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Effective January 1, 2014, unless otherwise noted, the following
member benefits changes and clarifications will be implemented for several
commercial programs for Pennsylvania members:
Type of benefit/service
Plans affected
Change/clarification
Maximum out-of-pocket
All HMO, All POS
As required by the Patient Protection and Affordable Care Act (PPACA), language
is being revised to indicate that all in-network out-of-pocket (OOP) amounts
(deductible, copayments, and coinsurance) will accumulate to the annual OOP
maximum upon renewal starting in 2014.
Bariatric (obesity) surgery/pre-existing condition
All HMO, All POS
Language is being revised to indicate that AmeriHealth will no longer limit
bariatric (obesity) surgery, even if the member had the surgery while covered
under a different insurance carrier. This means that if the member needs an
additional bariatric surgery, when deemed medically appropriate, it will be
covered.
Clinical trials
All HMO, All POS
As required by the PPACA, language is being updated to state that AmeriHealth
will broaden coverage of the routine costs of qualifying clinical trials in
phases I, II, III, and IV that are conducted in relation to the prevention,
detection, or treatment of cancer or other life-threatening diseases or
conditions.
Pharmacy benefit
Freestanding Rx, riders, and integrated drug
Language is being updated to include the following clarifications: