06/04/2019 (2) - Laserfiche WebLink

Home Browse Search

obtaining benefits under the plan. Some employers are self-insured and some employers are fully insured. The current health insurance program has an actuarial value of 88% and is considered a gold plan under the Affordable Care Act. It would be appropriate to classify this plan as a Premier Gold Plan. The current plan provides the following benefits: • Preventive care covered at 100% • In -network coverage of 80% and employee coinsurance of 20% • In -network deductible of $400 single/$800 family • Copays for services ranging from $5 to $100 in -network • Office visits and urgent care $25 copay • Specialist visits $45 copay • Emergency care $100 copay (waived if admitted) + deductible + 20% coinsurance • Specialty imaging $100 copay • In -network Inpatient hospitalization $200 per admission deductible + deductible + 20% coinsurance • Prescription copays of $10 generic/$35 formulary brand/$50 non -formulary brand • Out-of-pocket maximum of $3,000 single/$6,000 family (including all deductibles, copays and coinsurance) in -network • Out -of -network service are provided with increased deductibles, out-of-pocket maximum, and higher cost sharing Supporting Employee Wellness The County continues to emphasize wellness and provides a $25 gift card wellness incentive for employees who complete their annual wellness exam and redeem points on the Florida Blue Cafe Well website. Human Resources also coordinates various training opportunities throughout the year, hosts on-site no cost mammograms, free health risk assessment, low cost ultra sound screening and offers an annual health fair, to support physical, financial, and emotional wellness. Recent Plan Changes Over the last several years, the County has made minor plan changes and minimal changes to employee paid premiums. In order to address rising pharmacy costs, a midyear pharmacy change was made effective May 1, 2018 to carve out the pharmacy benefit from the medical plan. This resulted in changing the pharmacy benefit manager (PBM) from Florida Blue's PBM Prime Therapeutics to Express Scripts (ESI) and selecting RX Benefits to oversee and administer the pharmacy benefit. The change in the PBM was made to secure improved pricing and 100% rebates for the pharmacy benefit and to have improved transparency in pharmacy costs. Rx Benefits works for the County to provide independent expertise and service. They monitor trends and identify opportunities to implement cost saving (avoidance) measures. They evaluate our pharmacy claims experience and obtain negotiated pricing to secure the best pricing for the County. Rx Benefits completed a reverse pricing analysis for the period May 1, 2018 through February 22, 2019 reflecting that pharmacy costs would have been $1,029,872 higher under the prior PBM contract with Prime Therapeutics ($1,349,551 annualized). The pharmacy spend for this period 184