FOURTH QUARTER 2016

A health plan that works for you.

PPO

Member Update

2016 Physicians Health Plan Board of Directors

» Diana Rodriguez Algra

» Brittany Bogan

» James Butler, III

» April Clobes

» Timothy Hodge, D.O.

» Thomas Hofman, Ph.D.*

» David Kaufman, D.O.

» Shalimar Maynard *

» Deborah Muchmore

» Merritta Proctor

» Dennis Reese

» Paula Reiche

» Dennis Swan

» James Tischler *

* Denotes Enrollee Director

To contact the Board of Directors:

Call 517.364.8509

Correspondence can be directed to:

PHP Administration PO BOX 30377 Lansing, MI 48909-7877

In this IssueBenefit Spotlight: CVS transition announcement ...................................................................5

Utilization Management decisions ........................ 6

How to submit a claim for covered health services ...................................................................7

How your health benefits program works ..........7

Prior authorization requirements ........................... 8

Open Enrollment for individuals ............................. 9

Pinnacle Award ................................................................. 9

PHP Telehealth benefits ............................................10

Important tax information ........................................ 11

New technology .............................................................. 11

Network Provider Compensation Arrangements .................................................................. 11

Taking care of your health ........................................ 12

AsthmaWatch .........................................................13

Snort. Sniffle. Sneeze ........................................14

PHP is here to help!

Who can I contact with questions about benefit decisions?If you have questions or concerns about benefit decisions, or if you do not understand why a health service was denied or the benefit reduced, our Customer Service Department is here to help you find the answer.

During normal business hours:

Call: 517.364.8456 or 800.203.9519

Visit: 1400 E. Michigan Avenue, Lansing, Michigan 48912

Hours: General Office Hours: Monday-Friday, 8 a.m. to 5 p.m. Customer Service Call Center Hours: Monday-Friday, 8:30 a.m. to 5:30 p.m.

TTY/TDD ServiceYou can use the TTY/TDD service if you are deaf, hard of hearing, or have trouble speaking. Simply call 711 to reach the Relay Center, which will help you connect with our Customer Service Department.

Translation to EnglishPHP Insurance Company (PHP), as a subsidiary of Sparrow, complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

ATTENTION: If you speak a language other than English, language assistance services are free of charge and available to you. Call 1.517.360.1544. ATENCIÓN: Si habla un idioma distinto del inglés, hay servicios gratuitos de asistencia con el idioma, disponibles para usted. Llame al 1.517.360.1544.

نإف ،ةيزيلجنالا فالخب ةغل ثدحتت تنك نإ :هبتنا مقرب لصتا .كل ةحاتمو ةيناجم ةيوغللا ةدعاسملا تامدخ

1544.360.517.1.

PPO Member Update 5

What's changing:

With PHP's transition of pharmacy benefit services to CVS Caremark on Jan. 1:

» You will receive a new 2017 ID card with CVS Caremark information.

» The mail service pharmacy will be CVS Caremark and the CVS Caremark call center will support mail service pharmacy inquiries.

» A new online member portal – Caremark.com – will be available starting Jan. 1, 2017.

Frequently asked questions regarding the transition to CVS Caremark

» If I have a new or refill retail prescription on Jan. 1 – can I get it filled?

» Yes, there are over 60,000 pharmacies nationwide that can service your claim.

» Will I still have access to my mail order prescriptions?

» If you use mail order, your mail order refill prescriptions will transfer to CVS Caremark unless they are a compound, controlled substance, or the refill has expired.

» Are auto refill alerts available?

» You can sign-up for auto refill alerts on or after Jan. 1, 2017, at Caremark.com. If you have an auto refill service activated with Express-Scripts you will need to re-activate your service with CVS Caremark.

» I have a prior authorization. Will that change?

» All active prior authorizations through Express-Scripts will transfer to CVS Caremark on Jan. 1, 2017.

» Is there a different phone number for CVS Caremark Customer Service?

» Yes, to reach Customer Service for CVS Caremark – call 1.800.378.0973. However, for urgent issues, there is a Nurse on call at PHP available 24/7. Call the number on the back of your ID card.

» Will the Prescription Drug List (PDL) change?

» No. The prescription drug list will not change as a result of the transition to CVS Caremark.

» Will copays or benefits change?

» No. Copays and benefits will not change as a direct result of the transition to CVS Caremark. However, benefits may change as a result of your open enrollment choice.

» Will PHP still review requests for authorization?

» Yes. PHP will review requests for quantity limit overrides, non-covered drugs, and dosage exceptions.

» Are online services or a mobile app available through CVS Caremark?

» Yes. You will receive information in the near future regarding CVS Caremark special features available to PHP members, including a mobile app and online tools at Caremark.com. Starting Jan. 1, 2017 you have 24/7 access to:

» Order and manage prescriptions

» Check prescription drug coverage

» Manage costs and save money

» Where can I get answers to my questions?

» If you have any questions about your prescription plan or costs, call PHP at 1.800.203.9519. For TDD assistance, please call 7.1.1 relay service.

» If you need any information about your pharmacy network or mail order service, call CVS Caremark Customer Service at 1.800.378.0973. For CVS Caremark TDD assistance, please call 1.800.863.5488.

On Jan. 1, 2017, PHP transitioned its pharmacy benefit services to CVS Caremark. You can expect smooth and consistent service during this transition, as well as access to a full range of pharmacy benefits and support.

Benefit Spotlight: CVS transition announcement

PPO Member Update6

We want you to know...

Utilization Management (UM) is the evaluation of the medical necessity and appropriate healthcare services, procedures, and facilities under the provisions of your benefits plan. PHP follows a process that is clinically sound and respects Patients’ and providers’ rights while following approved guidelines and criterion.

It’s important for you to know that...

» Our Utilization Management decision-making is based only on appropriateness of care and service and existence of coverage.

» We do not specifically reward practitioners or other individuals for issuing denials of coverage or care.

» We do not offer financial incentives that encourage decisions by practitioners that result in under-utilization.

» We may offer appropriate incentives for fostering efficient, appropriate care.

We recognize there are problems associated with under-utilization. If necessary healthcare services are not delivered a member could be faced with serious medical problems. Failing to deliver needed services may cause an increased need for more serious or expensive health services in the future. As always, please remember PHP cannot and does not make decisions about the services you receive, only whether those services are covered under your benefit plan.

Utilization Management decisions

PPO Member Update 7

In most cases, the Physician who treated you will submit a claim on your behalf. Be sure to provide them with your current PHP ID card as it contains the claim submission address and other important information. They will make a copy of both sides of your card.

If the Physician will not submit a claim on your behalf, please send an itemized receipt and claim to:

CUSTOMER SERVICE PHYSICIANS HEALTH PLAN PO BOX 30377 LANSING, MI 48909-7877

Make sure your receipt includes the following:

» Your name, address, and phone number

» Your PHP ID number

» The date you received care

» The name, address, phone number, and identification number of the Physician who treated you

» The procedure and diagnosis codes

» The cost associated with each procedure performed

» Proof that you paid for the services

Most Physicians will provide you with a form at the end of your visit containing the above information. In general, reimbursement for covered health services will be processed in 4-6 weeks. We will contact you if additional information is needed.

How do I submit a claim for covered health services?

PHP Certificate of Coverage Your PHP Certificate of Coverage provides detailed information regarding your covered benefits, what is excluded from coverage, and which services require a prior authorization for coverage. You may obtain benefit information by contacting Customer Service at 517.364.8456 or 800.203.9519. You may also obtain information regarding your benefits through the PHP website, where you can view or print important member material, including your Certificate of Coverage, pharmacy information, Member Handbook, and Provider Directory. You can also request paper copies of your member materials to be mailed. Simply click on the Member Reference Desk link and enter your PHP identification number from the front of your PHP ID card.

Primary Care PhysicianWhen you join PHP, you should select a Primary Care Physician (PCP) from PHP’s list of Network PCPs. Each family member can select a different PCP. It is important for you to have a good relationship with a Physician or other practitioner. If you change PCPs, please contact Customer Service by phone or email or you can visit HealthWeb, our online member portal, to update your information.

PHP Network SpecialistsPHP does not require a referral or authorization to see a PHP Network specialist. You may “self-refer” to any Network specialist by simply scheduling an appointment. While PHP doesn’t require a referral, you may find

that some specialists require information from your PCP before scheduling an appointment. Also, some procedures or treatments performed by either the PCP or specialist may require prior authorization from PHP.

Hospital, Emergency, and Urgent Care Services Except in emergency situations, your PCP or Network specialist will arrange your hospital care with us. To ensure your hospital services are covered at the highest benefit level, make sure you receive hospital services from a facility in the PHP Network.

If you have severe symptoms that may seriously jeopardize your health, either at home or away, call your PCP and follow the instructions you are given. If you are unable to contact your PCP, go directly to the nearest emergency room if you have someone who can transport you safely. If you don’t have enough time to call your PCP and you need immediate assistance, call 911 and stay on the line until instructed to hang up. When minutes are at stake, emergency staff can help you get to the hospital safely. After your treatment, contact your PCP as soon as possible so needed follow-up services can be provided.

Urgent care is for non-life-threatening situations when you need care sooner than you can typically schedule an office visit. If you are in need of urgent care during normal office hours, after doctor’s office hours, or on the weekend, call your PCP first. Your PCP may direct you to obtain urgent care services at a Network urgent care facility or may arrange to see you personally on an urgent basis.

How your health benefits program works

PPO Member Update8

A prior authorization helps us to ensure that a service is a covered benefit under your plan for your specific condition. By requiring prior authorization for certain services, we prevent you from getting a surprise bill, and it allows us to determine if you need additional help from one of our Nurses to coordinate your care.

Your PHP Certificate of Coverage lists services that require a prior authorization. If prior authorization is required, it must be done before receiving the service unless it is an urgent or emergent situation. In these cases, you or the hospital must notify us of your admission the same day of admission, the next business day, or as soon as reasonably possible. PHP does not require referrals to see in-network specialists but some services they offer may require our authorization and review.

If you see a non-network provider, it is your responsibility, not that of the provider, to notify us before you receive certain non-network services.

Once a request for an authorization is received, PHP will review the request using medical criteria and determine if the service is a covered benefit under your plan. A determination is then sent to you and/or your Physician.

Why are there prior authorization requirements?

PPO Member Update 9

Have a friend or family member that needs health insurance coverage? PHP is the answer! PHP offers individual plans on the Marketplace (aka the Healthcare Exchange) and off the Marketplace (directly through PHP). What’s the difference in how or where you enroll? Let’s break it down.

The Affordable Care Act provides financial help for health insurance coverage based on income and family size. You cannot have insurance through your job, through Medicare or be eligible for Medicaid. Enrolling through the Marketplace (or through PHP’s portal to the Marketplace on our website) allows you to take advantage of financial help that may lower monthly premiums and/or cost shares (copays) when health services are received. You can enroll in a Marketplace PHP plan by visiting Marketplace.gov or by visiting the PHP website, PHPMichigan.com, and selecting Individual Plans.

Individuals may also enroll directly through PHP (off of the Marketplace) but it will not allow you to take advantage of financial help and you cannot enroll electronically at this time. Information about the benefit plans and how to enroll directly through PHP is on our website or you can call PHP Customer Service at 517.364.8456 or 800.203.9519.

Open enrollment runs now through Jan. 31, 2017, so spread the word! Whichever enrollment method is chosen, you’ll still get a great benefit plan, with award-winning customer service, at an affordable price. Tell your friends and family members to sign up for PHP today!

Individual Open Enrollment Dates 11/01/16-01/31/17

Application received by 12/15/16, coverage start date 01/01/17*

Application received by 01/15/17, coverage start date 02/01/17*

Application received by 01/31/17, coverage start date 03/01/17*

*Note: PHP must receive the first month’s premium payment before the coverage start date.

Open Enrollment for individuals

Eleven Michigan health plans from across the state submitted 31 ground-breaking programs to the Michigan Association of Health Plans (MAHP) Annual Pinnacle Awards on Tuesday, Sept. 13, showing entrepreneurial spirit as they increased efficiency and improved Patient healthcare to lower costs and increase services to Michigan citizens.

This year, the Commercial Clinical Service Improvement Award was given to PHP for “Closing Gaps in Care and Promoting Member Safety.” To combat adverse drug interactions, PHP contracted with Express Scripts for an evidence-based safety program that uses medical, pharmacy, and lab test data to prevent adverse drug events and find gaps in care. The extensive algorithm detects potential safety and health risks, and generates alerts for Pharmacists and Physicians. In two years, the program has generated more than 10,000 alerts.

MAHP is an industry voice for 14 healthcare plans, covering over 2.5 million Michigan residents, and 50 businesses

affiliated with the healthcare industry. MAHP facilitates communication among members, government, and the industry regarding healthcare issues of common concern. The mission of the MAHP is to provide leadership for the promotion and advocacy of high quality, affordable, accessible healthcare for the citizens of Michigan.

PHP awarded a 2016 Pinnacle Award

PPO Member Update10

The doctor will see you now.

PHP Members - On Jan. 1, 2017, new telehealth benefits mean access to a doctor online 24/7/365.

» No appointment necessary» Prescriptions when appropriate» Private and secure» Pay just your office visit copay» Free to sign-up and no monthly fees

For more information on how to sign up and receive PHP member pricing, log in to the Member Reference Desk at PHPMichigan.com or call PHP Customer Service at 517.364.8456.

You must have a credit card to use this service.

PPO Member Update 11

Important tax information coming soon!The Affordable Care Act requires PHP to provide information about your health insurance coverage to the Internal Revenue Service (IRS) using your social security number (SSN) or in some cases, an Individual Taxpayer Identification Number (ITIN). We are required to send you a 1095 tax form. The 1095 will contain information about your health insurance coverage with PHP during 2016. We will begin mailing 1095 forms at the end of January 2017.

The 1095 form contains important information you will

need to file your taxes for 2016. Make sure to keep it in a safe place. If you have questions about the coverage span noted on the 1095 and your health coverage is through your employer, contact your employer. If you have an individual policy through PHP, contact PHP’s Customer Service Department. (Note: PHP will not report coverage if an individual is enrolled through the Health Insurance Marketplace. The Marketplaces are responsible for completing the applicable 1095 form. If you have questions about your form, please contact the Marketplace.)

New technologyPHP continually reviews new and emerging medical technology for inclusion in our benefit plan coverage. Through our relationships with national companies and collaboration with local professionals, we review new services, procedures and pharmacological treatments. PHP committees composed of local Physicians, hospitals, and quality improvement administrators review recommendations for local implementation. When considering new technologies, PHP’s Medical Directors and clinical committees evaluate information from outside sources, including but not limited to regulatory approvals, empirical evidence of improved outcomes, and efficacy of the technology compared to established alternatives.

Network Provider compensation arrangementsYou are entitled to summary information concerning the financial relationship between PHP and any Network Physician or other provider, including:

» Whether a fee-for-service arrangement exists - under a fee-for-service arrangement, Physicians and other providers receive a payment that does not exceed their billed charge, or;

» Whether a capitation arrangement exists - capitation is a stipulated dollar amount established to cover the cost of healthcare for a person, and;

» Whether PHP payments to Physicians are based on quality, cost, utilization or Patient satisfaction.

You may contact our Customer Service Department for further information about PHP’s financial arrangements with Physicians and other providers.

PPO Member Update12

Taking care of your health

PPO Member Update 13

AsthmaWatchAsthma, a chronic lung disease that inflames and narrows the airways or tubes that carry air into and out of the lungs, affects more than 22 million people in the United States, 6 million of them children.

Asthma symptoms include periods of coughing, wheezing, chest tightness and shortness of breath. It can affect people of all ages, but most often starts during childhood and has no cure.

For people with asthma, the goal is to control the disease because a flare up can happen at any time. By working with a Physician to create a personal action plan and maintaining proper treatment, most can expect to have few, if any, symptoms.

In order to help you better manage your asthma symptoms, PHP's AsthmaWatch program helps members achieve and maintain control through preventative treatment and educational assistance. Visit PHPMichigan.com to learn more.

Long-term control medicines

Ashma action plan

Spacer

Peak flow meter

Rescue medicine

A holding chamber that increases the amount of medicine that reaches the lungs

A medicine used to prevent asthma symptoms

A medicine that acts quickly to relax tightened muscles around your airways

A plan for managing medications, and recognizing worsening asthma symptoms and triggers

Hand-held device that shows how well air moves out of your lungs

Connect the words with their definitions

Answers on page 15

Taking care of your healthI G L P Y T Z I K T K O G V G J Y L E AA W U R R E T E M O R I P S V W G N D ZI H P H P W O R K S H A R D F O R Y O UC R O O G M F F V P Z G D F C K E P N PP N L J E H G R K F A R H R G V L X T BD P Q D N A L P N O I T C A V U L J X FZ L U O Y G Y D N E V X K V P R A N W NL P O O F F S A A B Y F A J S A P I G OL U S G S T N A T I R R I S P D B I V PE I A U X P Z D H A D I Y J A J I J Z QQ N W H E E Z I N G B K G I C D J K L EZ P N Z J K O J E N I C I D E M N W J RF I A O Q K N G A B I L H Q R O O B Z UA P H A Z S O I G K R X Q A S Y E Q I S

Word List » Irritants

» Wheezing

» Allergy

» Spacers

» Action plan

» Medicine

» Spirometer

PPO Member Update14

What is the best treatment for my illness?

Antibiotics are not needed for common illnesses like colds, most sore throats, the flu, and even some ear infections. These illnesses are often caused by viruses, which do not respond to antibiotics. Sometimes the best treatment is symptom relief.

Pain relievers, fever reducers, saline nasal spray or drops, warm compresses, liquids and rest may be the best things to help you feel better. Ask your doctor or pharmacist what symptom relief is best for you.

IllnessUsual Care Antibiotic

NeededVirus Bacteria

Cold/Runny Nose Yes No No

Bronchitis/Chest Cold (in otherwise healthy children and adults)

Yes No No

Chest Cold (in otherwise healthy children and adults)

Yes No No

Whooping Cough No Yes Yes

Flu Yes No No

Strep Throat No Yes Yes

Sore Throat (except strep) Yes No No

Fluid in the Middle Ear (otitis media with effusion)

Yes No No

Urinary Tract Infection No Yes Yes

IMPORTANT INFORMATION WHEN TAKING AN ANTIBIOTIC

» Take it exactly as your provider tells you

» Do not skip doses

» Finish the prescription even if you feel better

» Do not save it for later

» Do not share it with others

Why is this important?Using an antibiotic the wrong way allows bacteria to multiply and cause unwanted or severe side effects. You can prevent this problem by getting smart about antibiotics. For more information call 1-800-CDC-INFO or visit cdc.gov/getsmart/community

Physicians Health Plan supports the Center for Disease Control (CDC) Get Smart program to reduce the use of antibiotics for treatment of viral diseases

The CDC estimates that each year two million Americans get an infection with an antibiotic-resistant germ and each year 23,000 of those Patients die. Antibiotic resistance is bacteria’s ability to resist the effects of an antibiotic, which then develop into dangerous life-threatening conditions. It is a growing problem across the world. It is time for everyone—state health departments, hospitals, healthcare workers, and parents—to preserve the power of antibiotics by understanding when they work and when they do not.

Treat colds and flu with care. Talk to your healthcare provider.As a parent, you want to help your child feel better. But antibiotics

aren’t always the answer. They don’t fight the viruses that cause

colds and flu. What will? Fluids and plenty of rest are best. Talk to

your healthcare provider. Find out when antibiotics work—and

when they don’t. The best care is the right care.

For more information, please call 1-800-CDC-INFO

or visit www.cdc.gov/getsmart.CS121386

Treat colds and flu with care. Talk to your healthcare provider.As a parent, you want to help your child feel better. But antibiotics

aren’t always the answer. They don’t fight the viruses that cause

colds and flu. What will? Fluids and plenty of rest are best. Talk to

your healthcare provider. Find out when antibiotics work—and

when they don’t. The best care is the right care.

For more information, please call 1-800-CDC-INFO

or visit www.cdc.gov/getsmart.CS121386

Snort. Sniffle. Sneeze.

PPO Member Update 15

Matching Answers

Long-term control medicine used to prevent asthma symptoms. The medicine works slower than a quick-relief medicine. You may need to take it for several weeks before you feel the effects.

Asthma action plan – detailed directions on: What medicines to take, how much to take, and when you should take each one How to recognize when your asthma is getting worse How and when to use a peak flow meter to monitor your asthma if your doctor prescribed one

Spacer – A holding chamber that makes using a metered dose inhaler (MDI) easier. Use a spacer with corticosteroid MDIs to decrease the amount of medicine that lands on your tongue or in the back of your mouth. This reduces irritation to your throat and increases the amount of medicine that gets into your lungs where it works best.

Peak flow meter – A hand-held device that shows how well air moves out of your lungs. Measuring your peak flow can help you tell how well your asthma is controlled. It can also alert you to an oncoming attack hours or even days before you feel symptoms. In addition, during an attack, it can help tell you how bad the attack is and if your medicine is working.

Rescue medicine – Everyone with asthma needs a quick-relief or rescue medicine to stop asthma symptoms before they get worse. An inhaled short-acting beta2-agonist is the preferred quick-relief medicine. It acts quickly to relax tightened muscles around your airways, to allow more air to flow.

Check out PHP online! PHPMichigan.com and Facebook!Visit the PHP website for links to HealthWeb and the Member Reference Desk.

Through our online portals you can:

» Find a doctor no matter where you are

» Change your address or your Primary Care Provider

» View your benefits, the status of a claim, Member Guide and other important information

» Order a new ID card and print a temporary card

» Request an Explanation of Benefits (EOB)

» Find a Pharmacy

» See a list of FAQ’s

» Manage your health through our interactive Health & Wellness resources

1400 E. Michigan Avenue P.O. Box 30377Lansing, MI 48909-7877

A health plan that works for you.

517.364.8456 PHPMichigan.com