Effective January 1, 2018, unless otherwise noted, 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
Alternative therapies/ complementary medicine
HMO
POS/DPOS
EPO/Closed Panel PPO
PPO
The definition of complementary medicine has been updated to recognize the
National Institutes of Health definition as the acceptable definition.
Chemotherapy
HMO
POS/DPOS
EPO/Closed Panel PPO
PPO
Language has been updated to include biologics as a type of chemotherapy and to
require reliable evidence in addition to U.S. Food and Drug Administration
approval to support the coverage of a drug or biologic.
Durable medical equipment (medical supplies)
HMO
POS/DPOS
EPO/Closed Panel PPO
PPO
The definition of consumable medical supply has been added. Consumable medical
supplies have been included in the benefit exclusion language. Additional
examples of excluded supplies have been added to the list.
Experimental/investigative services
HMO
POS/DPOS
EPO/Closed Panel PPO
PPO
Language has been updated to clarify that reliable evidence is required to
support coverage of a drug or biologic.
Hearing aids/cochlear implants
HMO
POS/DPOS
EPO/Closed Panel PPO
PPO
Exclusion language has been updated to clarify that cochlear electromagnetic
hearing devices are not considered cochlear implants.
Mental health (serious mental illness health care, alcohol, or drug abuse)
HMO
POS/DPOS
EPO/Closed Panel PPO
PPO
Language has been added to more clearly explain the exclusions for certain
treatments for mental health care and alcohol abuse and dependency to avoid
redundancy with other exclusions.
Methadone maintenance treatment
HMO
POS/DPOS
EPO/Closed Panel PPO
PPO
Language has been added to address coverage of in-network methadone maintenance
treatment at $0 member cost-sharing. For plans with a deductible, the
deductible must be met before the $0 cost-sharing applies.
Oral surgery (dental services)
HMO
POS/DPOS
EPO/Closed Panel PPO
PPO
Language has been updated to clarify that when oral surgery services are
available under a member?s dental plan, Independence has the right to seek
recovery from the dental plan.
Termination of in-network hospital or in-network skilled nursing provider
contract
EPO/Closed Panel PPO
PPO
Language has been updated to clarify the responsibility of in-network hospitals
and skilled nursing facilities whose provider contracts have been terminated.
Travel vaccines
HMO
POS/DPOS
EPO/Closed Panel PPO
PPO
Language has been revised to more clearly explain the exclusion of coverage for
vaccines for travel or employment purposes.
Treatment of sexual dysfunction
HMO
POS/DPOS
EPO/Closed Panel PPO
PPO
Language has been updated to clarify the sexual dysfunction benefit exclusion
to identify scenarios that fall under this exclusion.
Women?s preventive services (diagnostic mammography)
Effective on or after January 1, 2018, based on when the
member's plan benefits take effect.
HMO
POS/DPOS
EPO/Closed Panel PPO
PPO
Language has been updated to remove diagnostic mammography as a preventive
service.
Effective January 1, 2018, the following change applies to members
with an Independence prescription drug benefit:
Type of benefit/service
Plans affected
Change/clarification
Drug tier exception process
All plans with a pharmacy benefit
The updated formulary exception policy defines which drug tiers are eligible
for tier exceptions* and describes how member cost-sharing is applied if tier
exceptions are approved. The updated policy also defines the criteria for
requesting coverage of a non-formulary (non-covered) medication.
*Tier exceptions can only be requested for coverage of
non-preferred drugs at the preferred drug tier for brand drugs or at the
generic tier for generic products. Specialty drugs are not eligible for tier
exception requests. Visit our website to read the policy.
Please call Customer Service at 1-800-ASK-BLUE with any questions.