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Health Plan Updates

It seems that there are always new rules, regulations and changes in the realm of health care. From health care reform, industry changes and pressures to control costs while maintaining a valuable benefit, we are working hard to keep the health plan effective and affordable. There have been some changes to the health plan this year that you should know about. 


90 days of Generic Medications from Retail Pharmacy

As of July 1, you can now get up to a 90-day supply of generic medication from your local participating pharmacy. This means the mail order requirement is waived for generic medications. You will pay $5 for each 30-day increment of your prescription, so a 90 day refill at the local pharmacy will cost $15 vs. $10 at mail order.

This change is a direct result of the Joint Health Care Committee’s (JHCC) work. Employees asked for this change, and the JHCC carefully considered the costs compared to the increased member satisfaction. This change will cost both members and the plan more money, but it was seen as an acceptable cost when the needs of members were taken into account. Mail order is still a convenient way to get up to 90 days of any medication at reduced cost, and the cost impact for brand name drugs was too much to include those medications. But for members who want to get their generic medication at their local pharmacy, the change was seen as a reasonable compromise. 


Prior Authorization Requirement

Premera issued new ID cards this year with a note to providers on the back that prior authorization may be required. Coverage for some services depends on whether the service is approved by Premera before you receive it. This process is called prior authorization. It doesn’t apply to regular office visits or wellness checkups, standard labs and x-rays or immunizations.

A planned service is reviewed to make sure it is medically necessary and eligible for coverage under the plan. Premera will let you know in writing if the service is authorized by faxing approval to your provider, and mailing it to you. They will also let you know if the services are not authorized and the reasons why. If you disagree with the decision, you can request an appeal. See "When You Have An Appeal" in the Handbook or call Premera at 800-364-2982.

There are two situations where prior authorization is required. One is when you are going to receive certain medical services or prescription drugs. Your physician knows about the need for prior authorization, has a complete list and should handle the process for you. The other is when you want to receive the in-network benefit level for services you receive from a non-network provider. Each situation has different requirements.

It is your responsibility to get prior authorization. Certain services, devices and drugs need to be reviewed to make sure that they are medically necessary for you and meet the plan's other standards for coverage. It is to your advantage to know in advance if the plan would not cover them.

The plan has a specific list of services that must have prior authorization with any provider. The detailed list of medical services requiring prior authorization can be found at premera.com.  

Exceptions

The services below do not need prior authorization. Instead, you (or your provider) must notify Premera as soon as reasonably possible after you receive them:

  • Emergency hospital admissions, including admissions for drug or alcohol detoxification.
  • Childbirth admission to a hospital, or admissions for newborns who need medical care at birth.   


Services from Non-Network Providers

This plan provides benefits for non-emergency services from non-network providers at a lower benefit level. You may receive benefits for these services at the in-network cost-share if the services are medically necessary and not available from an in-network provider within 50 miles of your home. You or your provider may request a prior authorization for the in-network benefit level before you see the non-network provider.

These services will be covered at the in-network cost-share. In addition to the cost-shares, you will be required to pay any amounts over the allowable charge if the provider does not have an agreement with us or, for out-of-state providers, with the local Blue Cross and/or Blue Shield Licensee.

If there are in-network providers who can give you the same non-emergency care within 50 miles of your home, your request will not be approved.

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