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Healthy Times

Employee Health & Benefits Newsletter ? Spring 2009

State Employee Health Commission

Co-Chairs: Brett Hoskins Alicia Kellogg

Members: John Bloemendaal Lauren Carrier Becky Greene Carol Harris Tom Hayden Richard Hodgdon Kandi Jenkins Scott Kilcollins Jan Lachapelle John Leavitt Michael Mitchell Steve Moore Cheryl Moreau Ed Mouradian Carl Parker Kimberly Proffitt Will Towers Freeman Wood

Executive Director: (Ex-Officio) Frank Johnson

Staff: Tanya Plante

Editor/Layout: Patrick E. Paradis

Contributors: Bill McPeck Guida Libby Jane Paxton Earle Pease Heather Sargent/Plante


After five years of relatively good claims experience and low rate increases, the State employee health plan has been hit with a significant jump in plan expenses. Medical claims in 2008 increased by over 10% compared to the prior year for the point-of-service plan (covering active employees and non-Medicare retirees). Payments for medical services increased by over $16 million in 2008.

Most of this increase is due to a greater use of medical services and a small group of highcost claims. There were eight cases that exceeded $350,000 and these eight cases alone accounted for $4.6 million.

The budget for the next fiscal year projected an increase of 6%. As you know, the Legislature is confronted with a significant budget gap for FY2010. With these overall budget problems looming, the State Employee Health Commission was forced to examine ways to reduce plan costs. It was necessary that the estimated plan expenses for the upcoming year not exceed the amount budgeted. To meet that objective, the Commission recently approved a series of benefit changes that will be effective July 1, 2009.

A summary of these changes are listed below (These changes only apply to the pointof-service plan for active employees and non-Medicare retirees):

? Emergency Room Care ? the copayment for emergency room care is increased

to $75.

? Walk In Center ? A select number of facilities will provide walk in treatment for

a $15 copayment.

? Bariatric Surgery ? All deductible and copayments will be waived if members

receive this procedure from "centers of excellence". For bariatric surgery, East-

ern Maine Medical Center and Maine Medical Center are designated centers of


? Evidence-Based Benefits ? Members with asthma and congestive heart failure

may be eligible for reduced office visit and prescription drug copayments for

participating in disease management services.

? Prescription Drug Benefits ? For many years the State employee plan has had a

two-tier drug benefit. There were different copays for Tier 1 (generic) and Tier 2

(brand). In July, we will be introducing a three-tier drug benefit for the point-of-

service plan.


? Tier 1 (generic) = $10


? Tier 2 (preferred brand) = $30


? Tier 3 (non-preferred brand) = $45 ($50 for infertility and impotency


A series of informational meetings will be held at locations across the state in June and early July to go over these plan changes. We will provide a listing of the meetings once the schedule is finalized.



207-287-6655 Toll Free: 1-800-422-4503



207-287-6780 Toll Free: 1-800-422-4503 TTY Toll Free: 1-888-577-6690


Augusta: 207-287-9059 Bangor: 207-941-4774 Hours:

Monday - Thursday 6:00 a.m. - 7:00 p.m.

Friday 6:00 a.m. - 2:00 p.m.

Saturday 8:00 a.m. - 2:00 p.m. (September - May)


Portland: 207-797-5700 Hours:

Sunday 6:00 a.m. Friday 10:00 p.m.

24 hour access Saturday

6:00 a.m. - 8:00 p.m. Scarborough: 207-883-2979 Hours:

Monday - Friday 4:00 a.m. - 10:00 p.m. Saturday - Sunday 6:00 a.m. - 8:00 p.m.


Employee Assistance Plan

Contact us TOLL FREE at 1-800-451-1834


Medicines, or drugs, come as either prescription or over-the-counter. Prescription drugs are used under a doctor's care. When using a prescription drug, it is important to read the drug label. Not following the instructions can hurt your health. Read the label each time you use the drug. If the drug is a re-fill or a renewal, read the label again just in case there have been changes to it since the last time you used it. See the drug label below to know what to look for. If you read the label and still have questions, call your doctor, nurse, or pharmacist for help.


Today, there are many drugs available that work the exact same way to treat the same condition. For instance, there are several drugs that treat high cholesterol like simvastatin (generic Zocor), Crestor and Vytorin. Another example are drugs that treat high blood pressure such as Micardis, Avapro and Cozaar.

All of the drugs work exactly the same way as the other drugs in the same group, but are made by different pharmaceutical companies. When prescribed properly, these drugs are just as safe and effective in treating the same condition.

For example, generic drugs like simvastatin for high cholesterol, and omeprazole for heartburn are available on Tier 1 for a low co-payment. (Prilosec OTC, over-the-counter, is available for $0 co-pay when purchased with a prescription.) There are other situations where certain drugs must be tried before Advantra Freedom will cover another drug for the same condition. This is called "step therapy."

The clinical team of doctors and pharmacists have established these guidelines for step therapy and they have been approved by Medicare. Since Aciphex, Prevacid Solutabs, Protonix, Nexium, and omeprazole all treat heartburn and ulcers and work the same way, Advantra Freedom will not cover Aciphex or Prevacid Solutabs for you unless it is medically proven that the other medications do not work for your condition.

If your doctor states that you have tried the first line of alternatives, and they were not effective, Advantra Freedom will then cover the Aciphex or Prevacid Solutabs. It is important to remember to look at your Advantra Freedom "formulary" and ask your doctor if there are any lower-tier drugs that may be appropriate substitutes when getting a new prescription from your doctor. Please call Medco's Customer Service Representatives at 1-800-690-5924 for more information.



Many of our retirees and/or spouses who qualified for Medicare are having their Part B premiums deducted from a Social Security check. Some of them are not receiving a Social Security check or the check is not large enough so the deduction can not be taken. When Social Security can't take the deduction, they bill the member directly on a quarterly basis.

In the past few weeks, several of our state retirees or their spouses have lost their State of Maine Retiree health benefits because they failed to pay their Medicare Part B premium. When Social Security cancels Medicare coverage for nonpayment of premiums, it has an impact on your State health plan. Retirees and/or spouses who are enrolled in Medicare have been told they need to keep their Medicare Part A and Part B. If you are eligible for Medicare, then Medicare must be your primary insurance. For many years, the office of Employee Health and Benefits has been educating members who are approaching Medicare age. When Medicare became the primary coverage for retirees or spouses, they would be enrolled in a Companion Plan with Anthem. The State Retiree Health plan no longer offers Anthem to Medicare eligible members.

For 2009, the State Employee Health and Benefits Office has been converting Medicare retirees or spouses to Advantra Freedom. Members must be enrolled in Medicare Part A and Part B in order to be enrolled in Advantra Freedom. The Benefits office receives a weekly report notifying them of any members who are not enrolled in Medicare Part B. At the same time, the Advantra Freedom plan is cancelled for that member. The State Retiree Health plan can not keep a member enrolled if they fail to maintain their Medicare Part B.

Re-enrollment in the State Retiree Health plan is not allowed. There is a possibility that you might be reinstated, but only if the Social Security Administration allows a reinstatement of Medicare Part B so that there is no lapse in coverage. If your Medicare Part B has been cancelled, you may want to contact the Social Security Administration to discuss what options are available to you.


One could certainly describe today's environment as being one of uncertainty. With uncertainty can come increasing levels of stress and anxiety. Increased levels of stress and anxiety can impact your relationships at work, relationships at home or how you take care of yourself. Each of these can influence your performance at work, your quality of life and your health.

As the intensity of our current situation increases, don't feel you need to tackle the world by yourself. Openly and honestly sharing your concerns and fears with your spouse, family or friends will help to lessen your load. Another resource available to you is our Employee Assistance Program (EAP).

Let's review some information about our EAP Program:

? Who is eligible to use our EAP Program? Employees, family members who live with the employee, retirees and laid-off employees who have recall rights.

? What does it cost to use the Program? EAP provided services are free.

? What can EAP help me with Work issues, family issues, parent-child issues, relationship issues, alcohol and drug use issues, mental health issues, and any other issue that interferes with your attendance and performance at work.

? How many EAP sessions can I have? Depending upon the nature of your issue, you may have up to 8 in-person sessions with an EAP counselor.

? Can I see an EAP counselor on wok time? Yes. You are allowed reasonable time for the visit (session time plus travel) and your immediate supervisor must know you will be leaving the worksite specifically for an EAP visit.

? Is our EAP Program separate from our health insurance's mental health benefits? Yes. The benefits provided by each of the programs are different.

? How can I access services? To be eligible for the benefits of our EAP Program, call 1-800-451-1834 any time of day or night, any day of the week.


The State employee health plan uses the primary care physician ratings of the Maine Health Management Coalition (MHMC) to determine preferred practices. Ribbons are awarded to 3 types of practices: family medicine, internal medicine and pediatrics.

Beginning in May 2009 the ribbons awarded to practices will be changing. Blue ribbons will be based on national ratings. This is new.

Blue ribbons for family and internal medicine practices are based on national ratings for: ? Office systems quality ? Results of care for diabetics ? Results of care for heart disease

Blue ribbons for pediatrics are based on national ratings for: ? Office systems quality ? Care and outcomes for pediatric patients with asthma ? Rates of shots and vaccines to prevent diseases like measles and polio

Green ribbons used to be blue ribbons in 2007 and 2008. Green ribbons are made in Maine quality ratings based on local data:

? "Well on the way" quality ratings from 2 national ratings systems ? Results from a Maine office systems survey ? Quality of care data reported by medical practices

Blue ribbons are based on quality ratings from two national organizations: the National Committee for Quality Assurance (NCQA) and Bridges to Excellence (BTE). Green ribbons are determined by a mix of national and Maine data.

What does this mean for the State employee tiered benefit program? In 2007 and 2008 practices that earned two or three blue ribbons were considered preferred practices. That meant that you had no out-of-pocket expenses when you saw a preferred practice. The office visit copay is waived and there are no physician charges subject to the deductible. The tiered primary care benefit only applies to Anthem point-of-service members.

With the new blue and green ratings, a preferred practice will be any practice that is awarded two or three ribbons. A preferred practice can have two blue ribbons or two green ribbons or a combination of one blue and one green. As long as the practice has two or three ribbons it will be considered a preferred practice.

While the MHMC Physician Steering Committee awards blue and green ribbons using published quality standards, they use their collective best judgment as well. Committee members know that current standards don't tell thee whole story. Only certain parts of medical practice are measured and reported. As more measures, standards and valid data become available, the Committee will consider that information in rating practices.

We encourage you to visit the Maine Health Management Coalition website () to check on Maine Doctor Ratings.


The annual enrollment period for active employees for HEALTH and DENTAL plans only will start around the middle of May and extend through June 26th. Annual enrollment allows employees to make changes to their health or dental plans that they were not allowed to make during the year. Employees who are not enrolled in either plan, may enroll at this time. All enrollments or changes take effect July 1, 2009. More information and rates will be mailed in the next few weeks.

Presort Standard U.S. Postage


Permit No. 8 Augusta, ME


Check the State web-site for additions to the Forever Fitness Club Network. If you have any questions about Forever Fitness Clubs, please call toll-free 1-877-244-2452 for more information.


Come and walk with your co-workers and friends to celebrate National Employee Health and Fitness Day on May 20, 2009 starting at 12:00 noon (approximately 45 minutes). Walks will be held in multiple locations. Augusta: Eastside Wellness Center, Commerce Drive, Cross Building, Key Bank Plaza, Edison Drive, and Hallowell. Bangor: Griffen Road and the Bangor Wellness Center. Portland: Back Bay. Lewiston: Mollison Way. Sign up prior to May 8th and receive a FREE t-shirt. Walks will occur rain or shine. Ponchos will be available. For more information, and to register, please contact recept.bangor-wellness-ctr@


Advantra Freedom members will be receiving phone calls around May or June. The call is automated and is identified to you as Advantra Freedom. This annual call is required by the Centers for Medicare and Medicaid Services (Medicare). The automated caller will ask if you have other insurance. If you say no, you will not receive another call for one year. If you say yes, Coventry Health will mail you a questionnaire that must be returned. The caller will not ask for any personal information.


Both the health and dental plans will be renewed effective July 1, 2009. As we noted on page 1 the rates for the point-of-service plan (actives and non-Medicare retirees) will be increasing by 6%. Benefit changes are listed on the first page of the newsletter.

The dental plan will experience a rate increase of 4.2%. The only change to the dental plan will be the addition of two benefits: crown lengthening and partial pulpotomy. All other dental services and benefit levels remain the same.


State House Station 114 220 Capitol Street

Augusta, Maine 04333-0114

Return Service Requested

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