True Health New Mexico | true to your health | Spring 2018

Your True Health New Mexico member ID card tells you whether you are on a large- group or a small-group plan. If you are covered under a large-group plan, please note that our large-group formulary does not cover these products: •   Proton pump inhibitors (such as esomeprazole, lansoprazole, omeprazole and pantoprazole) •   Nasal steroids (such as Flonase ® /fluticasone, Nasacort ® , Nasonex ® and Rhinocort ® ) You can buy these drugs over the counter (OTC). In some cases, the OTC drugs will cost less than a prescription copay. The table below lists the non-covered drugs, the conditions they treat and some OTC alternatives. Non-covered product Condition treated Formulary alternatives (not an all-inclusive list) Dexilant Esomeprazole/Nexium ® Lansoprazole/Prevacid ® Omeprazole/Prilosec ® Pantoprazole/Protonix ® Rabeprazole/Aciphex ® Gastroesophageal reflux disease (GERD) OTC omeprazole/Prilosec OTC lansoprazole/Prevacid OTC esomeprazole/Nexium Beclomethasone/Qnasl ® Budesonide/Rhinocort Flunisolide/Nasarel ® Fluticasone/Flonase Mometasone/Nasonex Triamcinolone/Nasacort Allergic rhinitis/hay fever OTC Fluticasone/Flonase OTC Triamcinolone/ Nasacort OTC Budesonide/Rhinocort Category What you need to know Type of group (your True Health ID card will identify the group that you belong to) True Health provides coverage for large employer groups and small off-exchange groups. Pharmacy benefit manager (PBM)—this is the company that processes your pharmacy claims CVS/caremark. Mail-order pharmacy CVS/caremark Mail Service. Specialty pharmacy CVS Specialty. Formularies (list of covered prescription drugs) CVS/caremark: large group and small group members have separate formularies. Pharmacy prior authorizations True Health New Mexico Pharmacy Services. In-network pharmacies Local, regional and national network; includes Walgreens, Walmart and many other pharmacy chains. There are six copay tiers: •   Two generic tiers. •   One preferred-brand tier. •   One non-preferred-brand tier. •   One preferred specialty drug tier. •   One non-preferred specialty drug tier. These tips can help make this transition easier: •   When you go to the pharmacy, be sure to take your True Health New Mexico member ID card with you. This will help the pharmacy staff process your prescription efficiently. •   If you have questions about your pharmacy benefit, please call True Health New Mexico Customer Service at 855-769-6642 . •   Find our formularies, a list of in-network pharmacies, information about CVS/caremark and its mobile app, claim forms, and more at truehealthnewmexico.com/formulary.aspx . What’s your health insurance IQ? KNOW THE LINGO Sometimes, health insurance policies feel like they’re written in a foreign language. You read them and wonder, “What in the world does that mean?” Understanding basic medical insurance terms is important—especially if you’re shopping for a new policy. That knowledge can help you pick the plan that best fits your needs and may save you money. Healthcare.gov provides plain-language definitions of many health insurance terms. You’ll find a list of terms at healthcare.gov/glossary . You can also read definitions of some basic terms below. Premium . The monthly amount you pay for insurance. Coverage. The health services your plan will pay for. Deductible. The amount you’re required to pay for medical care each year before your insurance begins to pay. If you have a deductible of $1,000, you’ll pay $1,000 out of pocket for covered health services before your insurance pays anything. The deductible may not apply to all services. Copay. This is short for copayment . It’s a set dollar amount ($15, for example) you pay each time you see a provider, get a prescription or use another covered health service. Your copay can vary, depending on your plan and the type of service you get. Your insurance company pays the rest of the bill, up to the amount allowed by your plan. Allowed amount. The most your plan will pay for certain healthcare services. If your healthcare provider charges more than your insurance will pay, you may have to pay the difference. Co-insurance. The percentage of the cost of a service that you must pay after you’ve met your deductible. A common co-insurance ratio is 80-to-20. In other words, insurance pays 80 percent of the allowed amount for the service, and you pay 20 percent. Formulary. A list of prescription drugs that your health plan or prescription plan will cover. It’s also called a drug list. In-network/out-of-network. Providers— hospitals, doctors, specialists and therapists, for example—who accept your health insurance are called in-network providers. Ones that don’t are called out- of-network providers. It typically costs you more to see out-of-network providers, so check carefully to see if the healthcare providers you use or are considering using are in-network or out-of-network. Sources: AARP; Centers for Medicare & Medicaid Services O n Jan. 1, 2018, New Mexico Health Connections (NMHC) members who were on employer-sponsored health plans were transferred to our new health plan, True Health New Mexico. This brought changes to your pharmacy benefits. The table below breaks them down for you. Important changes to your pharmacy benefit for 2018 { P H A R M A C Y I N F O R M A T I O N F O R M E M B E R S O N L A R G E - G R O U P P L A N S } 2 { TRUE TO YOUR HEALTH } { M E M B E R N E W S } Copayment (copay) tiers