Acupuncture

HMO

POS/DPOS

EPO

PPO

Language has been updated to remove examples of when acupuncture can be used. Acupuncture treatment is based on medical necessity and guided by medical policy.

Inpatient/Birthing Center

HMO

POS/DPOS

EPO

PPO

Language has been updated to replace the term “Maternity/Obstetrics Care Facility” with “Inpatient/Birthing Center” in the Schedule of Covered Services document. 

Convenience packs

HMO

POS/DPOS

EPO

PPO

Language has been updated to state that “convenience packs” are not covered under the pharmacy benefit. Convenience packs contain two or more drug products in one package. These packs have a unique national drug code. They may include low-cost generic prescription drugs, common over-the-counter products, and/or products not approved by the U.S. Food and Drug Administration.

Tier descriptions

HMO POS/DPOS

PPO

Language has been updated to clarify that the non-preferred and specialty drug tiers include generic drugs. Non-preferred drugs generally have one or more generic or preferred brand options in the same drug class. They are subject to the Non-preferred drug cost-sharing (i.e., copayment, deductible, and coinsurance). Some generic drugs are in the Specialty tier and have Specialty drug cost-sharing.

Split fills

HMO

POS/DPOS

EPO

PPO

Language has been updated to clarify that “split fill” (i.e., a single prescription dispensed in two amounts) is applicable for the first fill and subsequent fills during the first three months of therapy. The first amount is dispensed right away, but the second amount can be delayed if a different dose is needed or if there are negative side effects. Cost-sharing is prorated for each amount of the split fill.