Effective January 1, 2017, unless otherwise noted, the
following member benefit changes and clarifications will be
implemented for several commercial programs for Pennsylvania members:
| Type of
benefit/service | Plans
affected | Change/clarification |
|---|
| Blood pressure monitoring | HMO ?
All
POS ? All
DPOS ? All | Language is being added to include coverage for
home
and ambulatory blood pressure monitoring to benefit plans
to comply with Preventive services requirements under the
Affordable Care Act. An ambulatory blood pressure monitor is
a portable device worn to measure blood pressure regularly
over 24-hour cycles. As an alternative, a home blood
pressure monitoring device may be covered as a Preventive
service for individuals ages 18 and older who meet certain
criteria. |
| Change to the definition of a
covered expense (commercial
member claims)
Date on or after April 1, 2017, when
the plan benefits take effect. | POS ? All
DPOS ? All | Language is being revised to indicate the
definition of a
covered expense applies to covered services for inpatient
treatment at an out-of-network facility. In the event that
covered services are not recognized or reimbursed by
traditional Medicare, the change allows AmeriHealth to use
its own established fee schedule* to determine the benefit
amount for the covered service. The change makes the
payment method for inpatient covered services at an out-ofnetwork
facility similar to the payment for outpatient covered
services at an out-of-network facility. |
| Chemotherapy | HMO ? All
POS ? All
DPOS ? All | Language is being revised to indicate the
definition of
chemotherapy more accurately. The updated language also
more clearly explains coverage of oral anti-cancer drugs for
enrolled members whose plan does not cover prescription
drugs. |
| Medical foods | HMO ? All
POS ? All
DPOS ? All | Language is being revised to more clearly
explain coverage
of medical foods. In Pennsylvania, medical foods are defined
as liquid nutritional products that are used to treat certain
disorders. |
| Obesity | HMO ? All
POS ? All
DPOS ? All | Language is being updated to more clearly
explain what
services are not covered under the obesity
benefit. |
| Routine foot care | HMO ? All
POS ? All
DPOS ? All | Language is being added to explain what is
not covered
under the routine foot care benefit. |
| Transsexual surgery
Date on or after January 1, 2017,
when the plan benefits take effect. | HMO ? All
POS ? All
DPOS ? All | Language is being added to indicate that
transsexual surgery,
also known as sex or gender reassignment surgery, will
no longer be excluded and coverage will be available in
accordance with applicable medical policies. |
| Transplants | HMO ? All
POS ? All
DPOS ? All | Language is being added to more clearly explain
how, and
under what circumstances, AmeriHealth pays for donor
coverage for transplants involving human organs, bone
marrow, and/or tissues. |
| Treatment of sexual
dysfunction | HMO ? All
POS ? All
DPOS ? All | Language is being updated to more clearly
explain what
services are not covered by the plan?s sexual
dysfunction
benefit. |
* Effective January 1, 2017, AmeriHealth will begin using
a new fee schedule for certain outpatient services. This applies to plans with
self-referred
benefits (POS). This fee schedule may be used to calculate member cost-sharing
for out-of-network services.
Effective January 1, 2017, the following changes apply to
Pennsylvania members with an AmeriHealth pharmacy
benefit:
| Type of benefit/service | Plans affected | Change/clarification |
|---|
| Naming of pharmacy benefit
formulary tiers | All plans with a
pharmacy benefit | We are changing the names of two of
the drug formulary
cost-sharing tiers to make it easier to understand the
cost-sharing differences when choosing medications.
- Formulary Brand has been re-named Preferred Brand.
- Non-Formulary Brand has been re-named Non-Preferred
Drug.
|
| Pharmacy Specialty Drug
Program administration | All plans with a
pharmacy benefit | For the pharmacy Specialty Drug Program,
we are removing
the option for members to get a ?first fill? of a prescription
for a specialty drug at a participating retail pharmacy. Select
specialty drugs will be subject to ?split fill.? This means the
prescription is filled in separate amounts. The first amount
is filled right away. The second amount may be filled at a
later date, allowing time for members to talk to their doctor
or pharmacist about changing the dose or stopping the
medication. The member?s cost-share is determined by the
amount of medication included in each split fill. |
Please call Customer Service at 1-800-275-2583 with any
questions.