Anthem HealthKeepers Renewal Information for Benefit Managers (for groups in the Large Group market)

Transcription

1 Anthem HealthKeepers Renewal Information for Benefit Managers (for groups in the Large Group market) Thank you once again for offering your employees Anthem HealthKeepers health care coverage. We d like to take this opportunity to let you know about some important changes affecting your plan. Changes are effective beginning January 1, 2016 (unless otherwise noted) for renewing groups. Health Care Reform and its impact to our products and our customers Final rules for Notice of Benefit and Payment Parameters (NBPP) will change HSA and HRA cost share calculations The Department of Health and Human Services (HHS) issued the final rule for the Notice of Benefit and Payment Parameters (NBPP) for Compliance is required effective beginning with January 2016 sales and renewals. In the preamble of the final notice, HHS clarified their stance on cost share rules, stipulating that the annual limitation for out-ofpocket maximums is $6,850. The annual limitations on cost sharing for self-only coverage applies to all individuals regardless of whether the individual is covered by a self-only plan or is covered by a plan that is other than self-only. This ruling impacts all non-embedded deductible plans. As a reminder, a non-embedded deductible plan has historically been calculated such that it is a plan in which all family members have a shared deductible and out-of-pocket maximum, regardless of the number of family members. To assure compliance with this annual limit, we reviewed all of our Anthem consumer driven health products, some of which included a non-embedded deductible plan design. We found that the majority of our non-embedded plans required modification to be compliant with this ruling. Accordingly, we are making the following changes to our nonembedded deductible products: HSA plans HRA plans - Plans with deductibles less than $2,000 will remain non-embedded. We will adjust out-of-pocket maximums to $3,425 for individuals and $6,850 for families. - Employers who have a non-embedded deductible plan with a deductible of $2,500 and above will be transitioned to an embedded deductible plan. - Plans with out-of-pocket maximums that are less than $4,000 will remain non-embedded deductible plan designs. Out-of-pocket maximums will be adjusted to be $3,425 for an individual and $6,850 for a family. - Employers who have a non-embedded deductible plan design with an out-of-pocket maximum of $5,000 will be transitioned to an embedded deductible design HRA plan. January

2 The following chart reflects product changes for new and renewing business effective January 1, HSA Non-embedded consumer driven health plan maximum out of pocket compliance changes Lumenos HSA plans Groups will migrate to: Product change HSA 579 New HSA 1369 Remain non-embedded accumulation and out-of-pocket maximum will be reduced to $3,425/individual and $6,850/family Elements Choice HSA 1030 New HSA 1361 Product will change from a nonembedded to an embedded deductible plan design Elements Choice HSA 1032 New HSA 1405 Product will change from a nonembedded to an embedded deductible plan design Lumenos HRA plans Groups will migrate to: Product change HRA 849 New HRA 1289 Remain non-embedded accumulation and out-of-pocket maximum will be reduced to $3,425/individual and $6,850/family HRA 855 New HRA 1294 Remain non-embedded accumulation and out-of-pocket maximum will be reduced to $3,425/individual and $6,850/family HRA 856 HRA 1052 Product will change from a nonembedded to an embedded deductible plan designchanged to [c1] HRA 857 HRA 1053 Product will change to an embedded deductible plan design[c2]changed to HRA 858 HRA 1054 Product will change to an embedded deductible plan design[c3]changed to HRA 850 HRA 1062 Product will change to an embedded deductible plan design[c4]changed to HRA 1126 HRA 1057 Product will change to an embedded deductible plan design[c5]changed to Deductible First HRA 859 Deductible First HRA 1058 Product will change to an embedded deductible plan design[c6]changed to Deductible First HRA 860 Deductible First HRA 1059 Product will change to an embedded deductible plan design[c7]changed to Deductible First HRA 852/853/833 Deductible First HRA 1060 Product will change to an embedded deductible plan design[c8]changed to Deductible First HRA 861 Deductible First New HRA 1264 Product will change to an embedded deductible plan design[c9]changed to Deductible First HRA 1127 Deductible First New HRA 1266 Product will change to an embedded deductible plan design[c10]changed to January

3 The following is a reminder of the difference in accumulation calculation for a non-embedded deductible design versus an embedded deductible plan design. Non-embedded Accumulation: All family members have a shared deductible and out-of-pocket (OOP) maximum, regardless of the number of family members. The entire deductible must be satisfied before any one member of the family can begin receiving benefits. The entire OOP must be satisfied before the family has satisfied the OOP maximum. Accumulation: Each member has an individual deductible/oop amount. Any deductible amount contributed by an individual family member will apply to the family deductible amount, but no individual family member is required to contribute more to the family deductible than their individual deductible amount. The OOP accumulates on an embedded basis also. Other product changes Healthy Support products now include a new incentive We launched Healthy Support products last year as part of our ongoing strategy to include incentives that reward members for healthy behaviors, which can lead to reduced costs for everyone. We re pleased to announce two new incentives that will be included in our Healthy Support products to further promote proactive wellness activities. Both of these incentives are designed to be claims generated, which means the member s participation will directly initiate the incentive being activated. These new incentives are as follows: - Adult wellness exam = $50 gift card incentive - Flu shot = $50 gift card incentive January

4 FitOrbit no longer available Previously FitOrbit, an online personal training program, was available as either part of our Healthy Support products or as a buy up stand alone option. We have been informed that this business has ceased operations and will no longer be an available option for our customers. Fortunately, there was very little enrollment so we do not anticipate any significant abrasion. Members who are affected will be notified by the FitOrbit organization directly. Pharmacy coverage changes 90-day maintenance medications are now available for local purchase Beginning January 1, 2016 for new sales and renewals, members will now be able to purchase 90-day supplies of their medications at three times the 30-day supply member cost share at participating local retail pharmacies. For the last several years, our pharmacy drug coverage has been designed to meet market demand while also trying to control costs as prescription drug use continues to be one of the highest utilizers of health care spend. One of the ways in which we ve tried to maintain cost controls was through 90-day prescriptions being available through mail order. Members would pay less out of pocket for the three-month supply, and in exchange, would benefit from the discounts we have negotiated with our pharmacy benefits manager, Express Scripts. However members have told us they prefer the convenience of being able to purchase 90-day supplies of their prescriptions from their local participating pharmacy versus waiting for prescriptions to come in the mail. Accordingly, we are modifying our pharmacy coverage to include the option of the 90- day supply at local pharmacies. We feel confident that members will appreciate this convenience that enables them to get their medications as quickly as possible. Compound drug coverage changes Compound (combination) medications, when one or more ingredients are FDA-approved, require a prescription to dispense, and are not essentially the same as an FDA-approved product from a drug manufacturer. Our Member Booklet Evidence of Coverage (EOC) document only addresses compound drugs in the what is not covered section. We are amending our Member BookletEOC language to clarify how compound drugs will be covered, which is specifically that they ll be covered under the following circumstances: - when a commercially-available dosage form of a medically necessary medication is not available, - all of the ingredients of the compound drug are FDA-approved - when the compound drug requires a prescription to dispense, and - is not essentially the same as an FDA-approved product from a drug manufacturer. Non-FDA approved non-proprietary, multisource ingredients that are vehicles essential for compound administration may be covered. New split fill program Members needing certain, specialty medications often have to go through test rounds of various medications to identify the ones that their system can tolerate and will work best for their condition. This can lead to a lot of waste with members paying for a 30-day supply of a medication that winds up being discarded. To help these members get more value out of their coverage, we are implementing a split fill program that will enable members to get a 10 or 15-day supply of a drug in order to try it out and make sure it s the proper medication for their needs. Increased monitoring of pharmacy benefits utilization Misuse of pharmacy benefits can lead to increased costs for everyone. As part of our ongoing efforts to reduce any instances of health care fraud or abuse, we are implementing tighter controls of our pharmacy benefits management program. If we determine that a member may be using a prescription drug in a harmful or abusive manner, or with harmful frequency, we may limit the member s future selection of participating pharmacies. For these instances, we may require the member to select a single participating pharmacy to provide and coordinate all future pharmacy services. Benefits will only be paid if members receive their prescriptions from the single, selected participating pharmacy. If a member does not select a single participating pharmacy within 31 days of the date we made this request, we will select the single participating pharmacy for the member. January

5 New pharmacy options Pharmacy continues to be a high driver of cost spend. We routinely revisit our pharmacy rider options to seek solutions that will enable our employer groups to continue offering pharmacy coverage that is beneficial to our members while also retaining cost increases where possible. Accordingly, we ve developed new options that will be available: Express Advantage Incentive (EAN) rider Our new EAN rider gives members financial incentives by offering the lowest copays when using the EAN network of pharmacies, while continuing to provide the security of the National Plus (legacy) pharmacy network for a higher cost share. Members will be able to select the pharmacy network that best meets their needs. Our EAN network contains major pharmacy merchants and chains, such as Walmart, Rite Aid and many large supermarkets. Below are the EAN rider options. All plans will include the 90 day retail option. When using EAN Preferred pharmacy, When using National Plus pharmacy, copay will be: copay will be: $10/20/35/20% or $20/30/45/20% $10/30/50/20% or $20/40/60/20% $10/30/50/20% w/ $150 Ded or $20/40/60/20% w/ $150 Ded $15/40/75/20% or $25/50/85/20% $15/40/75/20% w/ $150 Ded or $25/50/85/20% w/ $150 Ded $15/50/90/20% or $25/60/100/20% $15/50/90/20% w/ $250 Ded or $25/60/100/20% w/ $250 Ded New Essential Formulary-available (for fully insured and ASO business) Many employers are looking for ways to generate premium savings within their pharmacy programs. Our new Essential drug list is a closed formulary that removes drugs that have an over-the-counter or lower cost alternative covered. This formulary will also include limited Specialty drugs. New Preferred Formulary (for ASO business only) We have also developed a new Preferred formulary option to enhance rebate opportunities for ASO groups. This formulary is based on our existing National Plus formulary, but includes a provision in which certain classes of drugs are closed, meaning that non-preferred drugs will not be covered. We are hopeful that all of these new drug rider options will be an attractive choice for employers looking to continue offering pharmacy coverage while reducing cost. Please contact your Anthem Representative for more information[c11]. Local Legislative Changes The following changes to policy provisions were signed into law by the Virginia General Assembly and are effective for renewals beginning January 1, 2016 unless otherwise noted. House Bill 1940, which pertains to coverage of autism spectrum disorder For your group s market segment, coverage for this disorder had already been put into place through prior legislation that became effective in 2012, covering members up through age six. With this new bill, that coverage is now expanded to the age of 10. January

6 House Bill 1444, which outlines reimbursement arrangements for vision services. The intent of this law is to prohibit insurers from requiring discounts from optometrists on products connected to noncovered services and would also limit an insurer s ability to require use of certain labs as a condition of participation in our vision plans. We are working with our vision partner, EyeMed, to develop the next steps to ensure our compliance with this law. As part of our work, we will also plan to update our online Provider Finder tool to show providers who continue to offer discounts versus those who will not. January

7 House Bill 1942 This provision pertains to specific turnaround times and handling of prior authorization requests associated with pharmacy benefit requests. The law mandates that these requests be handled electronically (phone, fax or computer) to ensure timely outcomes. We are working with our pharmacy benefits manager, Express Scripts, to meet these new outlined timeframes. House Bill 2063, which pertains to telemedicine services Coverage for telemedicine services has already been in effect for several years. However, the newly passed law updates the definition of telemedicine services and requires Schedule VI prescriptions to have a face to face interaction. This update actually became effective beginning July 1, 2015, but we will update our Member booklet language to add this clarification beginning with renewals as of January 1, House Bill 2031 This law requires any contract between a health insurance carrier and its pharmacy benefits manager to maintain updated maximum allowable cost pricing lists no less frequently than once every seven days. This law also stipulates that contracts also require that that carrier or pharmacy benefits manager verify no less often than once every seven days that the drugs included on the maximum allowable cost list are available to participating pharmacies from at least one regional or national pharmacy wholesaler. We are working with our pharmacy benefits manager, Express Scripts, to ensure we are compliant with this bill. Evidence of Coverage updates We update our Member Booklet booklets, effective for new sales and renewals, to help our members stay informed regarding their health plan benefits, as well as to make it clear what is excluded from plan coverage. Our Member Booklets will be updated as described in this document to reflect product changes for new groups and renewals effective beginning January 1, Below are some changes we wanted to make you aware of: The exclusion pertaining to certain types of telemedicine services is being revised to clarify the types of non-interactive telemedicine services that will not be covered. A new exclusion has been added to clarify that benefits do not include waived cost shares for services outside of plan when if they had been received in-plan, the member would have had a cost share responsibility. The compound drug exclusion has been modified to indicate that exceptions to non-fda approved compound ingredients may include multi-source, non-proprietary vehicles and/or pharmaceutical adjuvants. The exclusion that pertains to drugs that are not on our formulary has been modified to indicate the process for requesting an exception. This insert is only one piece of your renewal material. Exclusions, limitations, related provisions and applicable policy form numbers are listed in the renewal package. HealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. ANTHEM, and Lumenos are registered trademarks of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. January