Effective January 1, 2016, unless otherwise noted, the
following member benefit changes and clarifications will be implemented for
several commercial programs for Pennsylvania members:
| Type of benefit/service | Plans affected | Change/clarification
|
|---|
Bariatric surgery*
(weight loss surgery)
| HMO ? All
POS ? All
DPOS ? All
| Language is being added to include a reference to bariatric surgery as
a surgical treatment for obesity when certain requirements are met. Also being
added is language to clarify that weight loss surgery to treat any medical
condition (e.g., diabetes) is limited to one surgery per lifetime. |
| Specialty drug list | HMO ? All
POS ? All
DPOS ? All | Language is being revised to indicate the changes made to
the list of injectable/infusion therapy drugs for which members covered under a
commercial plan (non-Medicare Advantage plan) are required to pay cost-sharing.
The drugs on this list are covered under a member?s medical benefit and are
typically administered by a health care provider. The cost-sharing amount will
be collected at the provider?s office or facility each time the drug is
administered. The actual cost-sharing amount is based on the terms of the
member?s benefit contract. The updated drug list is available on our website or by calling 1-800-275-2583.
Members should review the list at their earliest convenience and discuss any
questions with their providers. |
| Preventive care* | HMO ? All
POS ? All
DPOS ? All
| Language is being added about Affordable Care Act (ACA) preventive
care requirements. The new language directs members to visit our website
to view the most up-to-date list of preventive services that the ACA requires
AmeriHealth to cover, which will be available on January 1, 2016. |
| Medical foods* | HMO ? All
POS ? All
DPOS ? All | Language is being updated regarding coverage of medical
foods to clarify the items that are excluded from coverage. |
| Diabetic supplies* | HMO ? All | Language
is being updated to clarify that diabetic supplies that are not available at a
pharmacy may be purchased from a durable medical equipment (DME) provider and
will be subject to the plan?s DME cost-sharing. |
Exclusion for amounts payable by Medicare†
(Applies only to Medicare-eligible individuals who do not enroll in
Medicare) | HMO ? All
POS ? All
DPOS ? All | Language is being added to indicate that for purposes of
this program exclusion, coverage is not available for a service, supply, or
charge that is ?payable under Medicare? when the member is eligible to enroll
for Medicare benefits, regardless of whether the member actually enrolls for,
pays applicable premium for, or maintains, claims, or receives Medicare
benefits. The amount excluded for these claims will be either the amount
?payable under Medicare? or the applicable plan fee schedule for the service,
at the discretion of the plan. |
* Visit our Medical Policy Portal to review the medical and/or claim
payment policies for these benefits/services.
†Change is effective January 1, 2017.
Please call Customer Service at 1-800-275-2583 with any
questions.