PacifiCare HMO/MCO 101 Presentation

1. PacifiCare HMO/MCO 101 Presentation 2007

2. The purpose of this PowerPoint presentation is to provide a general overview of what you might want to include in a presentation given to either a new group or renewing group during enrollment season. Please verify that the information in the slides you choose to use is applicable to your region. Because there are so many different plan offerings and nuances in each market some information may not be applicable for your region. Please feel free to add or delete slides and/or language as needed.

3. HMO / MCO plans • If cost of coverage is the concern, an HMO / MCO may be the right choice. Care is provided entirely within a single HMO / MCO network, and the out of pocket expenses are general small. • Members select a primary care physician from the health plan’s network of contracted providers to coordinate all of their care • They see a primary care physician for covered services as often as they need and obtain referrals for specialist services • They pay a co-payment for designated services • Little or no paperwork or claim forms are required • There are no pre-existing exclusions • Coverage includes preventive health care, most immunizations and physical examinations at regular intervals

4. Who are the Primary Care Physicians (PCP) • Family Practice • General Practice • Internal Medicine • Pediatrics

5. What benefits are included in the HMO/MCO plan? • PCP office visits: at a set copay per visit • Specialist visits: at a set copay per visit – sometimes twice the PCP copay • Hospitalization: usually paid at 100% or may include a copay • Emergency: at a set copay; (waived if admitted) • Urgent Care: at a set copay copay – usually the same as the PCP office visit

6. What benefits are included in the PacifiCare HMO plan cont...? • Ambulance: Paid at 100% or a copay may apply • Standard Lab & X-Ray : a set copay applies per visit – waived it provided as part of office visit • Specialized Scanning & Imaging: a set copay applies per procedure • Rehabilitative Therapy : a set copay per therapy treatment • Physical, Occupational, & Speech Therapy • Limited to a specific number of visits per year

7. Prescription Medication (If applicable) PacifiCare Formulary • Generic: a set copay (30 day supply) • Brand-Name Drugs: a set copay copay (30 day supply) • Non-Formulary Drugs: [Require Pre-authorization] • Mail-order prescription service available through Prescription Solutions just call 1-800-562-6223

8. Health Improvement Programs • Pregnancy to Preschool • Menopause: “Understanding your Options” • 24 Hour Information & Nurse Line • Taking Charge of Your Heart Health™ • Taking Charge of DiabetesSM • StopSmokingSM

9. PacifiCare PerksSM**PacifiCare Perks services and/or products are administered through PacifiCare Health Plan Administrators, a subsidiary of PacifiCare Health Systems. • Exclusive “Members-Only” discount program • Includes discounts through vendor arrangements • Family safety products, health clubs, alternative care, vitamins, vision care services, natural body care products and much more!

10. PacifiCare HealthCreditsSM • Value-added program designed to help lower health care costs and increase employee productivity • Available to all PacifiCare commercial medical members at no additional premium cost • Encourages and rewards employees who actively participate in: • PacifiCare’s VirtualHealthClubSM • Completing a Health Risk Assessment • Health and disease management programs

11. Honors & Recognition • A Fortune Global 500 Company -- PacifiCare ranked 496 in Fortune Magazine's annual listing of the 500 largest corporations in the world, July 26, 2004 • Innovators Award sponsored by Health Insurance Association of America • Health Financing Innovator Award from the Foundation for Accountability • American Business Awards: Stevie award Finalist, Women’s Health Solutions: Best New Product/Service • One of the Best Places to work for Latinos, Hispanic Magazine • 10 Best Companies for Asian Americans, Asian Enterprise Magazine • Black Chamber of Commerce 2004 Corporation of the Year • Selected by local providers for being the best performer among HMOs

12. PHS Quality Pedigree: Quality & Accountability • NCQA Accreditation • QUALITY INDEX® Profile hailed by purchasers, regulators, consumers, providers, CMS, NCQA, IOM, AHRQ • HEDIS® - Met or Exceeded Industry Average in 5 HEDIS Effectiveness of Care Measures compared to California Health Plan Competitors • Ranked #1 for Patient Satisfaction Among Network Model HMOs in California (Consumer Reports, October 2001) • AAHP’s 2001 National Exemplary Practice Award for Congestive Heart Failure Program (CHF) in Colorado

13. PacifiCare of Arizona - Quick Facts • NCQA Status = Excellent (Commercial) and Commendable (Medicare+Choice) • Rated among the top-five NCQA Accredited plans in Arizona • Highest rated health plan in Arizona as reported in NCQA’s Quality Compass. • AM Best Rating = B++ Very Good

14. PacifiCare of California – Quick Facts • NCQA Status = Excellent (Commercial HMO/POS) and Commendable (Medicare+Choice) • Highest rated health plan in California as reported in NCQA’s Quality Compass. • Highest average ratings in CAHPS, cardiovascular health, women’s health and rated second in category of young families. • AM Best Rating = A- Excellent

15. PacifiCare of Colorado - Quick Facts • NCQA Status = Excellent (both Commercial HMO/POS and Medicare+Choice plans) • HEDIS and CAHPS Scores • AM Best Rating = B++ Very Good

16. PacifiCare of Nevada - Quick Facts • NCQA Status = Commendable (both Commercial and Medicare+Choice plans) • Highest rated health plan in Nevada as reported in NCQA’s Quality Compass. • AM Best Rating = B+ Very Good

17. PacifiCare of Oklahoma – Quick Facts • NCQA Status = Excellent (both Commercial and Medicare+Choice plans) • Rated among the top-five NCQA Accredited plans in Oklahoma • AM Best Rating = B++ Very Good

18. PacifiCare of Oregon - Quick Facts • NCQA Status = Excellent (both Commercial and Medicare+Choice plans) • HEDIS and CAHPS Scores • AM Best Rating = B++ Very Good • AHIP’s National Exemplary Practice Award for the Taking Charge of Diabetes Program in Oregon & Washington

19. PacifiCare of Texas - Quick Facts • NCQA Status = Excellent (Commercial) and Commendable (Medicare+Choice) • Rated among the top-five NCQA Accredited plans in Texas • AM Best Rating = B+ Very Good

20. PacifiCare of Washington - Quick Facts • NCQA Status = Excellent (both Commercial and Medicare+Choice plans) • HEDIS and CAHPS Scores • AM Best Rating = B++ Very Good • AHIP’s National Exemplary Practice Award for the Taking Charge of Diabetes Program in Oregon & Washington

21. Customer Service • First Call Resolution • Expanded hours of operation • New Member Welcome Campaign • IVR/ASR/CTI • Member Satisfaction drivers

22. PacifiCare Customer Service [1-800-347-8600] Available [7 a.m. - 8 p.m.] Monday - Friday Spanish Speaking Associates Also Available

23. www.pacificare.com HMO Provider Directory Formulary Frequently Asked Questions Health Improvement Programs PacifiCare Perks “Contact Us” area Online Member Publications PacifiCare on the Web

24. How to Enroll with PacifiCareIt’s as Easy as 1,2,3! • Select a PCP • Complete your Enrollment Form • Submit your Enrollment Form to your Employer