPPRESSANTS
(Prevention of Organ Rejection)
Astagraf XL SP
Azasan
azathioprine
Cellcept SP
Cyclosporine SP
cyclosporine modified SP
gengraf SP
hecoria SP
Imuran mycophenolate SP
mycophenolate SP
mycophenolic DR SP
Myfortic SP
Neoral SP
Prograf SP
Rapamune SP
Sandimmune SP
sirolimus SP
tacrolimus cap SP
Zortress SP
MULTIPLE SCLEROSIS SP*
Ampyra SP
Aubagio SP
Avonex SP
Betaseron SP
Copaxone SP
Extavia SP
Gilenya SP
Rebif SP
Tecfidera SP
HIV/AIDS SP*
(Antietroviral Therapy)
abacavir SP
SP
abacavir / lamivudine / zidovudine
SP
Aptivus
Atripla SP
Combivir SP
Complera SP
Crixivan SP
didanosine SP
Edurant SP
Emtriva SP
Epivir SP
Epzicom SP
Fuzeon SP
Intelence SP
Invirase SP
Isentress SP
Kaletra SP
lamivudine SP
lamivudine / zidovudine SP
Lexiva SP
nevirapine SP
SP
nevirapine ER
Norvir SP
Prezista SP
Rescriptor SP
Retrovir SP
Reyataz SP
Selzentry SP
stavudine SP
Stribild SP
Sustiva SP
Tivicay SP
Trizivir SP
Truvada SP
Videx SP
Videx EC SP
Viracept SP
Viramune SP
Viramune XR SP
Viread SP
Zerit SP
Ziagen SP
zidovudine SP
VITAMINS & HEMATINICS
Pediatric Vitamins with Fluoride
(for example; Poly-Vi-Flor, Tri-Vi-Flor)
Generic Products
Brand Name Products
Prenatal Multivitamins with Iron
and Folic Acid
(for example; OB Complete, prenatabs
FA)
Generic Products
Brand Name Products
To help you tell generic and brand drugs apart, all generics start with a lowercase letter. Oral and self-injectable Specialty
medications are denoted by “SP” superscript and may be subject to limitations based on plan benefit design.
This list is intended as a reference and may not be all-inclusive. Brand or generic availability may not be current due to changes in
the market. Use of generics may be required depending upon plan design.
(Rev 5.6.15)
OptumRx Mobile Friendly Website
Access your account anytime, anywhere
Manage your prescription drug benefits on your smartphone, iPad or other handheld device.
OptumRx Mobile makes it easy to:
 Refill mail service pharmacy prescriptions
 Check the status of and track orders
 Locate a pharmacy by ZIP code
 View your prescription history
 Set up text message medication reminders
 Search your formulary by generic or brand-name drug, status, or class
How do I find the Mobile Site?
Open your smart phone browser and type in m.optumrx.com. You also can type in our full
address, www.optumrx.com, and you will automatically be directed to the mobile version of our
site. Once the site is loaded on your phone, you can bookmark it.
Can I use the Mobile Site on any Smart Phone?
Yes. Just enter m.optumrx.com into the web browser of your smartphone.
Can I use both the Full Site and the Mobile Site?
Yes. If you make a change to your account or manage your prescriptions on one site, that information will be updated on the
other site as well.
How to Refill Prescriptions
1.
On the home page, click MY PRESCRIPTIONS. Click REFILL PRESCRIPTIONS. (If you are not logged in, you will be prompted
to log in first.)
2.
Select the prescription(s) you would like refilled by checking the box(es).
3.
Click ADD TO CART to proceed to the Shopping Cart page.
4.
Review your selections. You can remove items from your cart, keep shopping or check out. When you are finished, click
CHECK OUT.
5.
Review your shipping information and your order summary. You may change your shipping address or add a new one.
6.
Review your order summary. To make changes to your order, click BACK. If your order is complete, click SUBMIT.
How to Set Up Text Message Medication Reminders
1.
On the home page, click MY PRESCRIPTIONS. Click MEDICATION REMINDERS. (If you are not logged in, you will be
prompted to log in first.)
2.
Enter the mobile phone number where you want the text message reminder(s) to be sent.
3.
Select your time zone.
4.
Select your mobile carrier.
5.
Choose the type of reminder you would like to receive. You can get reminders when mail order prescriptions are ready
for refill and renewal, when prescriptions are eligible for transfer to mail service and when orders have been shipped. You
can also set reminders for specific times of day and for specific medications.
6.
When you are done, click SAVE.
(Rev 5.6.15)
PROVIDER CLINICAL PRACTICE GUIDELINE RESOURCES
Clinical practice guidelines for the provision of preventive, acute or chronic medical services and behavioral health services to both
providers and members
Topic
Attention Deficit
Hyperactivity Disorder
(ADHD)
Practice Guidelines
http://www.guideline.gov/content.aspx?id=36881
ADHD: clinical practice guidelines for the diagnosis, evaluation, and treatment of attention-deficit / hyperactivity disorder in children
and adolescents
Asthma
http://www.cdc.gov/ncbddd/adhd/guidelines.html
Attention-Deficit/ Hyperactivity Disorder (ADHD)
http://www.nhlbi.nih.gov/guidelines/asthma/index.htm
Guidelines for the Diagnosis and Management of Asthma (EPR-3)
National Heart, Lung, and Blood Institute
https://www.nhlbi.nih.gov/health/prof/lung/asthma/naci/asthma-info/asthma-guidelines.htm
Asthma Guidelines- National Heart, Lung, and Blood Institute
Bipolar Disorder:
Adults
Breast Cancer
Screening
http://www.cdc.gov/asthma/healthcare.html
Centers for Disease Control and Prevention- Asthma
http://psychiatryonline.org/guidelines.aspx
Treatment of Patients with Bipolar Disorder- American Psychiatric Association Practice Guidelines
http://annals.org/article.aspx?articleid=733957
Screening Mammography for Women 40 to 49 years of Age: A Clinical Practice Guideline from the American College of Physicians
Breast Cancer Screening Clinical Practice Guideline
http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm
Screening for Breast Cancer- U. S. Preventive Services Task Force
Cervical Cancer
Screening
Breast Cancer Screening
http://www.cdc.gov/cancer/cervical/basic_info/screening.htm
Cervical Cancer Screening- CDC
http://www.uspreventiveservicestaskforce.org/uspstf/uspscerv.htm
Screening for Cervical Cancer- U. S. Preventive Services Task Force
Child and Adolescent
Psychiatry
http://www.acog.org/About%20ACOG/Announcements/New%20Cervical%20Cancer%20Screening%20Recommendations.aspx
New Cervical Cancer Screening Recommendations from the US Preventive Services Task Force and the American Cancer
Society/American Society for Colposcopy and Cervical Pathology/ American Society for Clinical Pathology
http://www.aacap.org/AACAP/Resources_for_Primary_Care/Home.aspx
American Academy of Child and Adolescent Psychiatry
Colon Cancer Screening http://www.cdc.gov/cancer/colorectal/basic_info/screening/guidelines.htm
Colorectal Cancer Screening Guidelines- CDC
http://www.ncbi.nlm.nih.gov/pubmed/23207930
Colorectal Cancer Screening Guidelines-NCBI
Congestive Heart
Failure
COPD
Degenerative Joint
Depression
Colorectal Cancer Screening
Management of Chronic Heart Failure. A National Guideline
http://circ.ahajournals.org/content/119/14/1977.full.pdf
ACCF/AHA Practice Guidelines for the Diagnosis and Management of Heart Failure in Adults
Annals of Internal Medicine- Clinical Guidelines- Diagnosis and Management of Stable Chronic Obstructive Pulmonary Disease: A
Clinical Practice Guideline Update from the American College of Physicians , American College of Chest Physicians, American Thoracic
Society, and European Respiratory Society
Diagnosis and Management of Stable Chronic Obstructive Pulmonary Disease: A Clinical Practice Guideline Update from the American
College of Physicians , American College of Chest Physicians, American Thoracic Society, and European Respiratory Society
http://www.aaos.org/Research/guidelines/guide.asp
American Academy of Orthopaedic Surgeons
Practice Guideline for the treatment of patients with major depressive disorder, third edition.
http://www.aafp.org/afp/2011/0515/p1219.html
(Rev 5.6.15)
Topic
Practice Guidelines
APA Releases Guideline on Treatment of Patients with Major Depressive Disorder
Treatment of Patients with Major Depressive Disorder- American Psychiatric Association Practice Guidelines
Diabetes
Using Second- Generation of Antidepressants to Treat Depressive Disorders : A Clinical Practice Guideline from the American College
of Physicians
http://care.diabetesjournals.org/content/37/Supplement_1/S14.full
Standards of Medical Care in Diabetes-2014- American Diabetes Association
http://professional.diabetes.org/admin/UserFiles/0%20-%20Sean/dc132042%20FINAL.pdf
Nutrition Therapy Recommendations for the Management of Adults with Diabetes- American Diabetes Association
Hypertension
Clinical Practice Guideline for Type 2 diabetes
http://www.nhlbi.nih.gov/guidelines/hypertension/index.htm
The Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure
(JNC 7)- National Heart, Lung, and Blood Institute, NIH
Hyperlipidemia
http://onlinelibrary.wiley.com/doi/10.1111/jch.12237/full
Clinical Practice Guidelines for the Management of Hypertension in the Community- Journal of Clinical Hypertension
http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm
Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel
III)- National Heart, Lung, and Blood Institute, NIH
Screening and Management of Hypercholesterolemia
Ischemic Heart Disease http://www.ncbi.nlm.nih.gov/pubmed/23165665
Management of Stable Ischemic Heart Disease: summary of clinical practice guidelines from the American College of
Physicians/American College of Cardiology Foundation, American Heart Association/ American Association for Thoracic Surgery/
Preventive Cardiovascular Nurses Association/ Society of Thoracic Surgeons
Osteoarthritis
Osteoarthritis of the
Knee
Management of Stable Ischemic Heart Disease: summary of clinical practice guidelines from the American College of
Physicians/American College of Cardiology Foundation, American Heart Association/ American Association for Thoracic Surgery/
Preventive Cardiovascular Nurses Association/ Society of Thoracic Surgeons
http://www.ncbi.nlm.nih.gov/pubmed/9743815
Practice Guidelines in the management of Osteoarthritis
http://www.aaos.org/research/guidelines/guidelineoaknee.asp
Treatment of Osteoarthritis of the knee
American Academy of Orthopaedic Surgeons Clinical Practice Guideline on the Treatment of Osteoarthritis of the Knee, 2nd edition
Psychological Disorders http://www.apa.org/practice/
American Psychological Association
Schizophrenia
http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1742-9552
Clinical Psychologist- Wiley Online Library
American Psychiatric Association Practice Guidelines- Treatment of Patients with Schizophrenia
Preventive Health Practice Guidelines
Perinatal care
Prevention of perinatal group b streptococcal disease-revised guidelines from CDC 2010
http://www.cdc.gov/pregnancy/hcp.html
2009 Pandemic Influenza A (H1N1) Virus Illness Among Pregnant Women in the United States
Maternal and Infant Health
Pediatric Preventive
Health
Child up to 24 months
Child from 2 to 19
years
Routine prenatal care
http://www.aap.org/en-us/professional-resources/practice-support/Pages/PeriodicitySchedule.aspx
Routine preventive services for infants and children (birth – 24 months)
http://www.cdc.gov/flu/protect/children.htm
Children, The Flu and the Flu Vaccine
Advisory Committee on Immunization Practices (ACIP) recommended immunization schedule for persons aged 0 through 18 years —
United States, 2013.
(Rev 5.6.15)
Topic
Adults 20-64 years
Adults 65 and older
Practice Guidelines
http://www.guideline.gov/content.aspx?id=43849&search=preventive+care+2-19+years
Preventive activities in children and young people. In: Guidelines for preventive activities in general practice, 8th edition.
Routine preventive services for children and adolescents (ages 2-21).
http://www.uspreventiveservicestaskforce.org/adultrec.htm
Recommendations for Adults
Adult clinical preventive care
Ann Arbor (MI): University of Michigan Health System; 2011 Dec 20 p. [15 references]
http://www.guideline.gov/search/results.aspx?106=455,&103=522,
Prevention Guidelines
Preventive services for adults. 1995 June (revised 2013 Sep). NGC: 010043
Adult preventive services (ages 50-65+).
Michigan Quality Improvement Consortium. Adult preventive services (ages 50 - 65+). Southfield (MI): Michigan Quality Improvement
Consortium; 2013 Mar. 1 p.
(Rev 5.6.15)
PROVIDER CODING GUIDELINES
The Provider Coding Guidelines manual is located on your employer custom website under “Provider Network Information.”
Prompt Statute - Article 3.70.3, Texas Insurance Code
IEBP voluntary complies with most provisions of the Prompt Pay Statute. Provisions with which IEBP will not comply are listed
below:
1.
Provider must submit claim to insurer not later than 95th day from incurred date. The provider forfeits the right to
payment if the provider bills later than the 95th day from incurred date unless there is a documented TDI catastrophic
incident.
2.
Provider may not submit a duplicate billing less than 45 days after the original bill. A duplicate claim does not include
corrected claims or additional information provided to satisfy a carrier’s request. Providers are required to indicate on
the claim form whether the claim is a duplicate claim or corrected claim.
3.
Receipt date is:
Five (5) calendar days after claim mailed

Overnight - date signature on receipt

Electronic - date of electronic verification

4.
Within the 45 days for paper claims/30 days for electronic claims/18 for prescription claims payment day guideline for
clean claims one of the following must occur:
Pay the entire contracted amount of a clean claim.

Deny the entire claim and notify the physician or provider why the claim will not be paid.

Pay part of the claim and deny or audit the remainder and pay 100% of the applicable contracted rate for the

audited portion and notify the physician or provider.
Notify the physician or provider that the claim is being audited and pay 100% of the applicable contracted rate.

A claim is considered “clean” if it contains all the required data elements set forth in the rules and, if applicable,

the amount paid by the primary plan or other valid coverages. Claims submitted electronically are considered clean
if they are submitted using the standards for electronic transactions and codes set forth by the appropriate
regulatory body.
If audit is to be conducted, the audit must be complete within 180th day after claim received. Insurers who opt to

audit a claim must pay 100% of the applicable contracted rate and notify provider of the audit in writing within the
statutory deadline.
The insurer may make one request to the treating provider for additional information to process a claim. The

request must be made within thirty (30) days of the date the claim was received. If insurer is requesting
information, the insurer must receive information within forty-five (45) days after the request or the provider
forfeits amount of claim. Once the insurer has received the requested information, the insurer must act within
fifteen (15) days of receipt of the information or by the statutory deadline, whichever is later.
IEBP will comply except in the following circumstances:
 Investigations of Right of Recovery conditions.
 Investigation of order of benefits for multiple coverages when conflicting information is submitted.
 Delay in payment of claims due to non-payment of contributions by either a group, COC or retired individual.
 Delay due to actively at work investigation.
 Due to lack of benefit information delaying plan set-up for self-funded plans.
 Where claim does not meet the definition of a Clean Claim based on the definition per the Plan Document
Additional Information Requests
1.
Against Medical Advice Discharge – When an individual discharges themselves against medical advice, all services relating
to that confinement must be denied as not covered. If the covered individual is readmitted for the same or similar
condition, services related to the readmission are eligible for consideration
(Rev 5.6.15)
2.
Alternative Medicine Treatment or Therapy – Procedures or treatments that have not been scientifically tested, or were
tested and found to be ineffective or are not FDA approved will be denied as unproven according to plan language. The
following are examples of alternative treatments: Metabolic therapy, Live Cell therapy, Shark Cartilage therapy, Laetrile
(B-17 compound-high cyanide content), Electromagnetic therapy, Aromatherapy, Unspecified “vaccinations”, Cabbage
poultices, Rife therapy, Snake venom or coffee enemas.
3.
Ambulatory surgical facility anesthesia services – If a facility is billing for professional anesthesia charges, revenue codes
963 or 964, and the time is indicated that is 6 hours or over, corresponding anesthesia notes may be required.
4.
Billing for more than one piece of equipment on same day – Identical charges of a piece of equipment on the same day
will be reviewed for appropriateness.
5.
Handwritten Claims

Provider License Verification – Non Network Medical and Vision Providers and all Dental Providers
Any handwritten medical, dental or vision claims will require provider license verification. Please submit a copy
with your bill.
A Handwritten claim is a claim that includes one or all of the following items in writing:
»
Provider Information
»
Charges
»
Patient or EE information
Vision cash register receipts, such as those provided at Wal-Mart Eye Care centers and Flu Vaccine or other
immunization receipts from retail based pharmacies are not considered handwritten.
6.
Mammograms
Mammograms billed with 76499 are not billed with appropriate code and will be denied.
Computer Aided Detection (CAD)
This process enhances the interpretation process. Interpretive Mammogram charges billed with these codes are
acceptable as add on codes:
 77051 - Computer aided detection with further physician review for interpretation, with or without digitization of
film radiographic images; diagnostic mammography
 77052 - Computer aided detection with further physician review for interpretation, with or without digitization of
film radiographic images; screening mammography (See below grid).
Mammograms that can be billed with CAD add on codes 77051 & 77052
77055
77056
77057
Standard X-ray
Mammography; unilateral )
Mammography; bilateral
Screening mammography, bilateral
G0202
G0204
G0206
Digital
Screening Mammography producing direct digital image, bilateral, all views
Diagnostic Mammography, direct digital image, bilateral, all views
Diagnostic mammography, direct digital image, unilateral, all views
** Only one Mammography service, whether it is standard or digital, is eligible in the same encounter.
7.
Multiple family members receiving same treatment from same provider – If a provider is rendering the same treatment
to multiple family members, proof of service and benefit eligibility should be established. Medical notes/records and
pathology reports (if applicable) must be submitted. This would exclude preventive dental or vision treatment and well
child checkups and immunizations.
8.
Pathology Modifier 59 – Under iCES rules, UHN provider claims for multiple specimen charges must be billed with modifier
- 59 appended.
Rebundling of Panel Labs – Appropriate claim screening edits for rebundling to a panel lab will occur if all the components
have been billed.
9.
10.
Potential Other Coverage Investigation – The following criteria would prompt extra consideration for potential other
coverage and it is important that the clinic, facility, physicians office or claimant be contacted directly to verify if other
coverage may exist:
 Large payment on assigned or non-assigned claim
 No assignment on large dollar claim
 Dependent with different address to covered individual
 Covered individual over age 65 with a retiree status
 Active enrollee status with dependents over age 65
(Rev 5.6.15)


Diagnosis of End Stage Renal Disease
Indication of Social Security Insurance (SSI) disability participant
11.
Questionable provider billings – The claim will be referred for further review in any of the following:
 Providers billing on a HCFA with a billing address in Box 33 shown as a PO Box only. If the PO Box # is followed by
alpha letters such as, “SJO”.
 Providers billing with PO Box address only and using Social Security Numbers instead of a Tax ID number.
 Provider credentials shown as “Md” instead of “MD”.
 If the employee receiving treatment is from a different state (non-emergent care).
 The bill is for consultation and/or diagnostic testing. The bill does not provide the name of the referring physician.
 Provider will always be out of network and bill may indicate “non-participating provider”.
12.
Rebilled Services – If services are rebilled for a change in place of service, diagnosis code or procedure code and
reprocessing the claim will create a change in benefit (e.g., deductible, benefit percentage, covered vs. not covered),
medical records or notes will be required. If the rebilled service is for a change in servicing provider from an ineligible
provider, such as a scrub nurse, to an eligible credentialed provider, medical records will be required.
13.
Rebilled Facility Services – If the Level of Care billed on the claim is higher than what was approved through notification,
the charges will be denied for a corrected claim that accurately reflects the approved level of care for these dates. If the
billed level of care was provided, the provider must submit an itemized bill and medical notes substantiating the need for
the level of care.
14.
Robotic Arm – Robotic Arms used during surgery are not covered unless they are being utilized for an FDA approved
procedure. Some of the more commonly seen itemization descriptions include:
 Retractor Medcab
 Aesop
 Hermes
 Zeus
15.
Serial surgeries – Bills received for the same surgical procedures performed on the same site on a different day will require
review of medical records to establish medical appropriateness.
16.
Services possibly rendered by a relative – Investigation will be made when a patient and provider share same last name
(excluding the more popular last names). If claim is returned with proof of relationship that is excluded by the plan,
services will be denied.
17.
SIU Provider Holds – If a provider is on Provider Hold, medical records may be requested to substantiate the service(s)
being rendered.
18.
Unassigned claims – The provider will be contacted for verification of services and charge amounts in any of the following
situations:
 Bill altered in anyway (scratched out, white outs)
 Different Handwriting
 Change in ink style (i.e., fine v medium point)
 If charges appear excessive based on the MDR or fee schedule allowable amounts
 If paid benefits exceed $500
19.
Unidentified Providers – Credentials or name of individual performing service will be required on all claims.
20.
Use of a canned operative report – Additional review will be conducted for operative reports received that do not contain
the name of the patient, specific information on the surgery or appears to be the same paragraph used on all procedures
operative reports that appear to be a copy of a report where and only the name of the patient and surgeon were added.
21.
Video camera and equipment charges – Will only be reimbursed if billed in conjunction with a diagnostic procedure.
(Rev 5.6.15)
PROMPT PAY ADJUDICATION

Collection of overpayment must be requested no later than 180 days after date upon receipt. Provider must receive request
of overpayment in writing. Provider must pay overpayment within forty-five (45) days of notice unless appealed. Appeal
must be done within forty-five (45) days of notice. A carrier may recover an overpayment in the case of fraud or material
misrepresentation by a physician or provider.

Coordination of Benefits does not extend payment timelines. In instances where multiple coverages apply, the provider
must file a claim with the secondary payer within ninety-five (95) days of receipt of the determination of the primary payer.
If a carrier that is secondary payer overpays a claim, the carrier must recover the overpayment from the carrier that is a
primary payer and/or provider. If the primary payer has already paid the claim, the secondary payer may recover
overpayment directly from the provider.

Providers must receive medical management manual and coding guidelines. The coding guidelines must be provided to the
provider. Coding guidelines should include bundling, recoding or other payment process and fee schedules. Coding
guidelines must be received within thirty (30) days of request. Changes to coding guidelines must be received within ninety
(90) days of change.

Identification Card must display eligibility date the individual became insured under the plan and must provide a toll free
number a provider may call.

Pre-authorizations may be used to abide by turnaround time requirements not later than the third (3) calendar day after
the date of the request. Once pre-authorization is conducted cannot deny medical necessity unless misrepresentation.

Verification must be good for thirty (30) days. Verifications should include: deductible, copays, benefit percentage, and be
guaranteed for at least thirty (30) days unless the providers makes a misrepresentation.

Late Payment and Underpayment Penalties
IEBP is not subject to the penalties of the Prompt Pay Statute directly but access to the United Healthcare network requires
prompt pay contact compliance.

If the carrier pays a clean claim between one (1) and forty-five (45) days late, the carrier must pay the full contracted rate
of the services provided plus either 50% of the difference between the billed charges and the applicable contracted rate or
$100,000, whichever is less.

If the carrier pays a clean claim between forty-six (46) and ninety (90) days late, the carrier must pay the full contracted rate
of the services provided plus either 100% of the difference between the billed charges and the applicable contracted rate
or $200,000, whichever is less.

If the carrier pays a clean claim ninety-one (91) or more days late, it must pay the full contracted rate of the services provided
plus either 100% of the difference between the billed charges and the applicable contracted rate or $200,000, whichever is
less, plus 18% annual interest on the penalty amount, accruing from the date payment was originally due and through the
date of actual payment.
(Rev 5.6.15)
SAMPLE EXPLANATION OF BENEFITS (EOB)
(Rev 5.6.15)
(Rev 5.6.15)
ELECTRONIC FUND TRANSFER PAY-PLUS INFORMATION
IEBP contracts with Pay-Plus Solutions to provide the latest secure electronic payment technology which should significantly
accelerate and improve efficiency to the payment process. Pay-Plus delivers a dramatic savings of time and money by replacing
traditional paper checks with its secure electronic payment services, including Electronic Funds Transfer (EFT) and Electronic
Remittance Advice (ERA).
Easy to Use. Easy to get Started.
There are three different ways the provider pay take advantage of Pay-Plus Solutions:
1.
Pay-Plus Select
Select payments utilize a MasterCard branded, reloadable, virtual credit card which is faxed to the Provider. The Provider
inputs the virtual credit card information in their credit card terminal to receive immediate payment for that claim. Each
Select fax represents one payment.
2.
Pay-Plus Select Plus
SelectPlus payments utilize a unique terminal emulation process, allowing a MasterCard branded, reloadable, virtual
credit card to be automatically pushed each day to the Provider’s Merchant Account. Payments, when possible, are
aggregated to simplify the balancing of payments EOP.
3.
Pay-Plus Direct
Direct payments utilize Automated Clearing House (ACH) payment rails, directly depositing a consolidated payment into
the Provider’s Bank Account via UMB Bank, our FDIC insured depository partner.
Each Pay-Plus product gives the Provider multiple options to access their data and customize notifications, as well as
utilize a number of other features via the Pay-Plus secure web portal.
Electronic Fund Transfer Enrollment Instructions:
1.
Providers who have received a Pay-Plus Payment
Register online at www.ppsonline.cvom by choosing “Join Now” and following the steps as a Verified User. Contact a PayPlus Member Services Representative at (877) 828-8834 and selection option 1. Be sure to have your registration code
handy, which is found on the cover page of you fax payment.
2.
Provider who have not received a Pay-Plus Payment:
Submit a registration request online at www.ppsonline.com by choosing “Join Now” and follow the steps to “request User
Registration”. Submit a registration request by calling the Pay-Plus Member Services Team at (877) 828-8834 and selection
Option 1.
Helpful Hints for a seamless Electronic Fund Transfer Enrollment:
1.
Be sure to have the TIN (Tax I.D. Number) associated with the account your are registering
2.
Ensure that you are an authorized representative of the designated Provider.
3.
Have your contact, organization, and financial account information available.
4.
Review all terms, pricing and authorization forms prior to submitting them to Pay-Plus Solutions.
5.
Review the EFT Frequently Asked Questions (FA) at www.ppsonline.com/faqs.html
Pay-Plus Solutions, Inc
18167 US Highway 19 North, Suite 515
Clearwater, Fl 33764
Hours of Operation: Monday – Thursday 9:00 am-7:00 pm EST and Friday 9:00 am-5:30 pm EST
Member Services: (877) 828-8834
(Rev 5.6.15)
SAMPLE EXPLANATION OF PAYMENT (EOP)
(Rev 5.6.15)
HOW BENEFITS ARE PAID
The Pool relies mainly on information provided when a claim is submitted. If IEBP finds that additional information is needed to
determine if benefits are payable or for Right of Recovery under the Plan, a written request for such information will be made to
the Covered Individual, or if necessary, the healthcare provider. If the information is submitted and IEBP submits the claim for
audit the network provider will be reimbursed for eighty-five percent (85%) of the eligible charges. The audit will be conducted
within one-hundred and eighty (180) days of the receipt of the clean claim and any additional payment due to the network provider
or any refund due to IEBP will be made no later than the thirtieth (30 th) day after the completion of the audit. If the information is
not provided, the claim will be denied. If the claim is denied because requested information is not provided, the information may
be filed as long as the required information is filed within the twelve (12) months from the date the expense was incurred, unless
it was not reasonably possible to furnish the information within the filing deadline as determined by IEBP. Additional information
may also be submitted within ninety (90) days after a decision is made by the employer’s workers’ compensation carrier or by the
Workers’ Compensation Division of the Texas Department of Insurance, that the medical expense sought to be claimed is due to
an injury that is non-compensable, whichever is later. To avoid a prompt pay penalty, required information must be received by
IEBP not later than the prompt pay contract deadline.
Claims
Requests for Reimbursement
No benefits are payable for claims submitted by the employee or a provider unless the requirements of this paragraph are met.
Requests for reimbursement for a covered benefit should be received by IEBP within ninety (90) days of date of service but not
later than twelve (12) months from the date the expense was incurred, unless it was not reasonably possible to furnish the
information within the filing deadline as determined by IEBP, or within ninety (90) days after a decision is made by the employer’s
workers’ compensation carrier or by the Workers’ Compensation Division of the Texas Department of Insurance, that the medical
expense sought to be claimed is due to an injury that is non-compensable, whichever is later.
Determination of “reasonably possible” is at the sole discretion of IEBP.
Requests for reimbursement must include:
1.
the employee's name, address, unique subscriber identification number and group name;
2.
the covered individual's name and relationship to the employee;
3.
the healthcare provider's name, tax ID/national provider identifier (NPI), or unique identification number and address;
and
4.
a description of the service rendered including charge(s), diagnosis code(s), applicable procedure code(s), and the date(s)
of service.
Requests for reimbursement must be legible. If a request is not legible, it may be returned with a request to submit a legible
copy. Electronic claim submissions must meet the standards for electronic transactions and codes set forth by the appropriate
regulatory body. Claims will be considered for payment in the order received.
Claims may be mailed to:
TML MultiState IEBP
PO Box 149190
Austin, Texas 78714-9190
If you have any questions regarding your claim, please call IEBP’s Customer Care Team at (800) 282-5385 or contact Customer
Care via e-mail at www.iebp.org.
Benefits will not be recalculated to allow a better benefit for charges incurred at a later date.
Claim forms are not required for benefits to be payable under the Plan. The Pool may request specific information from the
Covered Individual or employer in order to complete processing of the claim or to verify eligibility in the Plan.
The information requested may include but is not limited to:
1.
verification of employment status;
2.
information related to accidental injuries;
3.
information related to work related accidents or illness; and/or
4.
information regarding any other source of benefits.
(Rev 5.6.15)
Covered Individuals must keep the Pool informed in writing of any change in address, phone number or dependents. IEBP may
rely on United States Postal Service and/or the employer demographic information for a covered individual’s last known address.
As a Covered Individual under the Plan, you must supply IEBP with the information necessary to determine whether the charges
incurred are for an Eligible Benefit or to otherwise administer benefits. Decisions with respect to the type of information
necessary to determine coverage shall be made at the sole discretion of IEBP. IEBP reserves the right to withhold or deny
payment until the requested information has been furnished.
Right to Receive and Release Necessary Information
All personnel involved in the processing of claims are advised of the need to treat all personal and medical information as
confidential. However, IEBP has the right to disclose information to or obtain information regarding a Covered Individual from
any organization or person if necessary to determine benefits payable under the Plan or if allowed by state or federal statute or
regulation.
No Replacement for Workers’ Compensation
The Plan does not replace Workers’ Compensation or provide any benefits if any Workers’ Compensation benefit was paid or
could have been paid, whether or not the employer is a subscriber or non-subscriber in a Workers’ Compensation Program,
including those individuals who could have been lawfully covered by workers’ compensation as volunteers. For purposes of this
booklet, work on the Covered Individual’s family farm or ranch is not considered an employment arrangement requiring
Workers’ Compensation.
Assignments
The benefits provided under the Plan are payable only to the Covered Individual. IEBP may pay benefits directly to the healthcare
provider if they are assigned by the Covered Individual.
Benefits may not be assigned to a pharmacy. In addition, benefits will not be paid to providers who negotiate benefit settlements
with patients, e.g., providers who agree to accept whatever payment the Plan makes or providers who waive deductibles or
copayments.
Legal Actions
No legal action (including arbitration) may be brought against IEBP prior to the expiration of sixty (60) days after a written request
for reimbursement has been furnished to IEBP in accordance with the requirements of the Plan, and all appeal rights available
to the Plan have been exhausted. No such action may be brought after the expiration of two (2) years from the date service was
incurred. This paragraph shall be applicable where a medical provider makes a complaint that a prompt payment contract was
not followed. Venue for any dispute arising under the terms of this plan, including but not limited to claims and subrogation
disputes or declaratory judgment actions, shall be in Austin, Travis County, Texas.
IEBP reserves the right to take any legal action available against a Covered Individual to recover expenses incurred by IEBP to
defend frivolous lawsuits or actions brought before all appeal rights have been exhausted.
Appeals
IEBP will conduct a full and fair review of your appeal. The appeal will be reviewed by appropriate individual(s) on the IEBP staff
for internal review; or a health care professional with appropriate expertise during the initial benefit determination process.
The appellant may request an independent review from an independent state licensed external review organization that is
credentialed under URAC (Utilization Review Accreditation Commission). The external review will be conducted by a random
URAC selected reviewer who was not consulted initially during the external clinical excellence review.
Once the review is complete, if the denial is maintained, the appellant will receive a written explanation of the reasons and facts
relating to the denial.
(Rev 5.6.15)
Appeal of Emergent Care Request for Benefits (Adverse Notification Determination Prior to Claim Submission)
Type of Request for Benefits or Appeal
If the appellant appeals the adverse notification determination or declination of
notification, the appellant must appeal within:
If the appellant’s request for emergent benefits is incomplete IEBP will send the
urgent/emergent incomplete pre-determination/notification information
declination letter within:
The appellant must provide a completed information request within:
Appeal of Urgent/Emergent Request for Benefits
(Adverse Pre-Determination/Notification Request)
Internal/External
Appeal Process
Business Hours/Days
Internal
one hundred eighty (180) days after
receiving the denial based on a completed
review process
Internal
twenty-four (24) hours of receipt of
appellant’s information
Internal
If the request for urgent/emergent benefits is complete and not approved, IEBP will
send an urgent/emergent pre-determination/notification denial letter within:
If the appellant requests an Independent Review Organization, (IRO), the external
review appeal request must be submitted for the review within:
Internal
The IRO will complete the review and IEBP will submit the response of an expedited
urgent/emergent pre-determination/notification of a benefit appeal within:
External
External
forty-eight (48) hours after receiving the
IEBP declination due to incomplete
information
seventy-two (72) hours
one hundred twenty (120) days of receipt
of the original denial or response to your
appeal
Appeal of Non-Emergent Care Request for Benefits for Pre Determination/Notification Prior to Claim Submission
Type of Request for Benefits or Appeal
The appellant must appeal the denial no later than:
If the request for a pre- determination/notification is benefit information
incomplete, IEBP will notify the appellant within:
If the request for pre-determination/notification is clinical information incomplete,
IEBP will notify you within:
The appellant must then provide completed information within:
Appeal of Non-Emergent Request for Benefits
(Adverse Pre-Determination/Notification Request)
Internal/External
Appeal Process
Business Hours/Days
Internal
receiving the denial
Internal
five (5) days
Internal
fifteen (15) days
Internal
forty-five (45) days after receiving an
extension notice*
fifteen (15) days after receiving the first
level appeal
sixty (60) days after receiving the first level
appeal decision
fifteen (15) days after receiving the second
level appeal*
appeal
thirty (30) days
IEBP will notify you of the first level appeal decision within:
Internal
The appellant must appeal the first level appeal (file a second level appeal) within:
Internal
IEBP will notify you of the second level appeal decision within:
Internal
The appellant may request the appeal be submitted to an Independent Review
Organization, (IRO). The External Review Request must be submitted within:
External
The IRO must complete the review of a non-emergent claim or benefit appeal
within:
External
* A one-time extension of no more than 15 days only if more time is needed due to circumstances beyond the appellant’s control.
Post Service Claims Appeal
Post-Service Claims
Type of Claim or Appeal
The appellant must appeal the claim denial no later than:
Internal/External
Appeal Process
Internal
If the appellant’s claim is incomplete, IEBP will notify the appellant within:
Internal
The appellant must then provide completed claim information within:
Internal
IEBP will notify the appellant of the first level appeal decision within:
Internal
The appellant must file the second level appeal within:
Internal
Business Hours/Days
receiving the denial
thirty (30) days
forty-five (45) days after receiving an
extension notice
thirty (30) days after receiving the first
level appeal
sixty (60) days after receiving the first level
appeal decision
(Rev 5.6.15)
Post-Service Claims
Type of Claim or Appeal
The appellant will be notified of the second level appeal decision generally within:
Internal/External
Appeal Process
Internal
The appellant may request an appeal be submitted to an Independent Review
Organization, (IRO). This request must be submitted for the review within:
External
The IRO must complete the review of a non-emergent claim or benefit appeal within:
External
Business Hours/Days
thirty (30) days after receiving the second
level appeal
appeal
thirty (30) days
The IRO must complete a requested expedited review of an emergent claim or
benefit appeal within:
External
Covered Individuals have access to all documents and records used in making the decision. Medical consultants used in making the decision
must be disclosed.
If a claim for benefits is wholly or partially denied, an Explanation of Benefits (EOB) will be furnished to the Covered Individual
and the provider of services. This EOB will give the reason(s) the claim was denied. If the Covered Individual or provider of
services does not agree with the claim decision or alleges that a contractual prompt payment requirement was not followed in
the administration of a claim, he or she may submit an appeal. Relevant information supplied by the Covered Individual or
healthcare provider should be included with the appeal.
For claims denied or partially denied for not being notified, the appeal must include:
 the admission history and physical;
 the discharge summary; and
 the operative and pathology reports (if applicable).
An appeal requested without proper documentation may not be considered. All written appeals should be sent to IEBP’s address
printed on the Medical/Prescription ID cards or complete the appeal form online at www.iebp.org. Your request must contain
the employee’s name, social security or subscriber ID number and the exact reason(s) for requesting the appeal and include any
supporting documentation. IEBP will notify you of the results of the review within thirty (30) days, unless IEBP informs you that
special circumstances require an extended review process. These appeal provisions shall be applicable where a provider makes
a complaint that a prompt payment contract was not followed.
The appealing party will be notified in writing of the results of an appeal for failure to provide Notification, and/or a denial or
reduction in benefits after receipt of all necessary information to make a determination. All available medical information must
be provided at no cost to the Plan. IEBP shall be under no obligation to respond to an appeal of a claim based upon complaints
that have previously been addressed by a prior appeal.
If the appealing party does not agree with the results of any appeal, the appeal may be elevated to the Plan’s Board of Trustees.
To appeal a decision to the Board of Trustees, the appealing party must send their appeal in writing to: TML MultiState IEBP
Board of Trustees, 1821 Rutherford Lane, Suite 300, Austin, TX 78754-5151. Unless the appeal specifically requests a Board
Appeal, IEBP shall have the discretion to consider the appeal on an internal staff basis. A committee of Trustees will schedule a
meeting and hear the appeal. The appealing party may submit additional information and/or appear before the committee. The
appealing party will be notified of the date, time and place the committee will meet at least five (5) days prior to the meeting
date.
A final decision will be made by the Board of Trustees Appeals Committee and sent to the appealing party. The Appeals
Committee's final decision will be in writing and include specific references to the Plan provisions on which the decision was
based.
Privacy of Your Health Information
A Federal regulation, called the “Privacy Rule,” requires IEBP to protect the privacy of each Covered Individual’s identifiable
health information. Under the Privacy Rule, IEBP may use and disclose a Covered Individual’s identifiable health information only
for certain permitted purposes, such as the payment of claims under the health plan. If IEBP needs to use or disclose a Covered
Individual’s health information for a purpose not permitted under the Privacy Rule, IEBP must first obtain a written authorization
signed by the Covered Individual.
IEBP has administrative, physical and technical safeguards in place to protect the privacy of health information. IEBP will notify
you regarding privacy breaches per Health and Human Services requirements.
(Rev 5.6.15)
In addition to restrictions on how IEBP may use and disclose a Covered Individual’s identifiable health information, the Privacy
Rule gives each Covered Individual certain rights. These include the right of a Covered Individual to access his or her health
information, to amend his or her health information and to receive an accounting of certain disclosures of his or her health
information.
IEBP’s Notice of Privacy Practices explains fully how IEBP may use and disclose a Covered Individual’s identifiable health
information and a Covered Individual’s rights under the Privacy Rule. IEBP’s Notice of Privacy Practices is available on IEBP’s
website at www.iebp.org, or an individual may request a paper copy of the notice by calling IEBP’s Customer Care number at
(800) 282-5385.
Security of Your Health Information
A Federal regulation, called the “Security Rule”, requires IEBP to ensure the confidentiality, integrity and availability of a Covered
Individual’s identifiable health information that IEBP receives, creates, maintains or transmits electronically. IEBP has
implemented administrative, physical and technical safeguards that meet both Federal requirements and industry standards for
the security of electronic health information.
NON-DUPLICATION OF BENEFITS
Once a claim or potential claim for benefits has been submitted and there are indications that another source of payment may
exist, IEBP will request further information to confirm or deny the existence of other coverage. A claim is not considered to be
complete until all the information needed by IEBP to make this determination has been received. IEBP has the authority to
determine the form, content and timing of the submission of such information and to resolve any questions with regard to those
requirements. This provision is designed to prevent the double payment of medical benefits for the same illness or injury and to
manage the high cost of medical coverage by seeking reimbursement from other sources.
Integration of Benefits
The Integration of Benefits (IOB) provision applies when a Covered Individual may receive medical benefits from more than one
source. The benefits payable under this Plan will not exceed 100% of this Plan’s allowable Eligible Benefit when combined with
all other plans. For Medicare information, please refer to the Integration of Medicare section.
The Covered Individual may receive benefits under the Plan that will not exceed 100% of this Plan’s allowable Eligible Benefit
when combined with all other plans.
Example: Charge - $100
 Our allowable - $100
 Our normal liability - $80
 Primary payer paid - $75
 Our liability as the secondary integrated payer would be $5 (the balance between what we would have paid, if we were
primary and what the primary carrier paid).
Application
IEBP will determine which plan is primary and which plan is secondary. The other plan will always be primary if that plan has no
coordination or integration provision. When this Plan is primary, it will pay benefits as if it were the only plan. When this Plan is
secondary or the Covered Individual accesses benefits through active employee status elsewhere, it will pay a reduced benefit,
which when added to the benefits paid by all other plans, will not exceed 100% of the total allowable benefit covered by this
plan. An itemized bill and an Explanation of Benefits (EOB) from the primary plan must be provided to the secondary plan to
review for payment.
Definitions for the purpose of Integration of Benefits
Closed Panel Plan
A plan that provides benefits primarily in the form of services through a panel of providers that have contracts with, or are
employed by the Plan, and excludes coverage for services provided by other providers, except in the case of an emergency or
referral by a panel member.
(Rev 5.6.15)
Custodial Parent
The parent awarded custody by a court decree or, in the absence of a court decree, is the parent with whom the child resides
more than one half of the calendar year excluding any temporary visitation.
This Plan
The medical benefits provided by your employer through IEBP.
Other Plan means any of the following arrangements that provide medical benefits or services:
1.
insurance or any arrangement of benefits for groups;
2.
prepayment coverage or any coverage toward the cost of which any employer makes contributions;
3.
a labor-management plan, union welfare plan, employer organization plan or employee organization plan;
4.
any governmental program or coverage required by statute;
5.
dependent ineligible employer sponsored healthcare benefit information; or
6.
coverage for expenses due to accidental bodily injury or disease to the extent to which payment as a settlement, judgment
or otherwise is made by any person or their insurers without regard to whether or not liability is admitted.
Primary Plan
A plan that pays Eligible Benefits without regard to the existence of any other Plans.
Secondary Plan
A plan that integrates payments so that the total payments from all plans shall not exceed 100% of the Plan’s allowable benefit
with the exception of an HMO plan or closed panel plan.
Special Rules
If both plans have a coordination or integration provision, the primary plan will be determined according to the following rules:
Rule 1 - Non-Dependent/Dependent:
 The benefits of the plan that covers the Covered Individual as an active
employee is primary to benefits accessed as a dependent.
Rule 2a - Dependent Child/Parents, (natural or adoptive), are married or are
living together, whether or not they have ever been married:
 The benefits of the plan of the parent whose birthday falls earlier in a
Calendar Year are determined before those of the plan of the parent whose
birthday falls later in that Calendar Year
 If both parents have the same birthday, the plan which has covered one
parent for the longer period of time will be primary
2b - Dependent Child/Parents, (natural or adoptive), are divorced or
separated or not living together, whether or not they have ever been
married:
 Dependent child covered under both parents group health plans. If a court
decree states both parents have responsibility for the health care expenses
or health care coverage: The benefits of the plan of the parent whose
birthday falls earlier in a Calendar Year are determined before those of the
plan of the parent whose birthday falls later in that Calendar Year;
 If both parents have the same birthday, the plan which has covered one
parent for the longer period of time will be primary
married:
 If a court decree states that the parents have joint custody without
specifying that one parent has responsibility for the health care expenses or
health care coverage of the dependent child, rule 2a will determine the
order of benefits
married:
IEBP Pays Primary when…
Active, pre sixty-five retiree or
former employee on COBRA
Continuation of Coverage of IEBP
plan
1. Natural or adoptive parent is
an employee of IEBP plan and
birthday falls earlier in the
year; and
2. If parents share the same
birthday, IEBP plan has
covered the dependent child
for the longest period of time
year; and
IEBP Pays Secondary when…
IEBP will pay secondary to a
spouse’s or dependent child’s
employer’s plan
year; and
IEBP plan has covered the
dependent child for the longest
period of time
birthday falls later in the year;
and
birthday IEBP plan has
for the shortest period of time
dependent child for the shortest
period of time
birthday falls later in the
year; and
birthday falls later in the
year; and
(Rev 5.6.15)
IEBP Pays Primary when…
IEBP Pays Secondary when…
1. Employee of IEBP plan is the
custodial parent; or
custodial step parent, (where
custodial parent does not
cover the dependent child); or
non-custodial parent, (where
custodial parent or step
parent do not cover the
dependent child)
dependent child for the longest
period of time
1. Employee of non-IEBP plan is
either the custodial step
parent, non-custodial parent
or non-custodial step parent;
or
either the non-custodial
parent or non-custodial step
parent; or
the non- custodial step parent
dependent child for the shortest
period of time
2b - Individual covered as a dependent child under a natural, adoptive or step
parent plan and also covered as a dependent under a spouse’s plan. The
order of benefits will be determined by the following:
 The plan that has covered the dependent child for the longest period of
time is primary
IEBP plan has been in effect the
longest period of time
IEBP plan has been in effect for
the shortest period of time
Rule 3 - Active/Inactive Employee:
 The benefits of the plan that covers the Covered Individual as an active
employee who is neither laid off nor retired are determined before those of
a plan which covers that same person as laid off or retired employee. The
same would hold true if the Covered Individual is a dependent of an active
employee and that same person is a dependent of a retiree or laid off
employee. If the other plan does not have this rule, and if, as a result, the
plans do not agree on the order of the benefits, this paragraph does not
apply.
IEBP plan is the active employee
plan
IEBP plan is the Retiree plan (for
the same person who is an active
employee under another plan)
Rule 4 - COBRA Continuation of Coverage:
 If a person has coverage provided under COBRA Continuation of Coverage
pursuant to federal or state law and is also covered under another plan, the
following shall be the order of benefit determination:
i. First, the benefits of a plan that covers the covered individual as an
employee, a Member or a subscriber (or as a dependent of an
employee, member or subscriber).
ii. Second, the benefits under the COBRA Continuation of Coverage.
 This rule does not apply if rule 1 determines the order of benefits.
 If the other plan does not have this rule, and if, as a result, the plans do not
agree on the order of benefits, this paragraph does not apply
IEBP plan is the active employee
plan
IEBP plan is the COBRA
Continuation of Coverage plan
(for the same person who is an
active employee under another
plan)
Rule 5:
 If none of the above rules determine the order of benefits, then the plan
that has covered the Covered Individual for the longest period of time is
primary
Covered Individual for the longest
period of time
Covered Individual for the
shortest period of time
 Dependent child covered under both parents group health plans and if the
court decree expires due to dependent child’s age, the order of benefits for
the child are as follows:
i. the plan that has covered the Covered Individual for the longest period
of time is primary
married:
 If there is no court decree allocating responsibility for the dependent child’s
health care expenses or health care coverage, and the child is under the age
of 19 years, the order of benefits for the child are as follows:
i. The Plan covering the Custodial parent;
ii. The Plan covering the spouse of the Custodial parent;
iii. The Plan covering the non-custodial parent; and then
iv. The Plan covering the spouse of the non-custodial parent
2b - If there is no court decree allocating responsibility for the dependent
child’s health care expenses or health care coverage, and the dependent
child attains the age of 19 years, the order of benefits for the child are as
follows:
 The plan that has covered the dependent child for the longest period of time
is primary
When a primary plan is a High Deductible Health Plan attached to a Health Savings Account, integration of benefits as the
secondary carrier will occur after the IRS Guidance deductible has been satisfied.
Facility of Payment
A payment made under another Plan may include an amount that should have been paid under this plan. If it does, this plan will
pay its full liability for services, and any overpayments received from another plan must be reimbursed directly back to the plan.
(Rev 5.6.15)
Recovery of Integration of Benefits (IOB) Overpayments
If the amount of the payments made by this plan for IOB administration is more than it should have paid under this IOB provision,
it will recover the excess from one or more of the persons it has paid or for whom it has paid; or any other person or organization
that may be responsible for the benefits or services provided for the Covered Individual. The “amount of the payments made”
includes the reasonable cash value of any benefits provided in the form of services.
Other Party Liability
This section applies if you:
1.
are injured in an accident, regardless of who is at fault;
2.
become ill, through the act or omission of another person, company or business and recover money from any source, you
must reimburse IEBP for the benefits provided by the Plan whether or not the third party has admitted liability; or
3.
For injuries from accidents on or after January 1, 2014, IEBP shall be subject to Chapter 140 of the Texas Civil Practices &
Remedies Code.
Contractual Right of Reimbursement
If a Covered Individual:
1.
is injured in an accident, regardless of who is at fault; or
2.
becomes ill through the act or omission of another person, the Plan shall provide benefits on the condition that the
Covered Individual cooperates with IEBP, its agents, subcontractors and attorneys by:
a.
providing notification of any accidental injury or illness which may involve another individual, business or insurance
company;
b.
providing any information requested that is associated with the injury or illness; and
c.
filing any claim documentation with an insurance carrier or third party as requested by IEBP.
In addition, the Covered Individual specifically delegates to IEBP the right to make a claim or assert a cause of action on the
Covered Individual’s behalf against any source of recoveries, and assigns to IEBP the right to any proceeds from the claim or
cause of action.
“Source of recovery” shall include, but not be limited to:
1.
any third party;
2.
any liability or other insurance covering the third party;
3.
uninsured motorist, underinsured motorist, no-fault, or medical payments which are paid or payable of a non-immediate
family member; or
4.
any other responsible party. IEBP may seek direct reimbursement for benefit coverage from any source of recovery.
By enrolling in this Plan, the Covered Individual agrees to abide by the provisions in one (1) through eleven (11) following this
paragraph. IEBP may suspend payment of claims for the injury or illness based on the amount of the claim, indication of other
insurance, indication there may be another source to pay for the medical services required as a result of the injury or illness, or
evidence that the claim may not be covered because it is work-related.
As an additional assurance, payment of the claim(s), and future claims relating to the injury or illness will only resume if the
Covered Individual:
1.
provides any and all information requested by IEBP; and
2.
agrees in writing not to settle damages whether by legal action, settlement or otherwise and only after consulting with
IEBP to determine the full and potential medical charges; and
3.
agrees that should the Covered Individual settle for damages as a result of an injury/illness with a third party or insurer,
prior to securing such written permission, IEBP and the employer’s health benefits plan is relieved of any liability for
medical benefits resulting from the injury/illness; and
4.
agrees that IEBP may provide any medical bills or payment information related to the injury/illness to the Covered
Individual’s attorney, any insurer or any other person who will be reimbursing IEBP for medical benefits; and
5.
agrees in writing to reimburse IEBP immediately upon collection of damages whether by legal action, settlement or
otherwise including, but not limited to, first party and third party motor vehicle insurance; and
6.
agrees in writing to provide IEBP with a first lien on all proceeds recovered for this injury to the extent of benefits provided
by the Plan; and
(Rev 5.6.15)
7.
8.
9.
10.
11.
agrees in writing that the first lien in 6. above represents the pro rata share of IEBP pursuant to Section 172.015(e), Texas
Local Government Code; and
agrees in writing that venue for all subrogation disputes shall be in Travis County, Texas; and
agrees in writing to provide IEBP with a copy of any settlement agreement relating to this injury/illness if requested; and
agrees to cooperate fully with IEBP in asserting its right to subrogate. This means the Covered Individual must supply IEBP
with all information and sign and return all documents reasonably necessary to carry out IEBP’s right to recover from the
third party any benefits paid under the Plan which are subject to this provision; and
agrees to all provisions of the benefit plan.
If the Covered Individual accepts reimbursement or assigns benefits for an injury or illness for which money or benefits were
received or paid by another source, and payment has also been made by IEBP, the Covered Individual must reimburse IEBP the
amount paid to the Covered Individual or any provider for services or treatment for the injury or illness. If the Covered Individual
does not reimburse IEBP, the amount not reimbursed may be withheld from future benefits.
Automobile/Homeowners Liability and/or Medical Payments Insurance Benefits
Benefits payable under this Plan may be adjusted by IEBP for any first party or third party insurance benefits available for medical
benefits, including no-fault medical payments uninsured motorist coverage which are paid or payable by a non-immediate family
member whether or not any party has admitted liability.
Right of Recovery
IEBP has the right to seek reimbursement on any overpayment from one or more of the following:
1.
the Covered Individual;
2.
the person to whom such payments were made;
3.
any other insurance company;
4.
any other benefit plan; or
5.
any other organization providing benefits.
In addition, the Covered Individual specifically delegates to IEBP the right to make a claim or assert a cause of action on the
Covered Individual’s behalf against any source of recovery, and assigns to IEBP the right to any proceeds from the claim or cause
of action.
A third party may be liable or legally responsible for expenses incurred by a Covered Individual for an illness, sickness or bodily
injury. Subrogation rights may take precedence over a Covered Individual’s right to receive payment of the benefits from the
third party. The Covered Individual must supply IEBP with all information and sign and return all documents reasonably necessary
to carry out IEBP’s right to recover from the third party any benefits paid under the Plan which are subject to this provision.
Overpayment Provisions
Right of Offset
If IEBP makes any payment on behalf of a Covered Individual exceeding the amount needed to satisfy its obligation under the
terms of this Plan, then IEBP reserves the right to offset the overpayment against future benefits otherwise payable to a Covered
Individual or provider.
Facility of Payment
When another plan makes a payment which should have been made under the Plan, IEBP reserves the right to decide:
1.
whether or not to reimburse the organization making the payment; and
2.
the amount to be paid in order to satisfy the intent of this provision.
Any such payment made by IEBP will fulfill IEBP's responsibility in the amount paid.
Fraudulent or Erroneous Billing
IEBP reserves the right to conduct its own investigation of any person or organization suspected of filing fraudulent claims and
to turn over its findings to an authorized governmental agency or department for further investigation and/or prosecution.
(Rev 5.6.15)
Integration with Medicare
Medicare is a federal health insurance program for people age sixty-five (65) or older and certain disabled individuals provided
by Title XVIII of the Social Security Act, as amended.
Full Medicare Coverage is coverage under both Part "A" (Hospital Insurance), Part "B" (Medical Insurance) and/or Part “C”
(HMO/Advantage Insurance). If a person is eligible for premium free Part "A", that person will be deemed to have full Medicare
coverage, even if they have not enrolled in Part “B” and/or Part “C”. For actively at work Covered Individuals who are enrolled
in and receive benefits under Medicare Part A, B, C and/or D, IEBP benefits will be accessed as the primary benefit coverage.
Who will pay first or primary usually depends on work status of the employee regardless of how many persons the employer
may employ.
Status
Retired
Spouse of Retiree
Spouse of Retiree
Age
65+
65+
<65
Primary Plan
Medicare
Medicare
Employer
Status
Active
Spouse of Active EE
Spouse of Active EE
Age
65+
65+
<65
Primary Plan
Employer
Employer
Employer
There are special rules for people with permanent kidney failure and persons under sixty-five (65) who have Medicare because
of a disability.
If the Plan is primary, the normal benefits payable under the Plan will be paid without regard to Medicare. If Medicare is primary,
the combined total payable by full Medicare coverage and the Plan will not exceed the normal benefit payable by the Plan.
If Medicare coverage is due to End Stage Renal Disease, the order of payment shall be determined by applicable federal
regulations.
IEBP will determine which plan is primary. The determination is based on the status of the Covered Individual on the date
expenses are incurred.
Even if a person does not enroll for full Medicare coverage or make due claim for Medicare benefits, IEBP will calculate the
benefits which would have been paid by full Medicare coverage (see chart above) and adjust the Plan benefits payable
accordingly to the Medicare allowed amount.
In cases where a provider has opted out of Medicare where neither the provider nor the beneficiary receives any reimbursement
from Medicare, IEBP will calculate the benefits which would have been paid by Medicare coverage (see chart above), according
to the Medicare allowed amount.
IEBP submits electronic eligibility information to Medicare as required by law and secondary payor regulations.
(Rev 5.6.15)
HEALTHY INITIATIVES
Preventive/Routine Care Benefit (Calendar Year)
The following will be processed for network reimbursement at 100% of network allowable. Non-network provider eligible billings
will be subject to usual and reasonable charges and are subject to the non-network deductible and benefit percentage. To be
considered as an eligible preventive/routine care benefit, the provider’s bill must designate or outline a routine diagnosis code.
These measures represent important areas for quality improvement by assessing the use of services that are recommendations
from the U.S. Preventive Services Task Force (USPSTF) and other national organizations.
Access your Personal Health Record and Health Power Assessment by signing in at www.iebp.org.
Age & Gender Biometric Screenings
Female
18 thru
29
X
X
X
X
Female
30 thru
35
X
X
X
X
Female
36 thru
39
X
X
X
X
X
Health Power Assessment Questionnaire
Preventive Office Visit
Lipid Panel
Comprehensive Metabolic Blood Panel
TSH
PSA
Fecal Occult (including colonoscopy and sigmoidoscopy as a qualifier)
Mammogram
* 1 per CY for females age 40 thru 49
** 1 every 2 CY for females age 50 thru 73
PAP
X
X
every 3 CY for females age 30 thru 50
Female
40 thru
49
X
X
X
X
X
Female
50
X
X
X
X
X
Female
51 thru
73
X
X
X
X
X
X
X
X
X*
X**
X**
X
X
Female Male 18 Male 40 Male 51 Male 7
74+
thru 39 thru 50 thru 70
1+
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Colon-Rectal Exam Benefit
The following will be processed for network reimbursement at 100% of network allowable. Non-network provider eligible billings
will be subject to usual and reasonable charges and are subject to the non-network deductible and benefit percentage. To be
considered as an eligible preventive/routine care benefit, the provider’s bill must designate or outline a routine diagnosis code.
This benefit will include routine and diagnostic colon-rectal examinations.
 Colon-Rectal examination - coverage for medically-recognized screening examination for the detection of colorectal cancer.
This includes:
 colonoscopy (performed every ten (10) years); or
» biopsy/polyp removal during preventive colonoscopy plans will be included in the 100% of network allowable cost
 flexible sigmoidoscopy (examination of the large intestine) performed every five (5) years.
This Benefit excludes coverage for virtual colonoscopies.
Preventive/routine care benefits also includes:







General Health Panel
 Rubella Screening
Screening for Visual Acuity
 Well Baby Care/Well Child Care
TB test
 Hearing Screening
PAP Smear
 Mammograms
Women's Reproductive Health
 Urinalysis
Annual Examination
 Prostate Specific Antigen (PSA)
Autism Screening – eighteen (18) and twenty-four (24) months of age





TSH
Bone Density Screening
Basic Metabolic Test
Venipuncture
Skin Cancer Counseling
Immunizations
The following network eligible immunizations and administrative fees are reimbursable at 100% of the allowable. Non-network
eligible billings will be subject to usual and reasonable charges and are subject to the non-network deductible and benefit
percentage. Allergy injections and expenses related to routine newborn care are not considered as part of this benefit. To be
considered under this benefit, the provider’s bill must designate a routine diagnosis code. This list is a guideline.
Immunizations/Inoculations
(Rev 5.6.15)







DT (Diphtheria and Tetanus Toxoids)
 Hepatitis A & Hepatitis B
 Td (Tetanus) booster
MMR (Measles, Mumps, Rubella)
 MMR booster
 Poliomyelitis Vaccine
Oral Polio
 Varicella Vaccine (Chicken Pox)  Influenza
Pneumococcal (Pneumonia)
 Rotovirus
 Any other immunization
required by federal or
HPV (Genital Human Papillomavirus)
 HIB (Hemophilus Influenza B)
state law or regulation
DtaP Diphtheria, Tetanus Toxoids and Pertussis  Zosatavax (Shingles Vaccine)
Pediarix (Diphtheria and Tetanus Toxoids and Acellular Pertussis Absorbed, Hepatitis B (Recombinant) and Inactivated
Poliovirus Vaccine Combined)
MEDICAL INTELLIGENCE CARE MANAGEMENT FEATURES W/DISCLAIMER1
This program is included to assist you in making informed healthcare decisions. Occasionally, proposed healthcare or the scheduled
length of stay or setting is not an Eligible Benefit. Please read this provision so that you understand the admission, continued stay
and notification process and are not faced with an out of pocket cost, penalty or denial for failure to provide Notification. Even
when Notification is provided, reimbursement is subject to the terms and conditions of the Plan including, but not limited to, all
plan exclusions and limitations. Notification does not constitute verification of eligibility for benefits. Notification is required for
Integration of Benefits when this Plan is secondary to other coverage.
If Medical Intelligence Care Management does not receive Notification prior to a scheduled service requiring Notification, claims
for benefits for that service will not be considered eligible unless a retrospective review request is filed. If the medical services
are eligible under the Plan, they will be reviewed for eligible payment.
How the Notification Process Works
The Twenty Three (23) Hour Rule
For the purpose of Notification, inpatient means treatment or confinement in a hospital or other medical facility for more than
twenty-three (23) hours. Outpatient means treatment or confinement in a hospital or other medical facility for twenty-three
(23) hours or less.
What is an admission?
When the hospital or facility submits a claim, the length of time the Covered Individual was in their facility and a designation of
inpatient, outpatient or observation is included. The number of hours, not the classification, determines if the stay is twentythree (23) hours observation or inpatient. If it appears that the Covered Individual will stay more than twenty-three (23) hours,
Notification of the stay must be provided to Medical Intelligence Care Management.
Medical Intelligence Care Management must be called for any inpatient expectant mother admission.
If a newborn requires more than routine nursery care, Medical Intelligence Care Management must be provided Notification so
that a separate determination can be issued for the baby. Newborns must be added to the Plan within sixty (60) days of birth in
order to be a Covered Individual.
Responsibilities of the Covered Individual
Between the hours of 8:30 AM - 5:00 PM Central time, call the Medical Intelligence Care Management number on the
Medical/Prescription ID card to provide Notification to Medical Intelligence Care Management prior to any healthcare service
that requires Notification. After hours, Voice Mail records your Notification twenty-four (24) hours-a-day and the Medical
Intelligence Care Management Intake Staff will return your call the next business day.
1 Disclaimer:
Affirmative Statement. Utilization Management (UM) decision making is based only on appropriateness of care and service and existence of
coverage, IEBP does not specifically reward practitioners or other individuals for issuing denials of coverage, and financial incentives for UM
decision makers are not encouraged to make decisions that result in underutilization.
(Rev 5.6.15)
Notification Requirements
Notification enables clinical support and educations, such as:
 Perform pre-op education for the patient and ensure adherence to nationally recognized guidelines in order to maximize
quality and cost efficiency;
 Facilitate post-op discharge planning to optimize clinical outcomes; and
 Refer patients to Centers of Excellence.
IEBP notification is required for the following admissions and/or procedures regardless if the IEBP plan is primary or secondary:
SERVICE
NOTIFICATION
LATE NOTIFICATION PENALTY
Inpatient Admissions
Scheduled Specialty Admissions
 Orthopedic/Spine Surgeries (spinal surgeries, total knee
replacements, and total hip replacements)
Facility: twenty-four (24) hours after actual
admission or by 5 pm the next business day for
weekend/holiday admissions
$400
Three (3) working days prior to services
$400

Transplants: At least ten (10) working days prior to any pretransplant evaluation, the Covered Individual or a family
member must provide Notification to Medical Intelligence Care
Management; failure to do so will result in a Late Notification
Penalty of $400 or a reduction in benefits.

Reconstructive/Potentially Cosmetic procedures

Bariatric Surgery: after the approved six (6) consecutive
months (within the most recent twelve (12) months) physician
supervised weight management treatment plan

Congenital Heart Disease
Other Inpatient Admissions
 Skilled Nursing Facility

Mental Health/Substance Use Disorder Inpatient

Mental Health/Substance Use Disorder Residential Treatment

Acute Care Hospital/Facility

Long Term Acute Care Facility

Acute Rehabilitation Facility

Scheduled Cesarean Section Delivery
Inpatient Pregnancy/Maternity (Delivery Admission)
 Vaginal Delivery admission in excess of forty-eight (48) hours

Cesarean delivery admission in excess of ninety-six (96) hours

Inpatient antepartum care or other undelivered admissions

Newborns who remain in the hospital after mother is
discharged
Pregnancy/Maternity
 Sonogram/Ultrasound in excess of three (3)

Amniocentesis

Home Health (uterine monitoring)

All High Risk obstetrical services

Multiple birth diagnosis
Scheduled Outpatient/Office Surgical Procedures
 Blepharoplasty (eyelid surgery)

Breast Surgery (excludes Breast Biopsies)

Carpal Tunnel Release (nerve decompression)

Jaw Surgery (including mandibular joint)

Joint Surgery (excluding fingers & toes)

Laparoscopy (except sterilization)

Myringotomy or Myringoplasty (tympanic/ear drum surgery)

Nasal Surgery

Tonsillectomy and/or Adenoidectomy

Uvulopalatoplasty (roof of mouth surgery)

Reconstructive Surgery
Facility: twenty-four (24) hours after emergency
Facility: twenty-four (24) hours after actual
$400
Three (3) working days prior to commencement for
office, outpatient and Home Health procedures,
within forty-eight (48) hours of multiple birth
diagnosis or high risk pregnancy
$200
Three (3) working days prior to procedures
$200
(Rev 5.6.15)
SERVICE
 Spinal Surgery

Cochlear Device and/or Implantation

Stereotactic Radiosurgery

Bariatric Surgery: after the approved six (6) consecutive
months (within the most recent twelve (12) months) physician
supervised weight management treatment plan
Outpatient/Office Infusion Therapy
 For Pain Management

NOTIFICATION
LATE NOTIFICATION PENALTY
Prior to commencement
$200
Three (3) working days prior to procedures
$200
Three (3) working days prior to dispensing/delivery
of durable medical equipment for charges in excess
of $1,000 per base piece of durable medical
equipment prior to purchase, lease, or rental
$200
Oncological Chemotherapy
Miscellaneous
 Mental Health/Substance Use Disorder Day Treatment

Hospice

Home Health Care

Physician Home Visit

Cardiac Rehabilitation

Pulmonary Rehabilitation

Positron Emission Tomography (PET) scans

Computerized Axial Tomography (CAT) scans

Computerized Tomographic Angiography (CTA) scans

Magnetic Resonance Imaging (MRI) scans

Magnetic Resonance Angiography (MRA) scans

Single Photon Emission Computed Tomography (SPECT)

Dental Injury (inpatient and outpatient)

Dialysis for Kidney/Renal Failure

Hyperbaric Oxygen Therapy

Radiation Therapy

Medically Necessary Evidence-Based Genetic Testing to direct
treatment (after diagnosis has been established)

Durable Medical Equipment
Responsibilities of Medical Intelligence Care Management
Medical Intelligence Care Management does not confirm eligibility or benefits for any treatment or service. Upon Notification,
Medical Intelligence Care Management will provide the Covered Individual or Provider with contact information to enable the
person to confirm eligibility and benefits with a Customer Care Representative.
What Happens on Treatment in Excess of Twenty-Three (23) Hours?
The Covered Individual must provide Notification to Medical Intelligence Care Management, (800) 847-1213, of a scheduled
admission per Notification Requirements. If the Notification is made after the above-referenced time frames, a Late Notification
Penalty or reduction of benefits will apply. Concurrent stay review requirements apply to all inpatient confinements. Failure to
provide Notification to Medical Intelligence Care Management will result in no paid benefits for facility or related charges.
What Happens if Outpatient Services Go Over the Twenty-Three (23) Hour Limit?
Outpatient Surgery not on the Outpatient Surgery List
If Notification is provided to Medical Intelligence Care Management within Notification Requirements of an outpatient surgery
that exceeds the twenty-three (23) hour limit, it will be considered an admission, and a late review will be performed. If the
services and the length of stay are Eligible Benefits, there is no penalty. If the services are determined to be non-Eligible
Benefits, charges are not covered. If you do not provide Notification to Medical Intelligence Care Management within the
Notification Requirement of the admission, the outpatient Late Notification Penalty will apply. Failure to provide Notification
to Medical Intelligence Care Management will result in no paid benefits for related charges.
Outpatient Surgery on the Outpatient Surgery List
(Rev 5.6.15)
If Notification was provided on a scheduled surgery requiring Notification and unforeseen circumstances require more than a
twenty-three (23) hour stay, the continued stay review process is required. If the length of continued stay is determined to be
inappropriate, charges related to the time for which Notification was not provided will not be a paid benefit. A Late Notification
Penalty will not be applied if prior Notification was provided and the services and length of stay are determined to be
appropriate.
Emergent or Immediate Care (Unscheduled) Medical Admission/Services
If Notification is provided to Medical Intelligence Care Management for emergent or immediate care, no Late Notification
Penalty will apply.
Maternity Care
Maternity care means services rendered to treat and maintain a pregnancy that is covered under this plan. Maternity care
includes prenatal visits and testing, delivery of the child, post-partum care, and routine care of the newborn child while the
mother is Hospital confined.
Continued Stay Review
If the Covered Individual’s treatment plan changes, the Healthcare Provider must provide Notification to Medical Intelligence
Care Management. Medical Intelligence Care Management will obtain an update on the treatment plan and will conduct a
concurrent review regarding the additional length of stay.
Medical Intensive Care Management
Medical Intensive Care Management services help you use your benefits wisely during periods of treatment due to serious
sickness or injury. This is done through early identification of the need for Medical Intensive Care Management, followed by ongoing work with you and your provider to plan health care alternatives to meet your needs. The Medical Intensive Care Manager
will try to conserve your benefits by making sure that your care is handled as efficiently as possible.
The Medical Intensive Care Management staff consists of licensed, professional nurses. The nurses have years of experience in
health care and know the importance of not intruding in the doctor/patient relationship. By promoting health care alternatives
that are acceptable to you, your doctors and your employer, Medical Intensive Care Management helps to control health care
costs and use your benefits wisely.
Medical Intensive Care Management is an option. However, should Medical Intensive Care Management be refused by the
Covered Individual or physician, benefits will pay at the Non-Network benefit percentage and will not, at any time, pay at
100% for any medical services under the out of pocket provision of the Plan. The individual deductible and out of pocket
amount must be met each calendar year.
Population Health Engagement
Population Health Engagement supports members 18> in all stages of health. This program provides information to the Covered
Individual regarding healthy lifestyle choices and management of chronic disease states. The program offers personalized
professional coaching to support the healthy lifestyle of change and plan of action. Online tools and educational material(s) are
available to the Covered Individual. The population health engagement team consists of an interdisciplinary team of licensed
professional nurses, licensed professional counselors, and registered dietitians.
The Personal Health Engagement Program includes:
Opt In
Enrollment method by which members call the professional health coaching line and request a professional healthcare coach or
agree to coaching upon receiving an outreach call or letter. Healthcare providers may refer their patient to a professional health
coach or they can call in a referral to (888) 818-2822.
Case Findings
Case Findings are currently done monthly for each program. A Case Finding identifies members for each disease management
program based on medical, prescription, Health Power Assessment, and/or lab value claim data information. The information is
stratified into risk index. Once the information is stratified, the Multidisciplinary Medical Care Management Service Team can
effectively identify the covered individuals that could benefit from a personal health coach. The program provides resources that
(Rev 5.6.15)
support the covered individual’s healthy lifestyle choices in areas of nutritional, emotional, social, intellectual, financial and
spiritual well-being.
Case Finding Summary Report
The information obtained on a Case Finding data run is analyzed. A case finding report is generated with a breakdown of risk
index. The information may be sorted by age and gender stratification, co-morbidities, adherence to practice standards and
medication usage. TML IEBP will implement the integrated data and reporting along with customized supportive programs that
help plan members achieve behavior change and long term improve health. The Multidisciplinary Medical Care Management
Team works with the covered individuals and educates them on healthy lifestyle behavior, cost effective medication options,
physician visit preparation, patient’s rights, understanding provider network options and consumer healthcare education.
Telephonic Outreach Program
Based on the clinical stratification, the covered individuals will be identified as potential high risk personal healthcare coaching.
The telephonic criteria identifies from 75% of the members for telephonic intervention.
Educational Mailings
TML IEBP’s cover letter includes the name and number of their Multidisciplinary Medical Care Management Health Coach and
the invitation for members to call if they would like additional information.
Modules of Care
Modules provide an organized collection of information needed by members to help them achieve a desired health goal.
Modules ensure that material is presented completely and in a coherent fashion to help members understand their disease(s)
process (es). Modules provide evidence based guidance for coaching sessions thus aiding coaches in focusing on the member’s
educational needs and stated goal.
Modules/practice guidelines arose from frequently stated health goals such as quitting smoking, losing weight, or managing
diabetes as well as the medical conditions reflected in the IEBP demographics. At present time, modules include: Asthma, COPD,
Diabetes, High Cholesterol, High Blood Pressure, Risk of Alcohol Use, Tobacco Cessation, and Weight Loss.
Self-Assessment Tools
 Health Power Assessment Overview
Summary of Your Responses
Healthy Lifestyle Habits
Exercise and Fitness
_____ days per week for aerobic exercise
 Be physically active for at least 30 minutes per day
_____ days per week for strength building exercise
 Do strength building exercises as recommended
Nutrition
_____ of fruits per day
 Eat 6 or more servings of fruits & vegetables / day
_____ of vegetables per day
 Drink 6 – 8 glasses of water/day
_____ glasses of water per day
 Eat 6 or more servings of nuts, beans, whole grain or other high fiber foods/day
_____ servings of high fiber foods per day
 Eat less foods with unhealthy fats such as foods that are fried or deep fried
_____ servings of “unhealthy” fats per day
 Maintain a healthy weight
 If overweight, reduce weight gradually by:
 Increasing intake of fruits, vegetables, whole grains, lean proteins, fish, nuts,
and seeds
 Decrease intake of high fat and processed meats and dairy products
 Decrease intake of trans fat, hydrogenated oils, and sodium (salt)
 Decrease sweets and beverages that are high in sugar
 Choose water instead of sweetened beverages
Alcohol and Tobacco Use
_____ average number of alcohol servings per day
 Limit alcohol intake; recommendations for men is two drinks per day and one
_____ description of use to tobacco products
drink per day for women
 Be tobacco free
Safety
_____ practices safe lifting techniques
 Practice proper lifting techniques to keep your back safe, healthy, and pain free
_____ frequency of seat belt use
 Wear your seat belt when riding in a motor vehicle
_____ get at least 7-8 hours of sleep per day
 Use sun block or wear protective clothing when in the sun for more than 20
_____ take precautions when in the sun more than 20 minutes
minutes
_____ per week that I floss my teeth
 Protect your skin from toxic chemicals by using gloves, wearing a mask and
_____ wash my hands well throughout the day
wearing long sleeves and long pants, wearing a hat with a wide brim and
_____ do the recommended self exams on a daily and monthly
sunglasses
(Rev 5.6.15)
Summary of Your Responses
basis
_____ Tetanus (Td/Tdap) shot within the last 10 years
_____ get a flu shot yearly
Healthy Lifestyle Habits
 Floss your teeth daily to prevent infections that affect your gums, teeth, heart
and social life
 Wash your hands many times throughout the day particularly before eating or
preparing food and after using the bathroom
 Perform monthly self exams such looking at your skin for any changes, perform
a breast self exam and a testicular self exam for men ages 20 – 40.
 Speak to your healthcare provider regarding adult immunizations
Perceptions / Stress & Resilience / Quality of Life
_____ I have a supportive network of family and friends
 Build and sustain a network of supportive family and friends
_____ stress or pressure is out of control
 Manage stress and practice relaxation
_____ I feel tense or anxious
 Getting the right exercise, sleep, make healthy food choices and taking quiet
_____ I feel depressed, down or blue
time each day
_____ I have experienced a personal loss or misfortune in past year  If you struggle with feeling down or blue speak to your health care professional
_____ effect of stress on my health
 Stress can affect your health, take steps to manage it
Disclaimer: This material is for informational purposes only, and should not be used to replace professional medical advice.
Always consult your physician before beginning a new treatment, diet, or fitness program. This information should not be
considered complete, nor should it be relied on in diagnosing or treating a medical condition.

Wheel of Life (WOL)
Wheel of Life is a tool that is used for the member to rate 12 areas of life that may be affecting healthy lifestyle choices. The
areas rated include: physical health, mental health, spirit health, relationship with significant other, relationship with
children, relationship with extended family, home/physical environment, job/career satisfaction, financial health,
recreation/ leisure time fun, and continued learning/ personal growth.
Preventive Care
In 2012, we started sending letters to our members identifying possible gaps in care associated with preventive care, heart
disease, diabetes and asthma/COPD. Attached to the letters are fact sheets, which explain why preventive care is important for
their health and an invitation to participate in health coaching. The professional health coaches routinely discuss “gaps in care”
with their members. We have seen some change in preventive screening compliance rates as a result of both initiatives.
Colorectal Screening
Cervical Screening
Breast Screening
Hyperlipidemia- Lipid profile within 12 mos.
Diabetes- A1C within 12 mos.
Compliance April 2014
Pool
Mini
39.2%
46.0%
65.2%
72.4%
68.2%
71.1%
82.5%
89.0%
74.2%
84.1%
Trend
Desired Direction
↑
↑
↑
↓
↑
↑
↑
↑
↑
↑
(Rev 5.6.15)
Diabetes- Lipid profile within 12 mos.
Diabetes- annual screening for nephropathy
Diabetes- screening for retinopathy
IVD-Without lipid profile within 12 mos.
CAD-Without lipid lowering drugs
COPD-Without Spirometry Testing
Asthma-Without inhaled corticosteroids
Asthma-Adults-With inhaled corticosteroids
Asthma-Peds-With inhaled corticosteroids
Positive Fecal Occult Results
Colorectal Screening
Cervical Screening
Breast Screening
Hyperlipidemia- Lipid profile within 12 mos.
Diabetes- A1C within 12 mos.
Diabetes- Lipid profile within 12 mos.
Diabetes- annual screening for nephropathy
Diabetes- screening for retinopathy
IVD-Without lipid profile within 12 mos.
CAD-Without lipid lowering drugs
COPD-Without Spirometry Testing
Asthma-Without inhaled corticosteroids
Asthma-Adults-With inhaled corticosteroids
Asthma-Peds-With inhaled corticosteroids
Positive Fecal Occult Results
Compliance April 2014
Pool
Mini
70.8%
83.1%
81.0%
81.9%
25.1%
26.7%
29.5%
17.6%
25.2%
41.5%
57.9%
77.3%
Trend
Desired Direction
↓↑
↑
↑
↑↓
↑
↓
↑
↑
↑
↓
↓
↓
91.1%
93.3%
91.1%
95.7%
0.038% (3 out of 77)
↑
↑
↑
↓
↓
Compliance in July 2012
Compliance in July 2013
Pool
Mini
Pool
Mini
39.3%
44.7%
38.6%
42.6%
55.1%
58.7%
64.7%
71.6%
51.9%
57.9%
64.1%
67.7%
70.1%
72.8%
86.6%
90.5%
70.3%
74.1%
73.2%
83.6%
70.32%
78.9%
72.4%
82.4%
51.9%
57.3%
80.9%
79.4%
20.1%
23.2%
23.4%
25.1%
29.8%
27.1%
26.7%
20.2%
25.8%
28.5%
26.0%
36.3%
63.2%
79.2%
62.2%
76.1%
33.9%
36.5%
13.4%
16%
66.1%
63.5%
86.6%
84.0%
New Indicator
0.05% (16 out of 279)
0.05% (20 out of 374)
Healthy Living Resources
Healthy Living Guides
 Located on our website at www.iebp.org. Click the "Health Resources" link found in the Health & Wellness menu at the
top.
List of Health Guides
Alcoholism
Asthma
Back Pain
Bariatric Surgery
Celiac Disease
Chronic Fatigue Syndrome (CFS)
Chronic Obstructive Pulmonary Disease (COPD)
Chronic Pain
Coronary Artery Disease (CAD)
Depression
Financial Health
Gout
Grieving and Your Health
Healthy Eating
Healthy Eyes
Healthy Pregnancy
Hyperlipidemia
Hypertension
Irritable Bowel Syndrome
Ischemic Heart Disease
Men’s Health
Mental Health
Migraine Headaches
Multiple Sclerosis
Neuropathy
Osteoarthritis
Osteoporosis
Physical Activity
Rheumatoid Arthritis
Skin Cancer Prevention
Sleep
Sleep Apnea
Smoking Cessation
Stress Management
Suicide Prevention
Type 2 Diabetes
Weight Management
Healthy Living Fact Sheets
 Located on our website at www.iebp.org. Click on the "Health and Wellness Tip of the Month" link on the first page.
Month
October
November
December
January
February
March
April
May
June
July
August
Health Topic
Breast Cancer
Diabetes
Managing the Season in Emotional and Physical Health
Eye Health (glaucoma/cataract/retinopathy)
Heart Disease
Colorectal Cancer
Skin Cancer Prevention
Hypertension
Men’s Health
Dental Health
Childhood Immunizations (flu/pneumonia/tetanus/shingles)
Tobacco Cessation
Smoking Cessation
Asthma
Chronic Obstructive Pulmonary Disease (COPD)
Women’s Health
Depression
(Rev 5.6.15)
Month
September
Health Topic
Eat Right and Exercise
Other Resources
 Community Resources: List of helpful websites for community resources
 Practice Guidelines: List of websites for practice guidelines for health topics
AFTER HOURS AND/OR WEEKEND MEDICAL AND MENTAL HEALTH CARE
When we get sick we go to our doctor for treatment. What happens when the office is closed or we cannot get an appointment
right away? When is the condition a medical emergency to be addressed by the emergency room? What happens if there is a
mental health crisis?
Primary Care
Primary care physicians are typically the first point of care unless you are experiencing a life-threatening event. Overtime, they
track your medical history; therefore, can provide care based on a more thorough knowledge of your condition. They can provide
treatment of illnesses, minor injuries, and pains. They can also conduct physical exams, follow-up care, and specialist referrals.
Some primary care physicians work in a multi-specialty clinic that provide after hours clinic. Some physician's offices offer limited
hours on Saturday.
Telemedicine
Teladoc is the first and largest provider of telehealth medical consultation service in the United States, allowing over 3M
members 24/7/365 on-demand access to affordable medical care via phone and online video consultations.
How do I request a consultation to talk to a doctor?
 Log into your account at www.teladoc.com and click 'Request a Consult'. Or you can call 1-800-Teladoc anytime day or night.
 By phone or online video
» Talk to a doctor anytime through the convenience of phone or online video consultations.
 Teladoc doctors can diagnose, prescribe medications, if necessary, for many conditions including allergies, cold and flu
symptoms, ear infections and more.
How quickly can I talk to the doctor?
A doctor will call you back within 30 minutes, average is 22 minutes. If you miss the doctor’s call (whether you are away from
the phone or you have anonymous call blocker on) you will be returned to the bottom of the waiting list.
The consultation request is cancelled if you miss three calls.
Can I provide the consultation information to my doctor?
Yes, you have access to your portable electronic medical record at anytime.
Download a copy from your online Teladoc account or call 1-800-Teladoc and ask to have you medical record mailed or faxed to
you.
How do I pay for Teladoc?
You may pay with a credit card, debit card or ACH transfer from you checking account. The plan will pay $28.00 and the covered
individual will be responsible for a $10.00 copay. All credit cards will be accepted.
If you are accessing a high deductible benefit plan, the covered individual will be required to pay the $38.00 in full until the high
deductible has been met.
Remember copays do not accumulate to your deductible or out of pocket expenses.
(Rev 5.6.15)
How do I pay for a prescription called in by Teladoc?
When you go to your pharmacy, of choice, to pick up the prescription your payment will be per your IEBP Medication Therapy
Management Program.
Medical History Disclosure Form Options
Account Set-Up is required prior to electronic completion of Medical History Form:
 Medical Disclosures are active for twelve months from completion date.
 Online/Electronic Transmission: www.teladoc.com
 Open enrollment and submitted in bulk (Paper has 14-day turnaround time from receipt date)
 Faxed to (972) 661-2312 (Paper has 14-day turnaround time from receipt date)
 Completed over the phone ($12.00 covered individual out of pocket charge this is a personal preference and is not an eligible
medical expense)
 Go to www.teladoc.com
» Click ‘Set up account’
» Were you given a Teladoc username? Select ‘Yes’ or ‘No’
 If the member selected ‘Yes’: Enter first name, last name, date of birth, username and hit ‘Continue’. The Teladoc
system will then be able to uniquely identify the member based upon the provided information.
 If the member selected ‘No’: Enter first name, last name, date of birth, and hit ‘Continue’. The Teladoc system will
then attempt to uniquely identify the member and provide access to the account. If the system is unable to uniquely
identify the member, they may call 1-800-Teladoc and a customer service representative will be able to assist the
member.
Covered Individual Out of Pocket Cost - 9.1.14 Plan Years thereafter
 Group 1: IEBP Risk Business ($30 member/$10 plan)

Group 2: IEBP Risk Business High Deductible Health Plan ($40 member)

Group 3: IEBP Non-Risk Business ($30 member/$10 plan)

Group 4: IEBP Non-Risk Business High Deductible Health Plan ($40 member)
Telemedicine Access
 Simply log into your account or call the toll-free number to request a consult with a Teladoc doctor. A medical history form
updated within the last twelve months will be required prior to a Teladoc consult.

Services include: Primary Care Services, pharmacological services, mental health support provided by a primary care
physician or dermatological consults with image of skin condition uploaded to Teladoc (rash, poison ivy, eczema, skin
infections, ringworm, athlete’s foot, lice, shingles, mouth sores, fungal infection and/or acne. Your image will be saved and
permanently be included in your medical history.

Medication Prescriptions not prescribed by telemedicine consults:
» DEA Controlled - (ex. narcotics)
» Behavioral - (ex. mental health)
» Lifestyle - (ex. erectile dysfunction)
(Rev 5.6.15)

Medical information that is communicated in real-time with the use of interactive audio and video communications
equipment, and is between the treating physician and/or a distant physician or health care specialist with the patient
present during the communication.

IEBP’s contracted telemedicine services via the convenience of phone or online, video consultation, diagnostic and/or
medication management services for many conditions including allergies, cold and flu symptoms, ear infection and other
minor medical conditions.
Teladoc Overview Flyer
(Rev 5.6.15)
Teladoc Member FAQ Flyer
(Rev 5.6.15)
In-store Clinic
Some pharmacies and/or stores have an in-house clinics staffed with nurse practitioners and physician assistants. They can
diagnose, treat and write prescriptions for common illnesses; administer common vaccinations; treat minor wounds, cuts,
sprains, and some skin conditions; conduct physicals and wellness screenings. They are walk-in clinics which are typically open
seven days a week 8 am to 8 pm. To minimize you’re out of pocket expenses, check the provider network for in network
providers.
Urgent Care Center
Urgent care centers are after hour walk-in clinics. They are staffed with physicians that can provide non-emergency care when
primary care physicians are not available. They provide immediate treatment for conditions such as minor sprains, strains, minor
broken bones, infections, small cuts, sore throats, and rashes. To minimize you’re out of pocket expenses, check the provider
network for in network providers.
Emergency Department
Emergency Departments offer inpatient care, emergency services, trauma services for life threatening conditions and late-night
traumas. They treat severe conditions such as severe pain, heavy bleeding, large open wounds, sudden loss or blurred vision,
chest pain, sudden numbness or paralysis, sudden weakness, trouble talking, major burns, loss of consciousness, head trauma,
spinal injury, difficulty breathing, major broken bones, seizures, poisoning, or drug overdoses. If these conditions occur call 911
or immediately go to the emergency department. Emergency treatment that results in an inpatient or observation stay of 23
hours or more must be notified. Call the Medical Intelligence Care Management number on the Medical/Prescription ID card.
(Rev 5.6.15)

PLAN YEAR 2014-2015

Transcription

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