New Health Enhancement Program

Effective October 1, 2011, the state will implement the voluntary Health Enhancement Program(Program). The Program has several important benefits. First, it will help you and your familywork with the medical providers that you choose from the existing state provider networkto get and stay healthy. Second, it will save you money on your healthcare. Third, it will savemoney for the state by focusing our healthcare dollars on prevention. It’s your choice whetheror not to participate, but there are many advantages to doing so.

You Save Money by Participating!

When you and all of your enrolled family members participate in the Health EnhancementProgram, you will pay lower monthly premiums and have no deductible for in-network carefor the plan year. If one of you has one of the five chronic conditions identified below, youwill also receive a $100 cash payment, providing you and all enrolled family members complywith Program requirements.

Requirements for Everyone Enrolledin the Health Enhancement Program

When you enroll in the Health Enhancement Program, you and your enrolled family memberswill need to get age-appropriate wellness exams and immunizations, early diagnosis screenings(such as colorectal cancer screenings, Pap tests, mammograms, and vision exams).Those enrolled in the dental plan must also get annual dental cleanings. All of the plans coverup to two cleanings per year. Annual dental cleanings and unlimited periodontal care areincluded in the Health Enhancement Program.

These particular conditions are targeted because they account for a large part of our totalhealthcare costs and have been shown to respond particularly well to disease education andcounseling programs. By participating in these programs, affected employees and familymembers will be given additional resources to improve their health.

These exams and screenings are designed to provide early diagnosis and appropriate education to employees and their enrolled family members to help them stay healthy, and, if ill, to treat their illness.For those enrolled in FLES, if one of the two employees chooses to enroll in HEP, then both parties must enroll.

Any enrolled member diagnosed with one of the five (5) chronic conditions outlined below must take part in an educational and counseling program. Those conditions are as follows:

  1. Diabetes
  2. Chronic Obstructive Pulmonary Disorder or Asthma
  3. Hypertension
  4. Hyperlipidemia (high cholesterol)
  5. Coronary Artery Disease (heart disease/heart failure).

This education and counseling programs consist of the following:

•Phone contact from a health care counselor from their medical insurance carrier;

•Receiving materials to help the individual to better understand and control or eliminate the disease condition;

•Being provided with a variety of on-line and/or printed support tools and materials to further assist them.

Individuals with one of these five conditions will not have a co-pay for office visits related to their chronic condition.

The pay is the same regardless of the employee’s class coverage or the number of enrolled dependents with a chronic condition.

Required Screenings

While the State Employee Health Plan will continue to cover an extensive schedule of periodicphysical wellness examinations and screenings, participants in the Health Enhancement program agree tocomply with the following minimum schedule of physical wellness exams and the followingspecific schedule of screenings in order to be compliant with the Program:

•Scheduled Preventive Physical Examinations

•Well Child Visits:

  • Birth to 1 6 exams (lmonth, 2 months, 4 months, 6 months, 9 months, 12 months)
  • Ages 1-5 one per year
  • Ages 6 -17 once every year

•Adult Wellness Physical Examinations:

  • Ages 18- 39 every three years
  • Ages 40- 49 every two years
  • Ages 50 + every year

•Preventive Screenings

  • Cholesterol screenings every five years from ages 20-29(typically done through a blood test in conjunction with the schedule of wellness physicals above.) every two years from Ages 40-50; every year from Ages 50 +
  • Clinical breast examination for women by their health care provider every three years; mammograms as recommended by your physician; one screening mammogram for every female member who is between age 35 and 39.
  • Cervical cancer screening every three years commencing at age 21
  • Colorectal screenings beginning at age 50 consisting of screening options as decided by your physician which options include colonoscopy every ten years; CT colonoscopy which may be an appropriate alternative to a colonoscopy; or annual fecal occult blood test.
  • Vision examination: every two years
  • Dental cleanings: two cleanings per year for participants. Participants not enrolled in dental coverage through the State Health Plan do not have to meet this screening requirement.

As to all of the above listed and described screenings, no employee or enrolleddependent shall be required to get a listed and described screening which is against therecommendation of a physician or other health care professional.

Participants who choose not to adhere to the requirements of the Health Enhancement program will be given appropriate notice and opportunity toimprove. The financial incentives for participation in the healthenhancement program shall be removed from members who themselves orwhose covered dependents fail to comply with the requirements of theprogram. They may return to the Health Enhancement Program only uponcoming into compliance and no sooner than the first day of the monthfollowing their demonstration of compliance. Removal from the programshall not, in any case, be based upon the decision of any patient as to thetreatment they receive, or on the progress or lack of progress in thetreatment of their illness. It shall not be based on any other factorwhatsoever except for the refusal of the patient to get required tests andscreening, and if applicable, to participate in one of the five (5) listed diseasecounseling and education programs. Any removal shall be only upon priornotice to and the review by the Health Care Cost Containment Committee.

Additional Benefit Plan Changes

The following changes affect your healthcare benefits whether or not you participate in theHealth Enhancement Program:

100% Coverage for Recommended Preventive Care

In-network well child visits and immunizations are already covered by the plan with no co-pay.As a result of the Affordable Care Act, preventive care for adults is now 100% covered with noco-pay as well, when you use in-network providers. This applies to all preventive services coveredunder the Affordable Care Act. For a list, visit

Pre-Certification Requirement

Making sure you get the right care – not too little and not too much – is one of the ways wecan make the best use of our healthcare dollars. Pre-certification is required before you havea diagnostic imaging procedure such as an MRI, CT, CAT, or PET scan. If you use an in-networkprovider, your provider will take care of this for you. If you use an out-of-network provider,you are responsible for getting pre-certification.

Emergency Room

Effective October 1, 2011, you will pay a $35 co-pay for emergency room visits, unless you areadmitted to the hospital from the emergency room or there was no reasonable medical alternative.Co-pays for use of urgent care and walk-in clinics will be the same as your plan’s office visit co-pay.

Prescription Drug Changes

The Governor and SEBAC (State Employee Bargaining Agent Coalition) have reached an agreement that establishes a Maintenance Drug Network Program, effective Oct. 1, that provides two options for state employees and retirees under age 65 to obtain their maintenance drugs for certain chronic conditions:

  • Obtain maintenance drugs through mail order; or
  • Pick up maintenance drugs in person at any local pharmacy that is participating in the Maintenance Drug Network.

To date, the following pharmacies are participating in the Maintenance Drug Network Program: all Big Y, CVS, Price Chopper, ShopRite and Stop & Shop pharmacies, as well as Bordornaro's Pharmacy in Portland, and Hope Street Pharmacy in Stamford. This means that instead of receiving these drugs through the mail, you may pick up your prescriptions for maintenance drugs at any of these pharmacies.

Your prescription drug coverage is through Caremark. Prescription benefits are the same nomatter which medical plan you choose.The plan has a 3-tier co-pay structure which means the amount you pay depends on whetheryour prescription is for a generic drug, a brand-name drug listed on Caremark’s preferred drug

list (the formulary), or a non-preferred brand-name drug.

If you or your family takes a maintenance medication, you will be able to get your first fill ofthat medication at any participating pharmacy. After that your two choices are:

• Receive your medication through the Caremark mail-order pharmacy, or

• Fill your medication at a pharmacy that participates in the state’s new Maintenance DrugNetwork

Prescription drug co -pays are as follows Effective October 1, 2011:

For… / Maintenance Drugs
90-Day Supply / Non-Maintenance Drugs
30-Day Supply
Tier 1: Generic drug / $5 / $5
Tier 2: Preferred
brand-name drug / $10 / $20
Tier 3: Non-preferred / $25 ($10 if your physician certifies the non-preferred brand-name
drug is medically necessary) / $35 ($20 if your physician certifies the non-preferred brand-name drug is medically necessary)

For those enrolled in the Health Enhancement Program, medications used to treat chronicconditions covered by the Program’s disease education and counseling programs cost even less:

•$0 co-pay for Tier 1 (generic)

•$5 co-pay for Tier 2 (preferred)

•$12.50 co-pay for Tier 3 (non-preferred).

  • There is zero co-pay for medications used to treat diabetes (Type 1 and Type 2).

To check which co-pay amount applies to your prescriptions, visit forthe most up-to-date information. Once you register, click on “Look up Co-pay and FormularyStatus.” Simply type the name of the drug you want to look up and you will see the cost andco-pay amounts for that drug as well as alternatives.

Preferred and Non-Preferred Brand-Name DrugsWhich tier a drug is placed in is determined by Caremark. Caremark’s Pharmacy andTherapeutics Committee reviews tier placement each quarter. If new generics have

become available, new clinical studies have been released, new brand-name drugshave become available, etc., the Pharmacy and Therapeutics Committee may changethe tier placement of a drug.If your doctor believes a non-preferred brand-name drug is medically necessary for you,they will need to complete the Coverage Exception Request form (available at fax it to Caremark. If approved, you will pay the preferred brand co-pay amount.

If You Choose a Brand-Name When a Generic Is AvailablePrescriptions will be automatically filled with a generic drug if one is available, unless yourdoctor completes Caremark’s Coverage Exception Request form and it is approved. (It is notenough for your doctor to note “dispense as written” on your prescription; a separate formis required.) if you choose a brand-name drug over a generic alternativeand it is not approved as medically necessary, you will pay the generic drug co-pay PLUSthe difference in cost between the brand and generic drug.If you have questions about your prescription drug benefits, contact Caremarkat 1-800-318-2572.

Below are some frequently asked questions about the Maintenance Drug Network Program

Question: What is a "maintenance drug?"

Answer: Maintenance medications are those used to treat chronic conditions and are typically taken on a regular basis. If you are currently getting a 90-day supply of a medication for a chronic condition at your pharmacy, it is likely a maintenance drug.

Question: How do I know if my medication is considered a "maintenance drug?"

Answer: Caremark, the state's pharmacy benefits manager, maintains a list of those drugs frequently used by state plan members that are considered maintenance medications.

Question: What do I need to do after Oct. 1 to comply with the maintenance drug program?

Answer: After Oct. 1 you can fill your prescription as you always have, in person, at your local pharmacy. If your prescription is for a maintenance drug you will only receive a 30-day supply. Following that prescription fill, Caremark will notify you directly by mail that your next refill for that medication must be refilled through the maintenance program. Caremark will also inform you of your options, which include filling it at a local pharmacy in the Maintenance Drug Network or using Caremark's mail order process. If you wish to register for the mail order process by phone, you may call 1-800-875-0867 or you can log on to and sign in to register. Have your prescription card number, the names of your medicines, your doctor's information and your payment information (credit card, debit card, check) ready for your co-pay.

Question: Which local pharmacies have joined the Maintenance Drug Network?

Answer: To date, all Big Y, CVS, Price Chopper, ShopRite and Stop & Shop pharmacies have agreed to participate. In addition, Bordornaro's Pharmacy in Portland, Hope Street Pharmacy in Stamford have agreed to participate. We will post details as additional pharmacies may join the network in the coming weeks.

Question: What if I need a prescription that is NOT a maintenance drug?

Answer: If your prescription is not a maintenance drug, then you can fill it - in person - at your pharmacy of choice as you always have.

Question: For security and privacy reasons, I would rather not receive my maintenance drug(s) by mail. Is there an alternative for me?

Answer: If you would prefer to pick up your maintenance medications in person, use one of the local pharmacies identified above that are participating in the Maintenance Drug Network. Caremark has offered every pharmacy in the state the ability to participate in this network. If you fill your prescription at these locations you will be able to get a 90-day fill for one co-pay.

Question: How do I know whether my pharmacy is participating in the Maintenance Drug Network?

Answer: The list of pharmacies participating in the Maintenance Drug Network will be updated regularly and is available on the comptroller's website

Question: If my prescription drug requires refrigeration or other special care, can it be delivered through mail order?

Answer: Drugs that require refrigeration will be delivered in a specialized package to maintain the necessary temperature. You may also wish to pick up these medications at one of the local pharmacies participating in the Maintenance Drug Network.

Question: If I elect to receive my drugs through the mail, rather than pick them up at a Maintenance Drug Network pharmacy, how will I be billed and pay for the co-pay?

Answer: You will be billed for your co-pay, and can pay by credit card, debit card or check.

Question: If I participate in the maintenance drug program and have a question about my prescription, who do I turn to for questions about my medication?

Answer: Call the pharmacy where you filled the prescription. If you used Caremark’s mail order service, you can call Customer Service at 1-800-318-2572.

Question: I am a retiree. Am I required to participate in the maintenance drug program?

Answer: The program is only required for current retirees under the age of 65. If you are a current retiree over the age of 65, you are not required to participate.

Question: If my spouse is covered under my insurance and uses CVS for a maintenance drug while I continue to use Walgreens for medications as needed, will we receive separate cards from each provider?

Answer: No – the prescription provider (CAREMARK) is the same.

GENERAL FAQ’s

Question:Will everyone get new cards?

Answer:

Anthem:New ID cards will be sent to active employees.

Oxford:New ID cards will be issued to all active employees.

Caremark:No new ID cards for anyone other than a new employee/dependent on the plan.

United Dental: Only members making a change to their dental coverage will get a new card.

CIGNA Dental: No new ID cards for anyone other than a new employee/dependent on the plan.

Question:Who will track compliance?

Answer: The health insurance carriers: Anthem, Oxford, Cigna and UnitedHealthcare.

Question:How is compliance tracked?

Answer: Through claims data. No information related to an individual’s health status or condition will be provided to the State of Connecticut.

Question:What if an employee has already completed a screening prior to October 1, 2011?

Answer: The health insurance carriers will be able do a look back at claims on record.

Question:Will employees be reminded of what they need to do?

Answer: Once per year a reminder notice will be sent out to employees that enrolled in HEP that haven’t completed their required screenings and exams.

Question:What if they’re reminded to do a screening they’ve already completed?

Answer: They would need to contact their health insurance carrier to “self-report” the screening. A method for “self-reporting” is currently being developed.