Member UpdateNovember 2011

In this Issue

2Seasonal flu

Managing diabetes

3New physicians

4Formulary updates

Prescription drug costs

Designating an authorized

representative

5Emergency care

information

Protect yourself against fraud

6Women’s health

issues

7Women’s health

issues

8Pharmacy

processing changes

Preventive Health Guidelines

Cultural needs

You can view your benefit documents, change your PCP and e-mail a customer service representative online at thehealthplan.com

GHP ranked top in Pennsylvania

GHP is committed to providing quality health care to our members. One way we can ensure that we are holding ourselves to the highest standards is to review the Health Plan’s performance against accepted care and service measures. The Healthcare Effectiveness Data and Information Set (HEDIS®)* provides a set of measures against which we can judge our effectiveness.

GHP conducts an aggressive preventive health program geared toward members most at risk for a variety of preventable illnesses, ailments and diseases.

Quality improvement nurses work directly through telephone calls and mailings to reinforce the importance of preventive measures and suggested screenings. These measures include mammography, pap smears, colorectal cancer screenings, blood pressure and cholesterol screenings, and comprehensive diabetes care.

Quality indicators such as HEDIS, are set forth by the National Committee for Quality Assurance (NCQA) to ensure that Health Plan members receive high-quality care. Administering the highest quality care possible helps GHP keep members healthy and happy.

* HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).

Our commitment to quality

For the fourth year in a row, Geisinger Health Plan (GHP) is the top-ranked private health plan in Pennsylvania.* Nationally, GHP’s health maintenance organization (HMO) is ranked eighth for quality and service by the National Committee for Quality Assurance (NCQA). The 2011-2012 rankings mark the first time that NCQA ranked PPO plans. Geisinger Choice was the second highest ranked plan in Pennsylvania and was ranked

No. 17 nationally. “We have worked hard to ensure that Geisinger Health Plan members receive better

care, and these rankings are the result of our hard work,” says GHP President and CEO Jean Haynes. NCQA ranked more than 483 private HMO and PPO plans. These lists are the only apples-to-apples comparison of

health-care quality and customer satisfaction in the nation.Duane Davis, M.D., GHP Vice President and Chief Medical Officer, says, “High rankings

such as those received by GHP send a message that our members ultimately receive better care. We have developed ways to ensure children see their doctors and receive important immunizations, and that adults remain on medications that prevent future heart attacks. We recognize how important it is to reach out to women to help them schedule screenings that detect breast and cervical cancer early. Our members want the best for their loved ones, and we work hard to deliver it.”

*NCQA’s Private Health Insurance Plan Rankings 2011-2012 and NCQA’s Medicare Health Insurance Plan Rankings 2011-2012. U.S. News/NCQA America’s Best Health Insurance Plans 2007-2009 (annual). “America’s Best Health Insurance Plans” is a trademark of U.S. News & World Report.

Geisinger Health Plan & Geisinger Choice Member Update 2

Cold and flu seasonGetting a flu vaccine is the best way to protect yourself against the flu. Flu seasons are unpredictable and can start early or run late,

which is why the flu vaccine provides protection that lasts through the entire flu season. CDC recommends that everyone six months and older get vaccinated yearly. You can get your vaccine at many places including your local health department, vaccination clinics, doctors’ offices, retail pharmacies, and some schools and workplaces.

Who should get the vaccine?All people, six months and older, are recommended for annual influenza

vaccination. While everyone should get a flu vaccine every year, it’s especially important that people in the following groups get vaccinated because they are at high risk:• Pregnant women (any trimester) • Children younger than 5, especially children younger than two years old • People 65 years of age and older • People of any age with certain chronic medical conditions• People who are morbidly obese (Body Mass Index [BMI] of 40 or greater) • People who live in nursing homes and other long-term care facilities • People who live with or care for those at high risk for flu complication• Health-care workers • Household contacts of persons at high risk for flu complications• Household contacts and out-of-home caregivers of children less than six months of age (children too young to be vaccinated)

For the full list of people at high risk, see “People at High Risk of Developing Flu–Related Complications” on the CDC Web site. Getting a flu vaccine is the first and most important step you can take in protecting yourself and your loved ones. Information for this article came from The Centers for Disease Control and Prevention (CDC)

Managing diabetes Diabetes is a serious condition

that affects many people and causes life-long health problems. People with diabetes are more likely to have higher blood pressure and higher cholesterol than people without diabetes. They also have an increased risk of heart disease, stroke, eye problems, kidney problems and nerve damage.

That’s why, if you have diabetes, it’s important to maintain your blood sugar carefully, stay active and eat a balanced diet to reduce your risk of developing other health problems.

If you have diabetes, there are several tests you should have on a regular basis: •A1C (average blood sugar level)

– your A1C level should be below 7 percent

• LDL (bad cholesterol) – your LDL level should be below 100 mg/dl

•Dilated eye exam•Kidney function test or

treatment with certain medicines such as ACE or ARBs to maintain good kidney function

•Blood pressure reading – your blood pressure should be less than 130/80

Talk to your primary care physician (PCP) to make sure you have received all the important tests and have your diabetes under control.

It is also important to make fitness a priority and eat a balanced diet. Work with your PCP to monitor your condition and set up a diet and fitness plan.

GHP can help you manage your diabetes

GHP’s health management programs help our members manage specific chronic health conditions. A health/case manager will educate you on how to monitor diet, exercise, medications and other lifestyle changes.

The diabetes program helps you understand the importance of blood sugar goals, diet and exercise, blood glucose monitoring, eye and foot care. The focus is to work with you and your doctor to find the

right combination of medications and diet to control blood sugar and prevent complications in the future

Other GHP health management programs offered include asthma, chronic obstructive pulmonary disease (COPD), Stop Tobacco Use, hypertension, coronary artery disease (CAD), heart failure, osteoporosis and weight management. For more information on any

our of health management programs, please call (800) 883-6355.

Stockbyte/Thinkstock

Geisinger Health Plan & Geisinger Choice Member Update 3

New physiciansThis list includes new primary care physicians (PCP) who have joined our network since May 2011. For more information on

these and other participating providers, please visit our Web site, thehealthplan.com, or call the customer service team at the number on the back of your member ID card.

AdamsFamily Practice Rachel Benelli Markey, MD

BedfordFamily PracticeJohn P. Forney, MD

BerksFamily Practice Jeffrey C. Brand, DOJennifer A. Dwyer, DOTimothy Andrew Ferenchick, MD

PediatricsJamie L. Chmielowski, MD

BlairInternal MedicineCatherine Elizabeth Comas, MD

CambriaFamily PracticeJarrett J. Bender, DORoy W. Warren, DO

CameronPediatricsHongye Li, MD

CentreFamily PracticePaul Richard Damaske, MD

ChesterFamily PracticeJeffrey C. Brand, DO

ClearfieldFamily PracticeCara Marie Dellegrotti, DO

CumberlandFamily PracticeCaissa F. Troutman, MD

PediatricsKylie M. Murray, DO

DauphinInternal MedicineJuanita M. Kreiser, DO

PediatricsKylie M. Murray, DO

LackawannaInternal MedicineRajiv V. Bansal, MDAriane M. Conaboy, DO

LancasterFamily PracticeRichard L. Grunden, MDAmy C. Hancock, MDDanielle J. Miller, MDDavid T. O’Gurek, MDJoanna Isabelle Trojanowski, MD

Internal and Geriatric MedicinePalak P. Mehta, MD

PediatricsSara D. Bowen, MDKelly Anne Curtin-Hallinan, DOKimberly Ann Slusser, MD

LehighFamily PracticeDavid M. Afzal, DOTimothy M. Daly, DODalya Delmar-Greenberg, MDSherwin Nepomuceno, MD

Internal MedicineTina M. Casey, DORena M. Lambert, DO

PediatricsJill E. Colabroy, MD

LuzerneInternal MedicineNicole Lee Balchune, DO

PediatricsDouglas R. Lincoln, MD

LycomingFamily PracticeErica Victoria Leonard, MDKathy L. Nase, DOLori A. Rinker, DOChristopher A. Wagner, MD

Internal MedicineSusan F. Borys, MDIngrid Ockenhouse Donato, MD

McKeanFamily PracticeA. Ramani Murugappan Arya, MD

MontourFamily PracticeKyungsook Cho Kim, MD

MifflinFamily PracticeGaurav Dang, MDCatherine Mary North, MD

NorthamptonFamily PracticeAnnElise Collier, MDSara Mirza, MDMary C. Stock-Keister, MD

Geriatric MedicineSara Mirza, MD

NorthumberlandInternal MedicineJuanita M. Kreiser, DO

PotterPediatricsHongye Li, MD

SchuylkillFamily PracticeJane R. Lagan, MD

PediatricsKara Fisher Miller, DO

TiogaInternal MedicineOlufemi Awosika, MDJill A. Burns, MD

PediatricsJill A. Burns, MD

UnionFamily PracticeAyn H. Kerber, MD

YorkFamily PracticeGregory Ahamad Khan-Arthur, DOJoshua Levi Warfel, MD

Internal MedicineCharles J. Gartland, DO

Geisinger Health Plan & Geisinger Choice Member Update 4

Formulary updatesA drug formulary is a continually updated list of prescription drugs that the Health Plan covers. The formulary list is

determined by the clinical judgement of the Pharmacy and Therapeutics Committee, which is made up of a diverse health-care team. As a general rule, drugs at tier 1 and tier 2 are considered preferred drugs, while non-preferred drugs are typically at tier 3. Prior authorization may be necessary for certain drugs. The table below represents recent updates to the Health Plan’s formulary. For a hard copy of the entire formulary, please contact our pharmacy customer service team at (800) 988-4861, Monday through Friday, 8 a.m. to 5 p.m. or view it at thehealthplan.com.

Drug

Status Tier Notes

Victrelis NF 3*, t Incivek preferred; 12 week initial authorization.

Incivek F 3*, t 12 week authorization.

Xarelto** F 3 Quantity limit of 34 tablets per dispense.

Lastacaft F 3*, t Alternatives include Azelastine and Pataday.

Fortesta F 3*, t Alternatives include Androderm patches and gel.

Simvastatin 80 mg F 1*, t

Member must have been on Simvastatin 80 mg for at least 12 months prior or have failed both Lipitor and Crestor.

Optichamber F 2 1 copay per unit; 2 units per year limit.

Lipitor is expected to be available in generic form sometime after December 1, 2011. Please note that Geisinger will cover the brand Lipitor at Tier 1 and the generic will not be covered at this time.

Status column key:Formulary (F)-drug is a preferred product; prior authorization may still apply according to key Non-Formulary (NF)-drug is not a preferred product; prior authorization will likely apply according to key

Tier key:* =prior authorization applies for the traditional benefitt = prior authorization applies for the triple choice benefit

** = quantity limit applies

The cost of prescription drugs is an important issue for all of us. It’s a smart financial decision to learn about the various discount drug programs available. Many retail pharmacies are offering generic medications at discounted prices for both 30- and 90- day supplies. Some pharmacies may even offer some medications for free. These discounted drug lists vary among pharmacies.

Most Geisinger Health Plan and Geisinger Choice prescription plans have copays associated with each tier of medications. If the actual cost of the medication is less than the assigned copay, the member will pay the cost of the medication. Therefore, in some instances, presenting your Geisinger Health Plan or Geisinger Choice prescription benefit drug card may result in a cost that is less than the pharmacy’s discounted drug program.

Always present your card to ensure you are getting the best price. If the advertised discounted price is lower than your copay, you still should receive your prescription for the offered discounted price. We want to help you maximize your benefits and save money wherever possible.

Prescription drug cost Should you designate an authorized representative?

By designating an authorized representative, you give us permission to talk to someone else regarding your care, claims, appeals and benefits. You can be as broad or as specific as you want when filling out an authorized representative form.

An authorized representative form can be very important if someone else is handling your finances or helping with your care. You may need an authorized representative form if you are:

1. a parent whose 18 year old child is still covered on your insurance and you need to question a claim

2. a spouse who takes care of the bills and needs to discuss a claim you received for your husband/wife

3. a son or daughter caring for an elderly parent who needs to understand ongoing health management with a health-care manager

An authorized representative form differs from a power of attorney form because the person you designate has no authorization to make medical decisions on your behalf. With an authorized representative form, you are simply giving us permission to talk to someone about your care.

You received an authorized representative form in your member packet. If you would like another copy, please call the customer service number on the back of your member ID card.

Geisinger Health Plan & Geisinger Choice Member Update 5

What to do when it’s not an emergencyFortunately, emergencies are rare. However, there are many

other situations when, although your health may not be in serious danger, you need medical attention for a sudden illness or injury. These situations are referred to as urgent care. Often, you may be unable to seek help from your PCP or other Health Plan providers because you are out of our coverage area.

In urgent care situations you have a few options. In most urgent care situations, it is usually best to contact your PCP, since they know your specific health-care needs. You can contact your PCP’s office 24 hours a day, seven days a week. They may have you schedule an appointment or provide you with other medical direction.

For non-emergency situations, you can also contact Tel-A-Nurse for advice regarding your situation 24 hours a day, seven days a week at (877) 543-5061, or visit thehealthplan.com to chat with a nurse via the Web. This is free of charge for all members.

Geisinger Health Plan will cover urgent care anywhere in the United States. If possible, contact your PCP before seeking urgently needed care or as soon as you can afterwards.

You should return to your PCP for follow-up care; however, you will be covered for continued care outside the service area as long as the treatment continues to fit the definition of urgently needed care.

Urgent and emergent care are covered no matter where you are

If you are traveling outside the Geisinger Health Plan service area, certain services will still be covered. The Health Plan will pay for medical emergency care, urgently needed care, renal dialysis and any care that has been pre-approved by Geisinger Health Plan.

If you have questions about coverage of treatment, please refer to your Subscription Certificate or contact the customer service team at the number on the back of your ID card.

When you are really sick or seriously injured, it’s important to call 911 or go to your nearest emergency room.

If your condition is not an emergency, you may still need medical attention but an emergency room may not be the best place to receive that care. You can have long waits and unnecessary costs in these instances.

For anything other than a true emergency, it’s usually best to call your primary care provider (PCP) to schedule an appointment or request advice.

What is an emergency?A medical emergency is when your health is in serious danger

– when every second counts. An emergency may include severe pain, a bad injury, or a serious illness or medical condition that is quickly getting worse. If you believe you are experiencing a medical emergency you should call 911 or go to the nearest emergency room.

Medical emergencies are covered anywhere in the United States, at any time. However, emergency services provided by non-participating providers are covered only until the doctor caring for you determines that your condition is stable. At that time, Geisinger Health Plan or your PCP may arrange to take over your care or, if you are out of the area, have you transported back to our coverage area.

Your PCP or Geisinger Health Plan should be notified of the emergency as soon as possible, preferably within 48 hours, so they can provide post-emergency care and coordinate follow-ups.

In the emergency room, you are required to pay any applicable emergency room copayments. These copays are waived if you are directly admitted to the hospital or admitted within 72 hours for the same condition.

After you have been discharged from an emergency room, any additional follow-up medical services must be authorized by your PCP to be covered.

Please note: You may be placed in an observation bed after an emergency room visit; this is not the same as an admission. If you are kept for observation and later discharged without being admitted, you will be charged an emergency room copay.

Is it an emergency? If you’re unsure, call your PCP

Tel-A-Nurse is available 24 hours a day, seven days a week to offer members

support and health-care advice.

*Choice PPO with No Referral members are not required to choose a PCP or obtain referrals for specialty care.

In an effort to protect you from health insurance fraud, Geisinger Health Plan maintains an Anti-Fraud Program designed to help detect and eliminate fraud and abuse.

Some examples of fraud and abuse include:• Selling or sharing one’s insurance identification number

or information so false claims can be filed• An employer who enrolls subscribers who do not work

for his or her business under a group service agreement• Using a member identification number that is not your

own to receive treatmentProtect yourself. Use discretion when providing your health

insurance information (including your member identification number). Never release your information in exchange for free services or gifts.

If you suspect fraud or abuse, you can contact us in any of the ways listed below. You may remain anonymous.• Email at FA@thehealthplan.com• Telephone, using the customer service team number listed

on the back of your member ID card• Send written correspondence to:

Geisinger Health Plan Anti-Fraud Program100 North Academy AvenueDanville, PA 17822-3220

Protect yourself from insurance fraud

Geisinger Health Plan & Geisinger Choice Member Update 6

Women’s Health Issues

Planning a babyIf you are planning a baby, take time

before you conceive to also plan a visit to your doctor.

During this appointment you and your doctor can discuss nutrition, exercise, vitamins and any other concerns you may have. Your doctor may review your immunization history and administer any needed vaccinations such as rubella (German measles) or varicella (chickenpox), which should be given at least three months prior to becoming pregnant. If you have any pre-existing health problems, such as high blood pressure or diabetes, it is important to talk to your doctor about getting these conditions under control before you conceive.

You’re pregnant

Once you become pregnant, receiving early and regular prenatal care is one of the best things you can do for the health of your baby and yourself.

You should schedule your first prenatal visit within the first three months of pregnancy. Many women choose to schedule their prenatal visits with an obstetrical/gynecological physician (OB/GYN) or a certified nurse midwife instead

of their primary care physician. If you do not use your primary care provider for your prenatal care, ask your OB/GYN or midwife to keep your PCP up-to-date on your pregnancy and care.

After your first visit, your provider will help you schedule regular visits throughout your pregnancy. These visits will increase as you get closer to your delivery date. It is important that you keep all of your appointments so your provider can quickly spot any health problems and administer vital tests and screenings needed during certain stages of pregnancy.

During your first prenatal visit, your provider may ask about your family history, your health history and any prior pregnancies. You can also expect your provider to conduct several tests including a Pap test, urine test and blood test. This appointment is a good opportunity for you to ask any questions you may have about your pregnancy.

Congratulations on your new baby! Once your baby arrives, life will

become a whirlwind of excitement until you find a new routine. Although you’re busy with your new responsibilities, it’s

imperative that you continue your care after the baby is born. A postpartum visit should be scheduled within six to eight weeks after your delivery. This visit is essential to make sure you are physically and emotionally healthy after your pregnancy. Your doctor will check to see that your are recovering normally, and answer any questions you may have. Take this time to talk to your doctor about issues such as breast health and breast feeding, sexual activity, exercise, and weight loss.

Are you pregnant or planning to have a baby?

If you’ve recently had a baby and you’re feeling sad or depressed, it’s okay. Depression after pregnancy, or postpartum depression, is a condition that can be triggered by hormonal changes in a women’s body after pregnancy. Stress, lack of sleep and a change in your routine can also contribute to these feelings of depression.

If you are experiencing postpartum depression you can become irritable, withdrawn, and overwhelmed. You may have trouble sleeping, lose interest in activities, have no energy, experience feelings of guilt and worthlessness, and cry often.

Often women are reluctant to talk to anyone about these feelings because they are ashamed. It’s important to understand postpartum depression can happen to anyone.

Postpartum depression can happen anytime within the first year after your pregnancy. If you are experiencing symptoms of depression, you should talk to your primary care doctor, OB-GYN or mental health provider. They may recommend counseling, medication or a combination of both. In addition, try to get as much rest as you can, don’t do everything yourself, ask for help, and develop support networks, such as other mothers, relatives and friends.

Are you feeling blue?

Geisinger Health Plan & Geisinger Choice Member Update 7

According to the American Cancer Society, breast cancer is the most common form of cancer in women. When detected in its early stages, breast cancer is highly curable. Early detection and treatment are the best ways to increase survival rates, and a mammogram is the best tool available for early detection.

All women over the age of 40 are encouraged to have annual mammogram screenings. Regular clinical breast exams by your health-care provider are also recommended.

Did you know that as a Geisinger Health Plan member, a

mammogram is a covered benefit with little or no additional cost to you? We encourage you to call your doctor and schedule your yearly mammogram today.

To find out what screenings are covered by GHP refer to your Subscription Certificate or call the customer service team at the number on the back of your ID card.

For more information on breast cancer, or for assistance with scheduling, call GHP at (570) 271-5108.

Women over 40 need annual mammograms

Cervical cancer is preventable, treatable and curable when the disease is detected in its early stages. However, many women still develop and even die from cervical cancer each year.

The American Cancer Society estimates approximately 11,070 women in the United States will be diagnosed with cervical cancer this year and about 3,870 will die from the disease.

Fortunately, the number of deaths related to cervical cancer has decreased over the last several years, and is continuing to drop. Probably the largest reason for this decline is the introduction of the Papanicolaou (Pap) test.

The Pap test (or smear) is when cells are scraped from the cervix and examined under a microscope to detect abnormal cells or pre-cancerous lesions. If found and treated in its initial stages, the five-year survival rate for cervical cancer is 92 percent, according to the American Cancer Society.

The leading cause of cervical cancer is a sexually transmitted virus called the human papilloma virus (HPV). There are usually no symptoms with HPV, and most of the time the infection clears up without any treatment.

Most sexually active women have had HPV sometime in their

life; however, the virus only leads to cervical cancer in some of those women. There are some risk factors that increase the possibility of the HPV infection developing into cervical cancer such as:• sexual

intercourse at an early age

• multiple sex partners

• smoking • failure

to have regular screenings

The Pap test is the most effective way to detect abnormalities in the cervix caused by HPV. Women who have regular Pap tests can drastically reduce their risk of developing cervical cancer because the abnormal cells are detected early.

If you are sexually active or over the age of 21, schedule a screening or talk to your physician about Pap tests.

The facts about cervical cancer

The importance of chlamydia screeningsHow would you know if you have chlamydia? You probably

wouldn’t. According to the Centers for Disease Control and Prevention (CDC), about three-quarters of the women infected with chlamydia never experience any symptoms from the disease.

Screening for chlamydia is an easy and painless process. Chlamydia can be detected either by a culture or through a simple urine test. If an individual is diagnosed with chlamydia, it can be treated with antibiotics. If diagnosed in the early stages, the chances of developing complications are greatly reduced.

If left untreated, however, chlamydia can cause lasting damage. About 40 percent of women with untreated infections develop pelvic inflammatory disease (PID), a very

serious infection that can cause scarring of the fallopian tubes. If this occurs, a woman’s ability to bear children may be affected.

A chlamydial infection can also affect a newborn baby. If the baby is exposed to a chlamydial infection in the birth canal at the time of delivery, he or she may develop conjunctivitis (pink eye) within the first ten days of life. The newborn is also at risk of developing pneumonia within the first three to six weeks of life.

Talk to your doctor about being screened. Chlamydia screenings should be completed for all sexually active women under the age of 25, women over the age of 25 with risk factors, women who are pregnant or as recommended by a physician.

Stockbyte/Thinkstock

Geisinger Health Plan & Geisinger Choice Member Update 8

100 North Academy Avenue Danville, PA 17822-3240

NON-PROFIT ORG.U.S. POSTAGE

PAIDGeisinger

HPM50 ad Nov 2011 HMOPPOMU 10 /13/11

Geisinger Health Plan/Geisinger Choice Member Update is published quarterly. Comments are welcome.Please write:EditorGeisinger Health PlanMember Update 100 North Academy Avenue Danville, PA 17822-3240or e-mail: memberupdate@thehealthplan.comFor questions about your plan, phone the number on the back of your member ID card weekdays between 8 a.m. and 6 p.m.

Geisinger Health Plan and Geisinger Choice are collectively referred to as “Geisinger Health Plan”, unless otherwise noted.

For members with prescription benefits, GHP is making improvements to your claims processing methods at the pharmacy. Beginning January 1, 2012, MedImpact will process your prescription drug claims. Our top priority is to make sure this transition occurs with no service interruption for our members, providers and pharmacies. Please note the following:

•NewcardswillbedistributedbeforethistransitiontakeseffectonJanuary1,2012.Those who have a separate Rx card will receive a new one. Those who do not have aseparate Rx card will receive a new member ID card. Beginning January 1, you willneed to present your new card to your pharmacy, including mail order pharmacy, forprescriptions to be paid•YourmemberIDnumberwillremainthesame•Youmayencounteraslightdelayinprescriptionprocessingduringyourfirst2012prescription fill•YouwillNOTbeabletouseyourArgusprescriptionbenefitcardafterDecember 31, 2011

Additional information will be available in the coming months. If you have questions, please call (800) 988-4861 or (570) 271-5673; TDD/TTY 711

Important pharmacy processing changes for 2012

Cultural NeedsIf you feel Geisinger Health

Plan is not meeting your cultural

needs, please call our customer

service team at (800) 447-4000.

Preventive Health GuidelinesOur Preventive Health Guidelines book is available online

at thehealthplan.com (Member section). If you’d like a hard

copy of this book, please call our customer service team at

(800) 447-4000.