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Individual & Family Health Insurance
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You’ve probably heard about H1N1 flu (commonly known as “swine flu”) from TV news or newspaper reports recently. Since the Fall and Winter months are generally known as “flu season,” it’s important that you and your family have the most up-to-date information on flu prevention and to get vaccinated. You can also take the H1N1 Flu Self-Evaluation if you have flu-like symptoms and unsure of what to do next.
The following information highlights some frequently asked questions and answers about the H1N1 flu, health plan vaccination benefits available to members, and where you can expect to receive an H1N1 vaccination.
For the latest information on vaccination locations near you, visit Additional information is being released by the Centers for Disease Control and Prevention (CDC) as they continue to receive it.

What is H1N1 flu?
H1N1 flu is a new strain of influenza (flu) virus. It’s a very contagious infection of the upper respiratory (breathing) tract that can easily spread from person to person. H1N1 flu is different and separate from the seasonal flu. Both flu strains are of concern for certain people who are considered at-risk for problems that can be caused by the flu.

Are there different vaccines for seasonal flu and H1N1 flu?
Yes, the vaccines are different and separate for seasonal flu and H1N1 flu. The seasonal flu vaccine is not expected to protect against H1N1 flu.
If you require both vaccines, you can receive them at the same time.

Who is at risk for H1N1 flu complications?
Anyone can get the flu. But some groups of people have a higher risk of developing complications from this new strain of H1N1 flu.
Unlike seasonal flu, younger people may be more susceptible to complications of H1N1 flu.
People with chronic illness, pregnant women, children and young adults aged 6 months to 24 years, and health care workers are also at increased risk.

How does H1N1 flu spread?
H1N1 flu is spread from person to person. It’s thought to occur in the same way that seasonal flu spreads. People can get H1N1 flu from:
Someone who has the flu who coughs or sneezes.
Touching a flu-contaminated object or surface like a door knob, telephone, toy, elevator button, etc.

How long is someone contagious?
People who have H1N1 flu and/or seasonal flu are contagious and can spread flu to others from one day before symptoms occur, to 5 to 7 days after the symptoms start. This time period for spreading the flu can be longer in some people, especially children and people with weakened immune systems, and in people infected with the new H1N1 flu virus.

What are some of the symptoms of H1N1 flu?
The symptoms of H1N1 flu can range from mild to severe, and are similar to the seasonal flu. They include:
Body aches
Sore throat
Runny or stuffy nose
Fatigue (feeling extremely tired; lack of energy)
Some people who have been infected with this virus also have reported symptoms of diarrhea and vomiting

What should I do if I get sick?
If you have flu-like symptoms, the CDC suggests:
You should stay home and avoid contact with other people. The CDC recommends that you stay home for at least 24 hours after your fever is gone except to get medical care or for other necessities. Your fever should be gone for 24 hours without the use of a fever-reducing medicine before leaving home.
Staying at home means that you should not leave your home except to seek medical care. This means avoiding normal activities, including work, school, travel, shopping, social events, and public gatherings.
Stay away from others as much as possible to keep from making others sick.
If you have severe illness or you are at high risk for flu complications, contact your health care provider or seek medical care. Your health care provider will determine whether flu testing or treatment is needed.

What prevention steps can I take to avoid the flu?
The following recommendations can help stop the flu from spreading. Take these everyday steps to help protect your health:

General illness prevention tips:
Avoid touching your eyes, nose, or mouth. Germs spread this way.
Try to avoid close contact with sick people.
Get a seasonal flu shot and an H1N1 shot if you require them. You can receive both shots at the same time.

If you are sick with a flu-like illness:
The CDC recommends that you stay home for at least 24 hours after your fever is gone without the use of a fever-reducing medicine. Do not leave home except to get medical care or for other necessities.
Keep away from others as much as possible to avoid making others sick.
Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it.
Wash your hands often with soap and water, especially after every time that you cough or sneeze.
Alcohol-based hand cleaners are also effective in killing flu germs.

Hand washing:
Washing your hands often will help protect you from germs. Wash with soap and water or clean with an alcohol-based hand cleaner.
The CDC recommends that when you wash your hands with soap and warm water that you wash for 15 to 20 seconds.
When soap and water are not available, alcohol-based disposable hand wipes or gel sanitizers may be used. You can find them in most supermarkets and drug stores.
If using gel, rub your hands until the gel is dry. The gel doesn’t need water to work; the alcohol in it kills the germs on your hands.

Be prepared:
Follow public health advice regarding school closures, avoiding crowds, and other social distancing measures.
Be prepared in case you get sick and need to stay home for a week or so. A supply of over the-counter medicines, alcohol-based hand rubs, tissues, and other related items will help decrease the need to make trips out in public while you are sick and contagious.

If you have more questions or concerns about H1N1 flu or seasonal flu, talk to your doctor. Also, visit for more information.

Vaccine Benefit Coverage Information

What is your company doing about the H1N1 virus? What is your company’s role in this crisis?
H1N1 virus is a public health issue. Our role is to support our public health agencies, such as the Centers for Disease Control (CDC), as well as our members, our providers and our customers.
Our priority is to ensure that our actions and communications support the CDC and other governmental entities on this issue. Our health plan is doing its part to minimize the impact of the H1N1 virus, which has spread throughout the country. We are waiving member cost shares (co-pays, coinsurance and deductibles) for fully insured members to receive the H1N1 vaccine from medical providers.
If you are a fully-insured member, you can also receive related flu treatments (Tamiflu and Relenza) at lower cost to you.
There will be no cost to receive the H1N1 vaccine for members enrolled in Medicaid, State Children’s Health Insurance Program or other publicly funded programs.

Will I have to pay for both the seasonal and the H1N1 flu vaccinations?
We are waiving co-pays, coinsurance and deductibles for the cost of the administration of the H1N1 vaccine to ensure that our fully insured members can take the appropriate actions to help protect themselves and their families. The cost of the vaccine itself is paid for by the federal government.
There will be no cost to receive the H1N1 vaccine for members enrolled in Medicaid, State Children’s Health Insurance Program or other publicly funded programs.
Benefits pertaining to seasonal flu vaccinations will not change and will be covered in accordance with existing members’ benefit plans.

Can I get my vaccination at a pharmacy or retail clinic? And what will it cost me?
You can get your vaccination at either type of facility but in order to get the most out of your health plan benefits, you should get it at a pharmacy or retail clinic that is a participating H1N1 vaccine provider in the network. These network pharmacies and retail clinics have agreed to accept our payment as payment in full. And that way you won’t have to pay anything extra. When you go to get your H1N1 vaccine, all you have to do is bring your member ID card with you.

Here is a list of the pharmacies and retail health clinics that are participating H1N1 vaccine providers in the network:

H1N1 vaccine participating pharmacies
Kmart (nationwide)
Publix (locations in GA)
Tops (locations in NY)
Rite Aid (nationwide)
UKrops (locations in VA)
Please note: Not all locations may offer vaccinations. Please check with your local store to see if they do.

What about my local independent pharmacy?
To check if your local independent pharmacy is a participating H1N1 vaccine provider, call Member Services. The number is on your ID card.

H1N1 vaccine participating retail health clinics
Minute Clinics
The Little clinic
Take Care
Redi Clinic
Remember: If you choose to go to pharmacies or retail clinics that are not on the above lists, you may have to pay out-of-network costs such as deductible, coinsurance and amounts above what we allow for the vaccination.

Are there times when I might be billed for H1N1 vaccine-related services?
Yes, when you go out of network.
If you go to a pharmacy or retail clinic that is not a participating H1N1 vaccine provider, you can be billed for out-of-network costs like deductible, coinsurance and amounts above what we allow for the vaccination.
Yes, when in-network doctors bill additional services.
While network doctors won’t bill you for the H1N1 vaccine, they can bill you if other services are provided or an office visit is performed. In those cases, you would be billed according to your usual benefits.

Why are you doing this?
We believe it’s the right thing to do. In cases of pandemic, it’s critical that coverage be extended to all of our members to assist them in obtaining treatment.

Are these changes temporary or permanent?
We will continue to monitor the recommendations of the CDC and the Food and Drug Administration regarding the H1N1 virus to ensure that coverage is available for treatment and prevention.

Medication Benefit Coverage Information

Is the health plan making changes to the medication formulary?
Our goal is to make sure that when clinically appropriate, our members have coverage for the drugs they need. To that end, we are placing the antiviral medications Relenza and Tamiflu on Tier 2 for all our members with a pharmacy benefit that currently lists these drugs on Tier 3. In general, this means a member’s co-pay will go from about $45 to about $30.
Most of our pharmacy benefit members already had coverage with no prior authorization.
In early 2009, to ensure everyone had appropriate coverage during a pandemic:
We asked Medicare to lift the prior authorization requirement;
We made changes to clinical edits for all formularies to quantities and age limits that expand coverage and allow for more preventative use, as well as treatment in young children; and
We extended coverage to about 250,000 customers in closed benefit plans who were not covered for Tamiflu or Relenza.

Are there age restrictions on coverage for Tamiflu and Relenza?
No. We want to make sure everyone with our pharmacy benefits is covered for these medications. Covered individuals and families may obtain these medications for the specified co-pays with a physician’s prescription.