October 25, 2012 – RE: Semi-Annual Notice of Changes
Posted on October 25, 2012
Dear Employers and Brokers:
As part of our commitment to provide affordable access to high quality health care, we continually review the benefits and services offered to our members. As a result, from time to time, we update the coverage we provide and change the way that coverage is administered. We then notify our subscribers and their employers, our brokers, and our contracted providers of these changes.
We have attached a copy of an amendment to the HNE Explanation of Coverage. We will notify HNE subscribers of this amendment with the next edition of our member newsletter, Living Well. If you have any questions, please call me at 413.233.3393.
Sincerely,
Wendy Bergeron
Sales Manager
AMENDMENT 01-2013
This is an Amendment to your Health New England, Inc. Explanation of Coverage (EOC). Please keep this Amendment with your EOC as it changes the terms of that EOC. Any language in the EOC that does not follow the terms of this Amendment no longer applies. This Amendment is effective as of January 1, 2013, unless noted below.
The EOC is amended as follows:
|
Benefit, Program, or Requirement |
Description |
| Services and procedures that require Prior Approval | The following items are added to the Prior Approval list. These procedures were not covered before effective date indicated for each one.
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| Hearing aids | HNE covers hearing aids for Members age 21 and under as required by new Massachusetts state law as follows:
The benefits described here are subject to further guidance from the Massachusetts Division of Insurance. |
| Treatment of cleft lip and cleft palate | HNE covers the treatment of cleft lip and cleft palate as required by new Massachusetts state law as follows:
The benefits described here are subject to further guidance from the Massachusetts Division of Insurance. |
| Coverage for mental health services by licensed marriage and family therapists | Effective January 9, 2013, “licensed marriage and family therapist” is added to the type of professionals who may provide covered mental health services. Services by licensed marriage and family therapists must be within the scope of practice allowed by law for these therapists. All services must be Medically Necessary. |
| Clarification: Treatment of medical complications from preventive services or procedures | Treatment of medical complications that are the result of preventive services or procedures are covered subject to member cost sharing.* This is the case even if the preventive service or procedure was not subject to member cost sharing. All services must be Medically Necessary.*For instance: deductibles, copays or coinsurance. |
| Clarification:Fitness Promotion and Weight Watchers® Reimbursement Program | HNE will reimburse up to $150 per family per Calendar Year for qualifying fitness memberships and fees and Weight Watchers®programs.Qualifying fitness memberships and fees include:
To be eligible for reimbursement, the health club that you choose must include both cardiovascular and strength-training exercise equipment.
Class instructors and personal trainers must be certified. They must work for a fitness or wellness facility. Classes may include: Pilates, yoga, spinning, aerobics, strength training, tai chi, kickboxing, and martial arts.
Qualifying Weight Watchers® expenses include:
Fees paid for food, books, videos or any other items or services are not eligible for reimbursement. This program does not include Weight Watchers at Home® or fees paid to any other weight loss program. Reimbursement for any of the above or any combination of the above will not exceed $150 per family per Calendar Year. |
| Clarification:Member responsibility to advise HNE of Out-of-Plan and PHCS hospital admissions | This applies to Members with PPO plans only.You must notify HNE of admissions to Out-of-Plan hospitals and skilled nursing facilities. If your plan has In-Plan benefits for PHCS* providers, you must also notify HNE of these admissions. As soon as you know about a planned admission, call HNE Member Services at 800.310.2835. For emergency admissions, call us as soon as possible.
If you do not notify HNE, you may have a Reduction of Benefits as shown in your Explanation of Coverage. *Private Healthcare Systems |
| Choosing your primary care physician (PCP) | This applies to HMO and Advantage Plus plans only.Effective November 6, 2012, a PCP may be:
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| Prescription Drug Coverage(Please disregard the following sections if your HNE plan does not include a prescription drug benefit.)
Note: Tier 1 – lowest copay; Tier 2 – mid copay level, Tier 3 – highest copay level |
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| Change to the name of HNE’s Pharmacy Benefit Manager | HNE’s Pharmacy Benefit Manager is CatamaranTM, formerly known as MedMetrics Health Partners. | ||
| Change to HNE’s mail order prescription drug vendor | Effective January 1, 2013, HNE’s mail order prescription drug vendor will change from WellDyneRx to CatamaranTM Home Delivery. For Members who currently use WellDyneRx, HNE is working to ensure a smooth transition. Please watch for further instructions by mail prior to the change date. | ||
| Dispensing of certain medications may be limited by state law | Effective January 1, 2013, the maximum supply of certain medications available through retail and mail order may change. This conforms to Massachusetts state law which allows the dispensing of no more than a 60-day supply of certain medications. | ||
| Step Therapy: For HNE to cover the Step Therapy drugs listed here, you first must try one of the corresponding First Line drugs. If HNE has paid a claim for the First Line drug within the previous 180 days, then you are eligible for coverage of the Step Therapy drug.
The use of samples does not satisfy the requirements of documented usage of a First Line drug or medical necessity for a Step Therapy drug. If it is Medically Necessary for you to use a Step Therapy drug before trying a First Line drug, then your doctor can contact HNE to request a medical review. |
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| You must try: | First Line Drug(s): |
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| Before HNE will cover: | Step Therapy Drug(s): |
Note: Applies to new prescriptions only
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| You must try: | First Line Drug(s): |
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| Before HNE will cover: | Step Therapy Drug(s): |
Note: Applies to new prescriptions only |
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| You must try: | First Line Drug(s): |
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| Before HNE will cover: | Step Therapy Drug(s): |
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| Tier Assignments The following Prescription Drugs are changing Copay Tier Assignment | ||
|
Drug Name |
Tier on or before 12/31/2012 |
Tier on or after 1/1/2013 |
| Ortho Tri-Cyclen Lo® |
Tier 2 |
Tier 3 |
| Onglyza® |
Tier 2 |
Tier 3 |
| Kombiglyze XR® |
Tier 2 |
Tier 3 |
| Victrelis® |
Tier 3 |
Tier 2 |
| Bydureon® |
New to Market |
Tier 2 |
| Provenge® |
New to Market |
Prior Approval required for coverage |
| Concerta® |
Tier 2 |
Tier 3 |
| Venlafaxine ER (Tablets only) |
Tier 1 |
Not covered |
| Norditropin® |
Tier 2 |
Tier 3 |
| Omnitrope® |
Tier 3 |
Tier 2 |
| Pegasys® |
Tier 2 |
Tier 3 |
| PEG-Intron® |
Tier 3 |
Tier 2 |
| PNV-DHA® |
Tier 1 |
Tier 3 |
| Ultimatecare One ® |
Tier 2 |
Tier 3 |
| Prefera OB® |
$0 |
Tier 3 |
| Folivane-PRX DHA NF® |
Tier 1 |
Tier 3 |
| Folcaps Omega 3® |
Tier 2 |
Tier 3 |
| Zatean-PN® |
Tier 2 |
Tier 3 |
| Virt-PN DHA® |
$0 |
Tier 3 |
| OB-Natal One® |
Tier 1 |
Tier 3 |
| PNV-Select® |
Tier 1 |
Tier 3 |
| Other Prenatal Vitamins (For full listing, please see our online formulary at www.hne.com) |
Various Tiers |
$0 |
| Quantity Limit AdditionsStarting 1/1/2013, HNE will add the following Quantity Limits to the following drugs:
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|
Drug Name |
Quantity Limit per 30 day supply |
| Simcor®500/20mg Simcor® 500/40mg Simcor® 1000/40mg |
30 tablets |
| Simcor®1000/20mg Simcor® 750/20mg |
60 tablets |
