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Introducing Optima Health Commonwealth of Virginia Health Benefits Meetings April 2009 Your New Partner in Improving Health. Today’s Agenda. About Optima Health - The Value of an Integrated Model COVA Connect Network Optima Employee Assistance Program (EAP) My Life My Plan

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Today s agenda

Introducing Optima Health Commonwealth of VirginiaHealth Benefits MeetingsApril 2009Your New Partner in Improving Health

Today s agenda

Today’s Agenda

  • About Optima Health - The Value of an Integrated Model

  • COVA Connect Network

  • Optima Employee Assistance Program (EAP)

  • MyLife MyPlan

    Getting Started

    Staying Healthy

    Improving Health

    Managing Meds

  • Discussion


We re excited to join your team

We’re excited to join your TEAM!

“We’re excited to join the Commonwealth team in providing quality healthcare services to those employees in Hampton Roads. We’ve been in Virginia for 25 years and are proud to call it our home. This new relationship is a milestone for our organization and we take our affiliation with you seriously. We look forward to showing you how we care for our members.”

Michael Dudley

President, Optima Health


Today s agenda

The Value of an Integrated Model


Cova connect advantages

COVA Connect Advantages

Better Health

  • Optima’s Employee Assistance Program (EAP)

  • MyLife MyPlan – a full spectrum of prevention and health improvement programs

  • Proven clinical success

    Easy to Use

  • Dedicated phone numbers and Web site for Commonwealth members

  • Access to Members Services, Clinical Advocate and Health Coach

    A Great Value

  • Local provider educators, nurses, and Medical Directors

  • Expansive provider access


Optima s provider network

Optima’s Provider Network

COVA Connect employee zip code area within Optima Health network

Optima Health network

National Optima Health network


The right providers access to quality physicians hospitals

The Right Providers: Access to Quality Physicians & Hospitals

  • Your Access

    • More than 15,000 providers across Virginia

    • Pilot Area:

      • 668 in-network PCPs at 227 locations

      • 2,407 in-network Specialists at 407 locations

      • 11 in-network hospitals

  • Diverse Network

  • Being local is the Key to Success


Finding a provider

Finding a Provider

  • Directly contracted providers are listed in printed provider directories or online at

  • A listing of national Optima Health providers may also be found on (select “Travel Access/National PPO Network”).


Accessing optima cova connect network

Accessing Optima COVA Connect Network

In-Network Coverage

  • Optima participating provider = In-network = Claims paid in-network

  • Private Healthcare System (PHCS)

    • For services outside the Optima provider network (purple area)

    • Nationwide access to healthcare providers for Optima Health members

    • Available in 48 contiguous states, Alaska and Hawaii

      Out-of-Network Coverage (with buy-up option, at In-Network less 25 percent)

  • Providers not in the Optima Health or the PHCS network

  • PHCS providers located in the dark or light green areas

    • May balance bill

      Not Covered (without buy-up option)

  • Providers who do not participate with Optima or PHCS

  • Any services using PHCS providers within the Optima network

  • 9

    • Emergency Services at In-Network coverage.

    Network access examples

    Network Access Examples

    Scenario #2

    • Member lives in Norfolk (dark green)

    • Member goes to provider in Richmond (light green) who is a participating provider with Optima

    • Member would havein-network coverage

    Scenario #1

    • Member lives in Chesapeake (dark green)

    • Member goes to provider in Chesapeake (dark green) who is a participating provider with Optima

    • Member would have in-network coverage


    Network access examples1

    Network Access Examples

    Scenario #4

    • Member lives in Suffolk (dark green)

    • Member goes to provider in Prince William County (purple) who is not an Optima participating provider, but does participate with PHCS

    • Member would have in-network coverage

    Scenario #3

    • Member lives in Hampton (dark green)

    • Member goes to a provider in Newport News (light green) who is not an Optima participating provider, but does participate with PHCS

    • Member with buy-up would haveout-of-network coverage; Member subject to balance bill

    • Member without buy-up would have no coverage


    Network access examples2

    Network Access Examples

    Scenario #6

    • Member lives in Virginia Beach (dark green) & is responsible for health insurance of dependent child who lives with mother in Kentucky (purple)

    • Dependent goes to provider in Kentucky (purple) who is not an Optima participating provider, but is participating with PHCS

    • Dependent would have in-network coverage

    Scenario #5

    • Member lives in Portsmouth (dark green) and covered dependent attends school in Blacksburg (purple)

    • Covered dependent goes to provider in Blacksburg (purple) who is not an Optima participating provider, but does participate with PHCS

    • Dependent would have in-network coverage


    Optima eap

    Optima EAP


    Optima eap can help

    Optima EAP Can Help

    • We help employees who may be struggling with issues affecting work performance.

    • We help organizational leaders who may be dealing with employees struggling with issues affecting work performance.

    • We are your partner in the effort to:

      • Evaluate issues,

      • Restore employees back to productivity,

      • Return your focus to organizational goals, and

      • Maintain a positive work environment.


    Optima eap assistance

    Access to 4 counseling sessions per presenting issue with licensed counselors – covers employee and all members of the household

    Unlimited Management Consultations

    On-site Leadership and Employee Orientations

    Employee and Leadership development training classes*

    Workplace Trauma Response Program

    24/7 phone assistance

    Convenient counseling appointments and locations

    Strong provider networks


    Privacy and confidentiality

    Exclusive Web site access with information on personal and professional development topics

    Optima EAP Assistance


    *Depending on organizational benefit

    Today s agenda

    EAP as a Management Tool

    • Optima EAP can assist the Commonwealth with maintaining a qualified and successful workforce.

    • Optima EAP can assist the Commonwealth with employee issues and concerns that threaten to impair an employee’s effectiveness or impose a possible risk or liability on the Commonwealth.

    • Leadership Orientation

      • Offered for all supervisors/managers at beginning of contract, and as needed

      • User-friendly Leadership Guide

      • Step-by-step overview of accessing EAP services, documentation guidelines and identifying situations that could benefit from EAP intervention

      • Identifying signs and symptoms of substance use in employees


    Today s agenda

    EAP as a Management Tool, continued

    • Manager Consultation

      • Direct access to Optima EAP for all organizational leaders and Human Resource Professionals

      • Unlimited, confidential consultations on a wide variety of topics

      • Proactive, preventative measure

      • Discuss problems they are having supervising or managing an employee

      • Helps leaders understand the different referral options, when to use them, and how to intervene

      • Provide support to the manager as they plan the intervention

      • Return to Work Agreement, when needed

    • Quarterly Bulletin written for Leadership


    Today s agenda

    Workplace Trauma Response Program

    • Helps employees deal with the emotions, aftermath and stressors associated with a traumatic event or critical incident

    • An important resource for the healing process

    • Addresses normal stress reactions and symptoms

    • Helps those involved identify the necessary coping skills

    • Structured, on-site intervention led by skilled Optima EAP counselors


    Referral option informal referral

    Referral Option: Informal Referral

    • A recommendation for the employee to use EAP

    • A chance to intervene, before the problem gets serious

    • Leadership uses the Informal Referral Process when:

      • The employee’s behavior is starting to impact performance

      • The employee approaches you with a problem

      • Co-workers approach you with concerns

    • Used for non-disciplinary action

    • Confidential and requires no documentation


    Referral option formal referral

    Referral Option: Formal Referral

    • Also known as a Mandatory Referral or a Supervisor Referral

    • The manager or a member of HR meets with the employee regarding a serious workplace problem

    • The employee is instructed to utilize Optima EAP

    • Formal Referral Paperwork is completed by the manager and reviewed with the employee, then faxed to Optima EAP

    • Optima EAP counselor will contact the referring manager - only information shared is the employee’s attendance and compliance with the program


    Optima eap1

    Optima EAP




    User Name: COVA Connect


    Today s agenda

    Brings together information and services that members need to take good care of themselves and their families.


    Today s agenda


    Today s agenda

    Getting Started


    Today s agenda

    Getting Started: Personal Health Profile (PHP)Available to registered users of only

    • Members complete online to identify their current health status.

    • Learn about areas for improvement.

    • Get personalized, easy-to-understand health information.

    • Receive immediate reporting upon completion of the questions.

    • Available July 1 to members.


    Online personal health profile

    Select Member Registration as a new member by creating your user name and password


    Select Personal Health Profile as indicated on the right

    Online Personal Health Profile


    Personal health report

    Personal Health Report


    Today s agenda

    Staying Healthy


    Staying healthy

    Staying Healthy

    Good health improvement information provided via the computer, phone, or mail.

    • Mammography

    • Cervical Cancer

    • Birthday Card – all members 3 years old & over

    • Immunization reminders

      Physician Notification

    • Physicians receive monthly lists of patients who were reminded of preventive health services.


    Healthyroads com

    Healthyroads offers Internet tools for members to increase their success in the program.

    Healthyroads Internet tools provide access to the following types of services:

    • Facility locator to find a participating fitness club

    • Health and fitness trackers

    • Overview of the Healthyroads programs

    • Exercise planner

    • Nutrition planner

    • Online health coaching classes

    • Wellness library

    • Online store


    Staying healthy award winning health improvement programs for use at your convenience

    Staying HealthyAward-winning health improvement programs for use at your convenience.

    • Healthy Heart

      Improve Your Heart Health

    • Get Off Your Butt: Stay Smokeless for Life

      Stop using tobacco to benefit your health

    • Eating for Life

      Develop healthy eating and exercise habits

    • Yoga

      Stretching and strengthening exercises

    • WalkAbout with Healthy Edge

      Walk your way to better health


    Today s agenda

    Improving Health


    Improving health

    Improving Health

    • CCS manages and administers every component.

    • Member-focused delivery of services.

    • Focused on employer group types:

      • Health & Prevention

      • Pharmacy Care Services

      • Medical Care Services

      • Behavioral Health Services

      • Disease Management

      • Quality Improvement

    Clinical Care Services (CCS) provides help when you need care. Includes a Life Coach team with clinical, behavioral and benefit specialists dedicated to answer member’s questions and provide support.


    Today s agenda

    Clinical Advocacy Program

    Advantages & Highlights

    • Clinical support and education

    • Coordination of medical treatment

    • Care managed along entire spectrum of services

    • Maximizes health benefits, ensures clinical resources are timely and cost-effective

    • Performance is measured and reported

    • Behavioral and medical health management and motivation

    • Coordinated personal care and coaching


    Accessing clinical advocacy program

    Accessing Clinical Advocacy Program

    • Contact Member Services to be directed to a case manager.

    • Identification of members through numerous clinical criteria who could benefit from such services, in which Optima will complete outreach to members.

    • Member’s physician may call Optima to refer a member to receive these services.

      Member confidentiality is always protected.


    Initial transition of care

    Initial Transition of Care

    • Medical

      • Seamless transition of services and authorizations from Anthem

    • Behavioral

      • Seamless transition of services and authorizations from Value Options

    • Pharmacy

      • Members will continue to receive their current medications, even if those medications require Prior Authorization through Optima.


    Today s agenda

    Managing Meds


    Tiers and copays

    Tiers and Copays

    *Mail order rates reflect up to a 90-day supply


    Lower tier drugs

    Lower Tier Drugs

    Some drugs will be on a lower tier with Optima,

    so members will have a lower copay.


    • Antibiotics and antivirals

      • Avelox, Valtrex, Zyvox, HIV medications

    • Drugs for heart and blood conditions

      • Coreg, Lovenox

    • Osteoporosis agent

      • Evista

    • Drugs for mental health disorders

      • Abilify, Geodon, Zyprexa


    Higher tier drugs

    Higher Tier Drugs

    Some drugs will be on a higher tier with Optima,

    so members will have a higher copay.


    • Cholesterol drugs

      • Lipitor, Vytorin

    • Diabetes drugs

      • Levemir, Novolin, Byetta, Symlin

    • Stomach and acid reflux drug

      • Nexium

    • Headache drugs

      • Frova, Maxalt, Zomig


    Frequently asked pharmacy questions

    Frequently Asked Pharmacy Questions


    How can you find out what tier your medication is on?

    How can you find out what lower tier alternatives are available?

    Can I view my prescription profile online?


    Go to


    Today s agenda

    Choose COVA Connect

    Enter drug name

    Click Search

    Today s agenda

    Click on drug

    See Tier

    See requirements


    Today s agenda

    See alternatives and tiers


    Today s agenda


    Today s agenda


    Mail order and specialty

    Mail Order and Specialty

    • Member’s mail order and specialty drug prescriptions will be transferred from Medco to Caremark.

    • The following prescriptions will not be transferred:

      (Member will need to mail in a new prescription)

      • Controlled substances

      • Compounds

      • Expired prescriptions

      • Prescriptions with no refills remaining


    Accessing services

    Accessing Services


    Our commitment to you

    Our Commitment to You…

    Today s agenda

    “The Next Generation of Health Care Services”


    Optima health

    Optima Health

    Better Health

    Easy to Use

    A Great Value



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