Effective January 1, 2019, the following member benefit changes and
clarifications will be implemented for several commercial programs for
Independence members:
Type of benefit/service | Plans affected | Change/clarification |
Air ambulance transport | HMO
POS/DPOS
EPO
PPO | Language for air ambulance transport has been
updated to clarify that nonemergency air transport may be covered when
medically necessary. In addition, the language about reasonable distance was
removed. |
Ambulatory surgical center | HMO
POS/DPOS
EPO
PPO | The definition of ambulatory surgical center has
been updated for consistency with the definition used by the Commonwealth of
Pennsylvania and to distinguish ambulatory surgical center from outpatient
hospital. |
Consumable medical supplies | HMO
POS/DPOS
EPO
PPO | Language has been updated to distinguish consumable
medical supplies from durable medical equipment to more clearly explain the
benefits. In addition, exclusion language has been updated to remove ACE
bandages. |
Emerging technology | HMO
POS/DPOS
EPO
PPO | Language has been added to allow Independence to
determine if a provider is eligible for reimbursement to perform covered
services that are considered emerging technology. |
Nutritional foods ? Additives | HMO
POS/DPOS
EPO
PPO | Exclusion language for additives has been updated
to list NeoSure, Scandishake, and oral probiotics as additives. |
Oral surgery ? Dental | HMO
POS/DPOS
EPO
PPO | Language has been added to clarify that when oral
surgery services are paid for by Independence, but those services were
available and should have been paid for by the member?s dental plan,
Independence has the right to seek recovery from the provider. |
Outpatient mental health | HMO
POS/DPOS
EPO
PPO | The definition of the outpatient mental health
benefit has been expanded to include telehealth. |
Payments to out-of-network providers | PPO | Language has been added to state that
Independence reserves the right to make payments directly to out-of-network
providers. |
Telemedicine services | HMO
POS/DPOS
EPO
PPO | Language for telemedicine services has been updated
to include primary care providers as eligible providers. |
Termination of in-network hospital or skilled
nursing facility | EPO
PPO | Language has been clarified and updated to remove
the statement that a hospital or skilled nursing facility would continue to
provide services to a member if the provider?s contract was
terminated. |
Effective January 1, 2019, the following changes apply to members
with an Independence prescription drug benefit:
Type of benefit/service | Plans affected | Change/clarification |
---|
Authorized generics | HMO
POS/DPOS
EPO
PPO | The definitions of generic and brand-name
drugs have been updated, and new language has been added to define authorized
generic drugs and clarify that those drugs are excluded from the generic tier.
Authorized generics are brand-name drugs that are marketed without the brand
name on its label and sold by the brand-name drug company, or another company
with the brand company?s permission. For cost-sharing purposes, authorized
generics are treated as brand-name drugs. |
Coordination of benefits | HMO
EPO
PPO | Language has been updated to remove the
statement that coordination of benefits does not apply to pharmacy
plans. |
Out-of-pocket accumulations | HMO
POS/DPOS
EPO
PPO | Language has been added to clarify that if a
member uses a drug manufacturer?s coupon or patient assistance program to get a
prescription at either no cost or a reduced cost, the dollar value covered by
the manufacturer will not be applied to the member?s deductible (if applicable)
or to the member?s out-of-pocket maximum. |
Refill thresholds | HMO | Language has been updated to
remove refill thresholds for prescription refills from the ?Prescription Drug
Limitations? section. |
More Information
Please call Customer
Service at 1-800-ASK-BLUE with any questions.