CalCPA ProtectPlus

Prescription Drug Covered Expense is the expense you incur for a covered prescription drug, but not more than the maximum amounts described in items i. and ii. below. Expense is incurred on the date you receive the service or supply.

Prescription drug covered expense does not include any expense in excess of: (i) the drug limited fee schedule for drugs dispensed by non-participating pharmacies; or (ii) the prescription drug negotiated rate for drugs dispensed by participating pharmacies or by the mail service program.

Participating Hospital is a hospital which has a claims administrator’s Participating Agreement in effect with the claims administrator, as appropriate, at the time services are rendered. Participating hospitals agree to accept the negotiated rate as payment in full for covered services. Participating hospitals agree to participate in procedures established to review the utilization of hospital services. Hospital services determined to be unnecessary, according to these utilization review procedures, are not covered by the plan. A list of participating hospitals is available upon request from the plan administrator, as appropriate.

February 1, 2013 marks the 10^th anniversary of National Wear Red Day®, which was created by the American Heart Association, along with the National Heart, Lung and Blood Institute. The day draws attention to the number one killer of women: heart disease. According to the American Heart Association’s campaign, Go Red for Women, heart disease is the cause of 1 in 3 deaths in women each year, which is approximately one woman every minute. The American Heart Association’s Go Red for Women movement helps spread awareness about heart disease in women and educates people about the disease so that the facts are learned. Knowing the truth about the disease will help prevent the disease and save lives.

Over the next few weeks we will feature articles from the American Heart Association that will inform our readers what causes heart disease, whether women of all ethnicities have the same risk level, survival rates, statistics, warning signs and prevention of the disease. It is important to arm ourselves with the facts so that we can help ourselves and those around us to live heart healthy lives.

The following information is from the American Heart Association.

It’s true: Heart disease is the No. 1 killer in women. Yet, only 1 in 5 American women believe that heart disease is her greatest health threat.

Here are some more unsettling facts:

• Heart disease causes 1 in 3 women’s deaths each year, killing approximately one woman every minute.
• 90 percent of women have one or more risk factors for developing heart disease.
• Since 1984, more women than men have died each year from heart disease and the gap between men and women’s survival continues to widen.
• The symptoms of heart disease can be different in women vs. men, and are often misunderstood.
• While 1 in 31 American women dies from breast cancer each year, 1 in 3 dies of heart disease.

It’s time to focus on finding, and becoming the solution. Here’s what you need to know about the causes of heart disease and ways you can prevent it.

What causes heart disease?

Heart disease affects the blood vessels and cardiovascular system. Numerous problems can result from this, many of which are related to a process called atherosclerosis, a condition that develops when plaque builds up in the walls of the arteries. This buildup narrows the arteries, making it harder for blood to flow through. If a blood clot forms, it can stop the blood flow. This can cause a heart attack or stroke. (continue reading…)

Many people are familiar with chickenpox and may have had it as a young child. But are you aware the virus that causes chickenpox remains in your body in an inactive state for years and can reactive and cause a condition called shingles? It is called the varicella zoster virus. To give you an idea of how common shingles is, according to the Centers for Disease Control, almost 1 out of every 3 people in the United States will develop shingles and there are an estimated 1 million cases each year in the United States (CDC.gov).

People that are at risk of developing shingles are:

• Anyone at any age who has recovered from chickenpox
• People over 60 years of age have a higher risk (about half of all cases are among people over 60 years old)
• People with weakened immune systems – such as certain cancer and human immunodeficiency virus (HIV)
• People who receive immunosuppressive drugs (i.e. steroids)

Symptoms

WebMD lists the following three stages of shingles:

Prodromal stage (before the rash appears)

• Pain, burning, tickling, tingling, and/or numbness occur in the area around the affected nerves several days or weeks before a rash appears. The discomfort usually occurs on the chest or back, but it may occur on the belly, head, face, neck, or one arm or leg.

• Flu-like symptoms (usually without a fever), such as chills, stomachache, or diarrhea, may develop just before or along with the start of the rash.

• Swelling and tenderness of the lymph nodes may occur. (continue reading…)

September is Atrial Fibrillation (AFib or AF) awareness month. According to the American Heart Association, an estimated 2.7 million Americans have AF. With so many people being affected by AF,  it is important that we learn about it and understand the warning signs. During the month of September we will share information from the American Heart Association that will define what AF is, what the symptoms are, getting the right treatment and how to reduce the risks for stroke and heart failure. To read about what AF is, click here.

The following information is from the American Heart Association and defines the symptoms and different types of AF as well as heart attack and stroke symptoms:

The most common symptom: a quivering or fluttering heartbeat
Atrial fibrillation (AF) is the most common type of irregular heartbeat. The abnormal firing of electrical impulses causes the atria (the top chambers in the heart) to quiver (or fibrillate). View an animation of atrial fibrillation.

Additional common symptoms of atrial fibrillation
Sometimes people with AF have no symptoms and their condition is only detectable upon physical examination. Still, others may experience one or more of the following symptoms:

• Rapid and irregular heartbeat
• Fluttering or “thumping” in the chest
• Dizziness
• Shortness of breath and anxiety
• Weakness
• Faintness or confusion
• Fatigue when exercising
• Sweating
• *Chest pain or pressure
  *Chest pain or pressure is a medical emergency. You may be having a heart attack. Call 9-1-1 immediately.

Are there different types of AF? Do they have different symptoms?
The symptoms are generally the same; however the duration of the AF and underlying reasons for the condition help medical practitioners classify the type of AF problems.

• Paroxysmal fibrillation is when the heart returns to a normal rhythm on its own.  People who have this type of AF may have episodes only a few times a year or their symptoms may occur every day. These symptoms are very unpredictable and often can turn into a permanent form of atrial fibrillation.
• Persistent AF is defined as an irregular rhythm that lasts for longer than 48 hours. This type of AF will not return to normal sinus rhythm on its own and will require some form of treatment.
• Permanent AF occurs when the condition lasts indefinitely and can no longer be controlled with medication. (continue reading…)

September is Atrial Fibrillation (AFib or AF) awareness month. According to the American Heart Association, an estimated 2.7 million Americans have AF. With so many people being affected by AF,  it is important that we learn about it and understand the warning signs. Over the next couple of weeks we will share information from the American Heart Association that will define what AF is, what the symptoms are, getting the right treatment and how to reduce the risks for stroke and heart failure.

The following information is from the American Heart Association and defines what AF is and what occurs during AF:

Atrial fibrillation (also called AFib or AF) is a quivering or irregular heartbeat (arrhythmia) that can lead to stroke and other heart-related complications. Some people refer to AF as a quivering heart. An estimated 2.7 million Americans are living with AF.

What happens during AF?
Normally, your heart contracts and relaxes to a regular beat. In atrial fibrillation, the upper chambers of the heart (the atria) beat irregularly (quiver) instead of beating effectively to move blood into the ventricles. About 15–20 percent of people who have strokes have this heart arrhythmia.

“Anything that allows blood to slow down or pool increases the risk of clotting, and so increases the risk of stroke,” says Dr. Steve Roach, Professor of Neurology and Director of the Comprehensive Epilepsy Program at Wake Forest University Medical School. If a clot breaks off, enters the bloodstream and lodges in an artery leading to the brain, a stroke results.“ This clot risk is why patients with this condition are put on blood thinners. People with atrial fibrillation have an increased stroke risk of about five percent per year.”

It’s the most common “serious” heart rhythm abnormality in people over the age of 65 years. Even though untreated atrial fibrillation doubles the risk of heart-related deaths and causes a 4–5-fold increased risk for stroke, many patients are unaware that AF is a serious condition. Watch an animation of atrial fibrillation.

According to the 2009 “Out of Sync” survey:

•  Only 33% of AF patients think atrial fibrillation is a serious condition
•  Less than half of AF patients believe they have an increased risk for stroke or heart-related hospitalizations or death

Not only does AF increase your risk of stroke, another sobering AF statistic is that 50% of those AF patients who do experience a stroke, die within one year.

[Information Source]

Qualified Beneficiary, for the purposes of COBRA, is any of the following who is not entitled to Medicare on the day before the qualifying event and who on the date of the qualifying event is covered under the plan pursuant to the Subscription Agreement of a COBRA participating employer:

1. The plan participant;
2. A plan participant’s spouse;
3. A plan participant’s former spouse (or legally separated spouse); or
4. A child, including a child born to or placed for adoption with the plan participant during the COBRA continuation period.

Qualified Beneficiary, for the purposes of CalCOBRA, is any individual who on the date of the qualifying event is covered under the plan pursuant to the Subscription Agreement of a CalCOBRA participating employer and is not a CalCOBRA excluded member. Qualified beneficiary also includes any child who is born to a former plan participant of a CalCOBRA participating employer, which plan participant is a qualified beneficiary who has elected CalCOBRA coverage, or a child who is placed for adoption with such a former plan participant so electing, if the child is enrolled in the plan within 30 days after the child’s birth or placement for adoption. Such entitlement to benefits, subject to applicable terms and conditions, shall continue for the remainder of the period during which the plan participant is covered under CalCOBRA.

Psychiatric Health Facility is an acute 24-hour facility as defined in California Health and Safety Code 1250.2. It must be:

1. Licensed by the California Department of Health Services;
2. Qualified to provide short-term inpatient treatment according to state law;
3. Accredited by the Joint Commission on Accreditation of Health Care Organizations; and
4. Staffed by an organized medical or professional staff which includes a physician as medical director.

Protected Health Information means information about you and your medical case, the privacy of which is protected under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Prosthetic Devices are appliances which replace all or part of a function of a permanently inoperative, absent or malfunctioning body part. The term “prosthetic devices” includes orthotic devices, rigid or semi-supportive devices which restrict or eliminate motion of a weak or diseased part of the body.

Prior Plan is a plan sponsored by us which was replaced by this plan within 60 days. You are considered covered under the prior plan if you: (i) were covered under the prior plan on the date that plan terminated; (ii) properly enrolled for coverage within 31 days of this plan’s effective date; and (iii) had coverage terminate solely due to the prior plan‘s termination.

Prescription Drug Negotiated Rate is the rate that the claims administrator has negotiated with participating pharmacies under a Participating Pharmacy Agreement for prescription drug covered expense. Participating pharmacies have agreed to charge beneficiaries no more than the prescription drug negotiated rate. It is also the rate which Prescription Drug Program – Mail Service has agreed to accept as payment in full for mail service prescription drugs.

Pre-Existing Condition means an illness, injury or condition which existed during the six-month period immediately prior to either: (i) your effective date; or (ii) the first day of any waiting period, whichever is earlier. A condition is considered to have existed when you: (i) sought or received medical advice for that condition; (ii) received medical care or treatment for that condition; or (iii) received medical supplies, drugs or medicines for that condition.

To review more health care terms, click here to visit the ProtectPlus Medical Plan glossary.

The following information is from the American Heart Association and explains how to understand blood pressure readings which is very important if we are to monitor our health. It is especially important to understand these numbers if we suffer from high or low blood pressure as well as other health conditions.

Step 1:  About High Blood Pressure – Understanding Blood Pressure Readings

What do the blood pressure numbers mean?

Blood pressure is typically recorded as two numbers, written as a ratio like this: 117/76 mm Hg (read as “117 over 76 millimeters of mercury”.

Systolic

The top number, which is also the higher of the two numbers, measures the pressure in the arteries when the heart beats (when the heart muscle contracts).

Diastolic

The bottom number, which is also the lower of the two numbers, measures the pressure in the arteries between heartbeats (when the heart muscle is resting between beats and refilling with blood).

What is the AHA recommendation for healthy blood pressure?

This chart reflects blood pressure categories defined by the American Heart Association.

* Your doctor should evaluate unusually low blood pressure readings.

How is high blood pressure diagnosed?

Your healthcare providers will want to get an accurate picture of your blood pressure and chart what happens over time. Starting at age 20, the American Heart Association recommends a blood pressure screening at your regular healthcare visit or once every 2 years, if your blood pressure is less than 120/80 mm Hg.

Your blood pressure rises with each heartbeat and falls when your heart relaxes between beats. While BP can change from minute to minute with changes in posture, exercise, stress or sleep, it should normally be less than 120/80 mm Hg (less than 120 systolic AND less than 80 diastolic) for an adult age 20 or over. About one in three (33.5%) U.S. adults has high blood pressure.

If your blood pressure reading is higher than normal, your doctor may take several readings over time and/or have you monitor your blood pressure at home before diagnosing you with high blood pressure.

A single high reading does not necessarily mean that you have high blood pressure. However, if readings stay at 140/90 mm Hg or above (systolic 140 or above OR diastolic 90 or above) over time, your doctor will likely want you to begin a treatment program. Such a program almost always includes lifestyle changes and often prescription medication for those with readings of 140/90 or higher.

If, while monitoring your blood pressure, you get a systolic reading of 180 mm Hg or higher OR a diastolic reading of 110 mm HG or higher, wait a couple of minutes and take it again. If the reading is still at or above that level, you should seek immediate emergency medical treatment for a hypertensive crisis.

Even if your blood pressure is normal, you should consider making lifestyle modifications to prevent the development of HBP and improve your heart health.

Which number is more important, top (systolic) or bottom (diastolic)?

Typically more attention is given to the top number (the systolic blood pressure) as a major risk factor for cardiovascular disease for people over 50 years old. In most people, systolic blood pressure rises steadily with age due to increasing stiffness of large arteries, long-term build-up of plaque, and increased incidence of cardiac and vascular disease.

[Information Source, Image Source]

Aggregate out-of-pocket maximum is met when the total of the out-of-pocket payments made by all family members exceeds two times the individual out-of-pocket amount.

Rights of Survivorship may apply to eligible family members following the death of a plan participant. These are rights to continued coverage under the deceased participant’s plan after the legally required rights provided under COBRA or CalCOBRA have expired. Family members who are eligible, and the conditions for continuation coverage, are set forth under the plan document. Rights of Survivorship do not apply to Anthem Blue Cross HMO Participants.

Prescription Drug Deductible is the amount of charges you have to pay for any covered brand-name prescription drug, before any brand-name prescription drug benefits are available to you. The prescription drug deductible does not apply to generic drugs and is not integrated with the medical deductible. It does not count toward the out-of-pocket maximum.

High Deductible Health Plan (HDHP) is a health insurance plan with minimum annual deductibles of $1,200 for individuals or $2,400 for family coverage. The annual out-of-pocket expense maximums (including deductibles and copayments but not including premiums) cannot exceed $5,950 for individuals or $11,900 for families. These amounts (for 2011) are indexed annually for inflation.

Usual, Customary and Reasonable (UCR) is a charge which falls within the common range of fees billed by a majority of physicians, hospitals, and other providers for a procedure in a given geographic region, or which is justified based on the complexity, or the severity of treatment for a specific case.

Health Savings Account (HSA) – is a special tax-sheltered savings account that is similar to a traditional Individual Retirement Account (IRA), but designated for medical expenses. An HSA allows you to pay for current health expenses and save for future qualified medical and retiree health care expenses on a tax-free basis. Contributions, earnings, and distributions all are exempt from federal income and Social Security (FICA) taxes when used to pay for qualified medical expenses.