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Member benefits changes and clarifications for commercial members 

November 1, 2013    

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, All PPO 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, All PPO Language is being revised to indicate that IBC 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, All PPO As required by the PPACA, language is being updated to state that IBC 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:
  • Drugs used to treat smoking cessation for members ages 18 and older will be covered with a doctor's prescription

  • Effective January 1, 2015, all covered self-administered specialty medications will be provided through the FutureScripts Specialty Pharmacy Program after an initial fill at a retail pharmacy.

  • The language regarding smoking cessation exclusion is being removed.
Air ambulance All PPO Language is being revised to state that air ambulance for transportation back to a member’s home service area during medical emergency situations may be approved when medically necessary.
Specialty drugs All HMO, All POS, All PPO Language is being added to define self-administered drugs and to state that self-injectable drugs are considered to be one type of self-administered drug.

Please call Customer Service at 1-800-ASK-BLUE with any questions.

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