{"id":448,"date":"2012-10-25T10:56:33","date_gmt":"2012-10-25T15:56:33","guid":{"rendered":"http:\/\/www.hnetalk.com\/Broker\/?p=448"},"modified":"2012-10-25T10:56:33","modified_gmt":"2012-10-25T15:56:33","slug":"october-25-2012-re-semi-annual-notice-of-changes","status":"publish","type":"post","link":"https:\/\/hnetalk.com\/broker\/2012\/10\/25\/october-25-2012-re-semi-annual-notice-of-changes\/","title":{"rendered":"October 25, 2012 – RE: Semi-Annual Notice of Changes"},"content":{"rendered":"
\n

Dear Employers and Brokers:<\/p>\n

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.<\/p>\n

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<\/em>. If you have any questions, please call me at 413.233.3393.<\/p>\n

Sincerely,
\nWendy Bergeron
\nSales Manager<\/p>\n

AMENDMENT 01-2013<\/strong><\/p>\n<\/div>\n

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\u00a01, 2013, unless noted below.<\/p>\n

The EOC is amended as follows:<\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n
\n

Benefit, Program, or Requirement<\/strong><\/p>\n<\/td>\n

\n

Description<\/strong><\/p>\n<\/td>\n<\/tr>\n<\/thead>\n

Services and procedures that require Prior Approval<\/strong><\/td>\nThe following items are added to the Prior Approval list. These procedures were not covered before effective date indicated for each one.<\/p>\n
    \n
  • Proton Beam Therapy \u2013 effective September 1, 2012<\/li>\n
  • Spinal Muscular Atrophy (SMA) Testing \u2013 effective July 1, 2012<\/li>\n
  • Total Ankle Replacement (TAR) \u2013 effective September 1, 2012<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
Hearing aids<\/strong><\/td>\nHNE covers hearing aids for Members age 21 and under as required by new Massachusetts state law as follows:<\/p>\n
    \n
  • Coverage is effective January 1, 2013.<\/li>\n
  • HNE covers the cost of one hearing aid per hearing impaired ear, every 36 months, up to a maximum of $2,000 for each hearing aid.<\/li>\n
  • Coverage for related services prescribed by a licensed audiologist or hearing instrument specialist includes:\n
      \n
    • Initial hearing aid evaluation<\/li>\n
    • Fitting and adjustments<\/li>\n
    • Supplies, including ear molds<\/li>\n
    • You may choose a higher priced hearing aid and pay the difference in cost above the $2,000 limit. If you choose to pay the difference in cost, the amount you pay will not apply to any Out-of-Pocket limit your plan may have.<\/li>\n
    • Any payment responsibilities and other requirements that are a part of your plan apply to this coverage.<\/li>\n
    • HNE requires a written statement from the Member\u2019s treating physician that the hearing aid is Medically Necessary.<\/li>\n
    • Prior Approval by HNE is required.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n

      The benefits described here are subject to further guidance from the Massachusetts Division of Insurance.<\/td>\n<\/tr>\n

Treatment of cleft lip and cleft palate<\/strong><\/td>\nHNE covers the treatment of cleft lip and cleft palate as required by new Massachusetts state law as follows:<\/p>\n
    \n
  • Coverage is effective January 1, 2013.<\/li>\n
  • Coverage for Members age 18 and younger includes:\n
      \n
    • Medical, dental, oral and facial surgery<\/li>\n
    • Surgical management and follow-up care by oral and plastic surgeons<\/li>\n
    • Orthodontic treatment and management<\/li>\n
    • Preventive and restorative dentistry to ensure good health and adequate dental structures for orthodontic treatment or prosthetic management therapy<\/li>\n
    • Speech therapy<\/li>\n
    • Audiology<\/li>\n
    • Nutrition services<\/li>\n
    • The services above are covered when prescribed by the treating physician or surgeon who certifies that the services are:\n
        \n
      • Medically Necessary<\/li>\n
      • Related to the treatment of the cleft lip or the cleft palate<\/li>\n
      • Dental or orthodontic treatment not related to the management of a cleft lip or cleft palate is not covered.<\/li>\n
      • Any payment responsibilities and other requirements that are a part of your plan apply to this coverage.<\/li>\n
      • Prior Approval is required.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n

        The benefits described here are subject to further guidance from the Massachusetts Division of Insurance.<\/td>\n<\/tr>\n

Coverage for mental health services by licensed marriage and family therapists<\/strong><\/td>\nEffective January 9, 2013, \u201clicensed marriage and family therapist\u201d 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.<\/td>\n<\/tr>\n
Clarification: <\/strong>Treatment of medical complications from preventive services or procedures<\/strong><\/td>\nTreatment 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.<\/em><\/strong><\/td>\n<\/tr>\n
Clarification:<\/strong>Fitness Promotion and Weight Watchers\u00ae<\/sup> Reimbursement Program<\/strong><\/td>\nHNE will reimburse up to $150 per family per Calendar Year for qualifying fitness memberships and fees and Weight Watchers\u00ae<\/sup>programs.Qualifying fitness memberships and fees include:<\/p>\n
    \n
  • Fitness club memberships<\/li>\n<\/ul>\n

    To be eligible for reimbursement, the health club that you choose must include both cardiovascular and strength-training exercise equipment.<\/p>\n

      \n
    • Aerobic and wellness classes and personal trainer fees<\/li>\n<\/ul>\n

      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.<\/p>\n

        \n
      • Children\u2019s school and town sports registration fees<\/li>\n<\/ul>\n

        Qualifying Weight Watchers\u00ae <\/sup>expenses include:<\/p>\n

          \n
        • Weight Watchers\u00ae<\/sup> Traditional meetings<\/li>\n
        • Weight Watchers at Work\u00ae<\/sup> meetings<\/li>\n
        • Weight Watchers\u00ae<\/sup> On-line<\/li>\n<\/ul>\n

          Fees paid for food, books, videos or any other items or services are not eligible for reimbursement. This program does not<\/em><\/strong> include Weight Watchers at Home\u00ae <\/sup>or fees paid to any other weight loss program.<\/p>\n

          Reimbursement for any of the above or any combination of the above will not exceed $150 per family per Calendar Year.<\/td>\n<\/tr>\n

Clarification:<\/strong>Member responsibility to advise HNE of Out-of-Plan and PHCS hospital admissions<\/strong><\/td>\nThis applies to Members with PPO plans only.<\/em><\/strong>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.<\/p>\n

If you do not notify HNE, you may have a Reduction of Benefits as shown in your Explanation of Coverage.<\/p>\n

*Private Healthcare Systems<\/td>\n<\/tr>\n

Choosing your primary care physician (PCP) <\/strong><\/td>\nThis applies to HMO and Advantage Plus plans only.<\/em><\/strong>Effective November 6, 2012, a PCP may be:<\/p>\n
    \n
  • A doctor<\/li>\n
  • A participating Pediatric, Adult, or Family Nurse Practitioner<\/li>\n
  • A participating Physician Assistant (PA)<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

    \u00a0<\/strong><\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
    Prescription Drug Coverage<\/em><\/strong>(Please disregard the following sections if your HNE plan does not include a prescription drug benefit.)<\/p>\n

    Note: Tier 1 \u2013 lowest copay; Tier 2 \u2013 mid copay level, Tier 3 \u2013 highest copay level<\/td>\n<\/tr>\n<\/thead>\n

    Change to the name<\/em> of HNE\u2019s Pharmacy Benefit Manager<\/strong><\/td>\nHNE\u2019s Pharmacy Benefit Manager is CatamaranTM<\/sup><\/strong>, <\/strong>formerly known as MedMetrics Health Partners.<\/td>\n<\/tr>\n
    Change to HNE\u2019s mail order prescription drug vendor<\/strong><\/td>\nEffective January 1, 2013, HNE\u2019s mail order prescription drug vendor will change from WellDyneRx to CatamaranTM<\/sup> Home Delivery<\/strong>. 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.<\/td>\n<\/tr>\n
    Dispensing of certain medications may be limited by state law<\/strong><\/td>\nEffective 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.<\/td>\n<\/tr>\n
    Step Therapy: <\/strong>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.<\/p>\n

    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.<\/em><\/strong><\/p>\n

    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.<\/strong><\/td>\n<\/tr>\n

    You must try: <\/strong><\/td>\nFirst Line Drug(s):<\/strong><\/strong><\/td>\n\n
      \n
    • Rebif\u00ae<\/sup> AND<\/span> Copaxone\u00ae<\/sup><\/strong><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
    Before HNE will cover:<\/strong><\/strong><\/td>\nStep Therapy Drug(s):<\/strong><\/strong><\/td>\n\n
      \n
    • Avonex\u00ae<\/sup><\/li>\n
    • Betaseron\u00ae<\/sup><\/li>\n<\/ul>\n

      Note: Applies to new prescriptions only<\/p>\n

       <\/td>\n<\/tr>\n

    You must try: <\/strong><\/td>\nFirst Line Drug(s):<\/strong><\/strong><\/td>\n\n
      \n
    • metformin or a metformin containing product<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
    Before HNE will cover:<\/strong><\/strong><\/td>\nStep Therapy Drug(s):<\/strong><\/strong><\/td>\n\n
      \n
    • Bydureon\u00ae<\/sup><\/li>\n<\/ul>\n

      Note: Applies to new prescriptions only<\/td>\n<\/tr>\n

    You must try: <\/strong><\/td>\nFirst Line Drug(s):<\/strong><\/strong><\/td>\n\n
      \n
    • Januvia\u00ae<\/sup>, Janumet\u00ae<\/sup>, Janumet Xr\u00ae<\/sup>, Tradjenta\u00ae<\/sup><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
    Before HNE will cover:<\/strong><\/strong><\/td>\nStep Therapy Drug(s):<\/strong><\/td>\n\n
      \n
    • Onglyza\u00ae<\/sup><\/li>\n
    • Kombiglyze XR\u00ae<\/sup><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

       <\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
      Tier Assignments <\/strong>The following Prescription Drugs are changing Copay Tier Assignment<\/td>\n<\/tr>\n
      \n

      Drug Name<\/p>\n<\/td>\n

      		\n

      Tier on or before 12\/31\/2012<\/p>\n<\/td>\n

      		\n

      Tier on or after 1\/1\/2013<\/p>\n<\/td>\n<\/tr>\n

      Ortho Tri-Cyclen Lo\u00ae<\/sup><\/td>\n\n

      Tier 2<\/p>\n<\/td>\n

      		\n

      Tier 3<\/p>\n<\/td>\n<\/tr>\n

      Onglyza\u00ae<\/sup><\/td>\n\n

      Tier 2<\/p>\n<\/td>\n

      		\n

      Tier 3<\/p>\n<\/td>\n<\/tr>\n

      Kombiglyze XR\u00ae<\/sup><\/td>\n\n

      Tier 2<\/p>\n<\/td>\n

      		\n

      Tier 3<\/p>\n<\/td>\n<\/tr>\n

      Victrelis\u00ae<\/sup><\/td>\n\n

      Tier 3<\/p>\n<\/td>\n

      		\n

      Tier 2<\/p>\n<\/td>\n<\/tr>\n

      Bydureon\u00ae<\/sup><\/td>\n\n

      New to Market<\/p>\n<\/td>\n

      		\n

      Tier 2<\/p>\n<\/td>\n<\/tr>\n

      Provenge\u00ae<\/sup><\/td>\n\n

      New to Market<\/p>\n<\/td>\n

      		\n

      Prior Approval required for coverage<\/p>\n<\/td>\n<\/tr>\n

      Concerta\u00ae<\/sup><\/td>\n\n

      Tier 2<\/p>\n<\/td>\n

      		\n

      Tier 3<\/p>\n<\/td>\n<\/tr>\n

      Venlafaxine ER (Tablets only)<\/td>\n\n

      Tier 1<\/p>\n<\/td>\n

      		\n

      Not covered<\/p>\n<\/td>\n<\/tr>\n

      Norditropin\u00ae<\/sup><\/td>\n\n

      Tier 2<\/p>\n<\/td>\n

      		\n

      Tier 3<\/p>\n<\/td>\n<\/tr>\n

      Omnitrope\u00ae<\/sup><\/td>\n\n

      Tier 3<\/p>\n<\/td>\n

      		\n

      Tier 2<\/p>\n<\/td>\n<\/tr>\n

      Pegasys\u00ae<\/sup><\/td>\n\n

      Tier 2<\/p>\n<\/td>\n

      		\n

      Tier 3<\/p>\n<\/td>\n<\/tr>\n

      PEG-Intron\u00ae<\/sup><\/td>\n\n

      Tier 3<\/p>\n<\/td>\n

      		\n

      Tier 2<\/p>\n<\/td>\n<\/tr>\n

      PNV-DHA\u00ae<\/sup><\/td>\n\n

      Tier 1<\/p>\n<\/td>\n

      		\n

      Tier 3<\/p>\n<\/td>\n<\/tr>\n

      Ultimatecare One \u00ae<\/sup><\/td>\n\n

      Tier 2<\/p>\n<\/td>\n

      		\n

      Tier 3<\/p>\n<\/td>\n<\/tr>\n

      Prefera OB\u00ae<\/sup><\/td>\n\n

      $0<\/p>\n<\/td>\n

      		\n

      Tier 3<\/p>\n<\/td>\n<\/tr>\n

      Folivane-PRX DHA NF\u00ae<\/sup><\/td>\n\n

      Tier 1<\/p>\n<\/td>\n

      		\n

      Tier 3<\/p>\n<\/td>\n<\/tr>\n

      Folcaps Omega 3\u00ae<\/sup><\/td>\n\n

      Tier 2<\/p>\n<\/td>\n

      		\n

      Tier 3<\/p>\n<\/td>\n<\/tr>\n

      Zatean-PN\u00ae<\/sup><\/td>\n\n

      Tier 2<\/p>\n<\/td>\n

      		\n

      Tier 3<\/p>\n<\/td>\n<\/tr>\n

      Virt-PN DHA\u00ae<\/sup><\/td>\n\n

      $0<\/p>\n<\/td>\n

      		\n

      Tier 3<\/p>\n<\/td>\n<\/tr>\n

      OB-Natal One\u00ae<\/sup><\/td>\n\n

      Tier 1<\/p>\n<\/td>\n

      		\n

      Tier 3<\/p>\n<\/td>\n<\/tr>\n

      PNV-Select\u00ae<\/sup><\/td>\n\n

      Tier 1<\/p>\n<\/td>\n

      		\n

      Tier 3<\/p>\n<\/td>\n<\/tr>\n

      Other Prenatal Vitamins (For full listing, please see our online formulary at www.hne.com)<\/td>\n\n

      Various Tiers<\/p>\n<\/td>\n

      		\n

      $0<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n\n\n\n
      Quantity Limit Additions<\/strong>Starting 1\/1\/2013, HNE will add the following Quantity Limits to the following drugs:<\/p>\n

       <\/td>\n<\/tr>\n

      \n

      Drug Name<\/p>\n<\/td>\n

      		\n

      Quantity Limit per 30 day supply<\/p>\n<\/td>\n<\/tr>\n

      Simcor\u00ae<\/sup>500\/20mg
      \nSimcor\u00ae<\/sup> 500\/40mg
      \nSimcor\u00ae<\/sup> 1000\/40mg<\/td>\n      		\n

      30 tablets<\/p>\n<\/td>\n<\/tr>\n

      Simcor\u00ae<\/sup>1000\/20mg
      \nSimcor\u00ae<\/sup> 750\/20mg<\/td>\n      		\n

      60 tablets<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

       <\/p>\n","protected":false},"excerpt":{"rendered":"

      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 […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"jetpack_post_was_ever_published":false,"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_publicize_message":"","jetpack_publicize_feature_enabled":true,"jetpack_social_post_already_shared":false,"jetpack_social_options":{"image_generator_settings":{"template":"highway","default_image_id":0,"font":"","enabled":false},"version":2}},"categories":[1],"tags":[],"class_list":["post-448","post","type-post","status-publish","format-standard","hentry","category-uncategorized"],"jetpack_publicize_connections":[],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"jetpack_shortlink":"https:\/\/wp.me\/p6ZZOS-7e","_links":{"self":[{"href":"https:\/\/hnetalk.com\/broker\/wp-json\/wp\/v2\/posts\/448","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/hnetalk.com\/broker\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/hnetalk.com\/broker\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/hnetalk.com\/broker\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/hnetalk.com\/broker\/wp-json\/wp\/v2\/comments?post=448"}],"version-history":[{"count":0,"href":"https:\/\/hnetalk.com\/broker\/wp-json\/wp\/v2\/posts\/448\/revisions"}],"wp:attachment":[{"href":"https:\/\/hnetalk.com\/broker\/wp-json\/wp\/v2\/media?parent=448"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/hnetalk.com\/broker\/wp-json\/wp\/v2\/categories?post=448"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/hnetalk.com\/broker\/wp-json\/wp\/v2\/tags?post=448"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}