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Member benefit changes and clarifications for commercial members 

October 31, 2016    

Effective January 1, 2017, unless otherwise noted, the following member benefit changes and clarifications will be implemented for several commercial programs for Independence members:

Type of benefit/servicePlans affectedChange/clarification
Blood pressure monitoringHMO – All
POS – All
DPOS – All
PPO – 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.
BlueCard® disclosure languageHMO – All
POS – All
DPOS – All
PPO – All
Hospital – All
Language is being updated to expand the description of the BlueCard program and reimbursement to BlueCard providers. The BlueCard program is offered through the Blue Cross and Blue Shield Association and allows members to access covered health care services when they are temporarily living or traveling outside the coverage service area.
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
PPO – All except
Closed Panel PPO
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 Independence 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.
ChemotherapyHMO – All
POS – All
DPOS – All
PPO – 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 foodsHMO – All
POS – All
DPOS – All
PPO – All
Major Medical – 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.
ObesityHMO – All
POS – All
DPOS – All
PPO – All
Language is being updated to more clearly explain what services are not covered under the obesity benefit.
Routine foot careHMO – All
POS – All
DPOS – All
PPO – All
Major Medical – 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
PPO – All
Major Medical – 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.
TransplantsHMO – All
POS – All
DPOS – All
PPO – All
Language is being added to more clearly explain how, and under what circumstances, Independence pays for donor coverage for transplants involving human organs, bone marrow, and/or tissues.
Treatment of sexual dysfunctionHMO – All
POS – All
DPOS – All
PPO – All
Major Medical – All
Language is being updated to more clearly explain what services are not covered by the plan’s sexual dysfunction benefit.
Use of out-of-network providersPPO – All except Closed Panel PPOLanguage is being added to more clearly explain that if a member receives covered services from an out-of-network provider for any reason, Independence will pay according to the out-of-network reimbursement schedule.

* Effective January 1, 2017, Independence will begin using a new fee schedule for certain outpatient services. This applies to plans with self-referred benefits (POS, PPO). This fee schedule may be used to calculate member cost-sharing for out-of-network services.

Effective January 1, 2017, tthe following changes apply to members with an Independence pharmacy benefit:

Type of benefit/servicePlans affectedChange/clarification
Naming of pharmacy benefit formulary tiersAll 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 administrationAll plans with a pharmacy benefitFor 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-ASK-BLUE with any questions.





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