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Member benefit changes and clarifications for commercial members 

November 6, 2017    

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/servicePlans affectedChange/clarification
Alternative therapies/ complementary medicineHMO
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.
ChemotherapyHMO
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 servicesHMO
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 implantsHMO
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 treatmentHMO
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 contractEPO/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 vaccinesHMO
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 dysfunctionHMO
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/servicePlans affectedChange/clarification
Drug tier exception processAll plans with a pharmacy benefitThe 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.





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