your highmark blue cross blue shield transition guide

YOUR HIGHMARK
BLUE CROSS BLUE SHIELD
TRANSITION GUIDE
CHANGES EFFECTIVE UPON YOUR GROUP’S 2016 RENEWAL
Highmark Inc. and Blue Cross of Northeastern Pennsylvania
have worked together for decades to bring you the
quality health care benefits and services that you and
your employees have come to rely on.
TABLE OF CONTENTS
1 Enrollment and Billing
2Claims
2 Customer Service
3 Plans and Networks
6 Population Health Management
7 Tools and Resources
9 Pharmacy Benefits
11 General Benefit Changes
11 Health & Wellness
Highmark and Blue Cross of Northeastern Pennsylvania have merged, and we’ll
continue to serve the 13 counties of northeastern Pennsylvania as Highmark
Blue Cross Blue Shield.
As we complete this transition, we continue to build on our long-standing
relationship to enhance, over time, the benefits and services you and your
employees receive. The merger brings additional value to the market with
new products and services, continued affordability and a positive experience
for your employees.
In addition, you benefit from things like expanded care delivery systems
and continued access to high quality and efficient provider networks and
value-based care through population health management programs like
Patient Centered-Medical Homes (PCMH).
This guide gives you an overview of the operational and process changes,
including general benefit changes that you’ll experience starting with your
2016 renewal.
Regardless of what health plan(s) you choose to offer in 2016, you will have
specific benefit changes. You can discuss benefits in more detail with your
Highmark client manager when reviewing your plan renewal documents.
As Highmark brings further innovations to the market, we will share new
information and updates with you through your Highmark client manager
and client communications.
ENROLLMENT AND BILLING
ID CARDS
GROUP/CLIENT NUMBERS
You and your employees will receive new Highmark ID cards
when your plan renews in 2016. You’ll notice a Highmark Blue
Cross Blue Shield logo on your employees’ new ID cards. There
will be a new alpha prefix in front of the ID number. If your
plan name has changed, you’ll notice the new name on the
ID cards as well as any new member service numbers. Remind
your employees to use their new Highmark ID cards when they
receive them, and show them to their health care providers and
pharmacies. This will help ensure their claims are filed quickly
and accurately, with no delays.
When your plan renews in 2016, it will be assigned a new client
number. The client number is used for enrollment, billing and
reporting purposes. You will receive a report listing your new client
number(s) before your group’s renewal date for coverage in 2016.
A sample ID card
ENROLLMENT AND BILLING TOOLS
Once your plan renews in 2016, you will be able to use Highmark’s
employer website at highmarkbcbs.com to manage your group’s
enrollment and billing needs quickly and easily. Quick links to
these online tools are easily accessible on the employer home
page. A tutorial is available online to help you get started. You can
also call the new number on your billing invoice if you need help.
Refer to page 7 in this guide for more details on registering
for Highmark’s employer website. You’ll find that keeping your
membership data up to date has never been easier!
BILLING CHANGES
• You will receive a new invoice once your plan renews with
Highmark. The Highmark invoices will have a different look
and will include a guide to help you understand the new
billing process.
You will also receive new Highmark Blue Cross Blue Shield
ID cards if you offer a BlueEdge Dental plan and/or a Highmark
vision plan in 2016.
• The new Highmark billing process is balance forward billing.
This is different from the current process, where you make
adjustments to the billing roster and reconcile the amount
each month. This means that with the new process, you will
make up for any shortage or receive any credit on the next
billing cycle, much like a credit card statement.
• Your new billing date is the 14th of each month. Your new
due date is the first of the following month.
• If you use auto-debit service, your payment will be pulled on the
first of the month, rather on the fifth of the month, as it is now.
COORDINATION OF BENEFITS
Coordination of benefits (COB) is needed when a member has
dual coverage. For example, some employees may be covered
through their spouses’ plans as well. Please encourage your
employees to call the toll-free number on the ID card sticker
immediately to report if they have dual coverage. This will
allow us to identify the primary payer and eliminate claims
payment delay.
• You will send your payment to a new address, which will
appear on your new monthly invoice, rather than to the
current Wilkes-Barre address.
A sample COB sticker
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ENROLLMENT AND BILLING Continued
CLAIMS
ENROLLMENT CHANGES
CLAIMS
• The new Highmark member enrollment application and
change form will have a different look.
You and your employees will be able to review medical claims
in real time by logging into Highmark’s member website at
highmarkbcbs.com. Once your plan renews in 2016, your
employees will need to register for the Highmark member
website. Members will then be able to track their health care
spending and budget in order to reduce confusion over the
costs they must pay.
• You will send or fax the completed forms to the new address/
fax number listed on the Highmark form, rather than to your
Highmark client manager or current contact information.
ANSI 834 ELECTRONIC ENROLLMENT
If you currently use ANSI 834, you will switch to Highmark’s
ANSI 834 platform when your plan renews in 2016. You will
receive a notice about 90 days before your renewal with details
on Highmark’s EDI transactions process and new Trading
Partner Agreement. The notice will include an invitation to
a kickoff call explaining Highmark’s electronic processing
guidelines, how to establish connectivity and when you will
get a new Trading Partner Agreement to sign and return.
The new process will reflect Highmark’s policy of “pursue then
pay.” This means that Highmark will contact a third party for
payment first. Your employees may notice a slight delay in
claims processing while Highmark determines if a third party,
such as auto or workers comp insurance, is involved. If a third
party is not responsible, then Highmark will pay the claim.
DOMESTIC PARTNER COVERAGE
EXPLANATION OF BENEFITS (EOB) STATEMENT
Currently our fully-insured plans cover BOTH domestic partners
and same sex marriage partners. When your plan renews
with Highmark in 2016, you will have the choice to cover only
domestic partners, if you prefer. However, we will keep your
current coverage unless you notify your Highmark client
manager otherwise.
The EOB statement is a document (not a bill) we send to your
employees after we receive and process a medical claim. They
receive an EOB only if they have paid money or owe money for
the claim. The EOB lists important information like how much
the employee owes the doctor and how much the insurance
plan has paid. Highmark’s EOBs will display similar information,
but have a different look and format. They are available on
the member website at highmarkbcbs.com. Once your plan
renews in 2016, your employees will be able to sign up for
electronic EOBs instead of paper. Those employees will get an
electronic alert each time a new EOB posts.
SUBROGATION
CUSTOMER SERVICE
PHONE NUMBERS
Many of the Customer Service numbers will be changing
January 1, 2016, but your employees can use the current phone
numbers until your plan renews in 2016. New member service
numbers will be on the back of Highmark’s ID cards, which you
and your employees will receive when your plan renews. The
new number for all group plans, except BlueCare HMO and
BlueCare HMO Plus, is 1-800-241-5704. BlueCare® HMO and
BlueCare HMO Plus will remain the same at 1-800-822-8753
and (TTY) 1-800-413-1112.
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PLANS AND NETWORKS
PLAN COVERAGE & NAME CHANGES
As this chart indicates, some of the 2015 group plans will transition to different plans for 2016 coverage effective dates starting
January 1, 2016. There will be changes in covered and non-covered services. And for some plans, provider networks will change.
Your client manager will be able to offer more information on specific differences closer to renewal.
CURRENT BLUE CROSS OF
NORTHEASTERN PENNSYLVANIA PLANS
NEW HIGHMARK BLUE CROSS
BLUE SHIELD PLAN
NETWORK CHANGES
2015 Plans for Large Groups
(51+ employees)
2016 Plans for Large Groups
(51+ employees)
BlueCare PPO (FPLIC)
PPOBlue (HBCBS)
Highmark Blue Shield statewide facility
network (which includes the First Priority
Life facility providers) and PremierBlue
Shield professional physician network
BlueCare Qualified High Deductible PPO
(FPLIC)
PPOBlue Qualified High Deductible
Health Plan (HBCBS)
Highmark Blue Shield statewide facility
network (which includes the First Priority
Life facility providers) and PremierBlue
Shield professional physician network
BlueCare EPO (FPLIC)
EPOBlue (HBCBS)
Highmark Blue Shield statewide facility
network (which includes the First Priority
Life facility providers) and PremierBlue
Shield professional physician network
BlueCare Traditional (FPLIC)
ClassicBlue (HBCBS)
Highmark Blue Shield statewide facility
participating providers (which includes
the First Priority Life facility providers)
and PremierBlue Shield professional
physician participating providers
BlueCare Custom PPO
BlueCare Custom PPO
No change
BlueCare Qualified High Deductible
Custom PPO
BlueCare Qualified High Deductible
Custom PPO
No change
AffordaBlue
AffordaBlue
No change
BlueCare HMO
BlueCare HMO
No change
BlueCare HMO Plus
BlueCare HMO Plus
No change
BlueCare Senior (FPLIC)
with or without BlueCare Major Medical
with or without Rx coverage
Signature 65 (HBCBS)
with or without Major Medical
with or without Rx coverage
No change
FPLIC = First Priority Life Insurance Company®
FPH = First Priority Health®
HBCBS = Highmark Blue Cross Blue Shield
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CURRENT BLUE CROSS OF
NORTHEASTERN PENNSYLVANIA PLANS
NEW HIGHMARK BLUE CROSS
BLUE SHIELD PLAN
NETWORK CHANGES
2015 Plans for Small Groups
(2-50 employees)
2016 Plans for Small Groups
(1-50 employees)
BlueCare PPO
BlueCare PPO
Highmark Blue Shield statewide facility
network (which includes the First Priority
Life facility providers) and PremierBlue
Shield professional physician network
BlueCare QHD PPO
BlueCare QHD PPO
Highmark Blue Shield statewide facility
network (which includes the First Priority
Life® facility providers) and PremierBlue
Shield professional physician network
BlueCare Custom PPO
BlueCare Custom PPO
No change
BlueCare QHD Custom PPO
Not available for new or renewing
business. You will be mapped to the
closest BlueCare QHD PPO option
AffordaBlue
AffordaBlue
No change
BlueCare Traditional
BlueCare Traditional
Not available for new business
Highmark Blue Shield statewide facility
network (which includes the First Priority
Life facility providers) and PremierBlue
Shield professional physician network
BlueCare Senior
Not available for new or renewing business
FPLIC = First Priority Life Insurance Company
FPH = First Priority Health
HBCBS = Highmark Blue Cross Blue Shield
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SENIOR PLANS
DEFINED CONTRIBUTION PLANS
If you have more than 50 employees—When your plan
renews in 2016, Highmark’s Signature 65 will replace your
BlueCare Senior plan. If you have BlueCare Senior, your plan
will transition to the Highmark Signature 65 option that is most
closely based on your current plan option.
If you currently offer defined contribution plans, you’ll want to
look into the Highmark defined contribution platform, myBenefits.
Your Highmark client manager will be able to give you more
details closer to your plan’s renewal in 2016.
If you have 2 – 50 employees—Your employees with BlueCare
Senior will have the opportunity of moving to an individual,
“direct pay” Medicare plan when your plan renews in 2016. Or,
if they are actively employed, they may be eligible for your plan
for active employees. Check with your Highmark client manager
for more details.
DENTAL PLANS
If you currently offer dental coverage through United Concordia,
you can keep what you have, without benefit changes. However,
you’ll also receive a new quote for a Highmark Blue Edge Dental
plan. It’s your choice if you want to switch dental plans for 2016.
EXCEPTION
If you are a small group with an ACA health insurance plan, you
are not eligible for Blue Edge Dental. You would need to buy or
keep your current United Concordia dental plan.
VISION PLANS
If you currently have Davis Vision coverage, when your plan
renews in 2016, you’ll receive a quote for a Highmark vision
plan instead of your current vision coverage.
STOP LOSS COVERAGE (FOR SELF-INSURED GROUPS ONLY)
If you presently have stop loss coverage bundled with your
medical plan, when your plan renews in 2016, your stop loss
coverage will be offered by HMIG (HM Insurance Group, a
Highmark Company). You can expect to receive different stop
loss reports with the migration to the Highmark platform, and
with different field data than you currently receive.
HEALTH SPENDING ACCOUNT PLANS
If you currently offer a BlueCare HSA, HRA or FSA, and want to
continue when your plan renews in 2016, your health spending
account administrator will change from HealthEquity (with
Bancorp Bank as custodian) to Highmark (with Bank of America
as custodian). You’ll see the FSA fee as a separate line item on
your monthly invoice. Currently, it is embedded in your health
insurance premium, for fully-insured plans.* You and your
employees will receive updated information from Highmark
when you make the transition. Your employees will be able to
easily access their Highmark health spending account via the
member website through the Spending tab. If your employees
currently have a HealthEquity HSA account and wish to close
the account and transfer a balance to Bank of America, Highmark
will pay the closing fee from HealthEquity, provided the account
is closed within 90 days of the new coverage. Your Client
Management team can walk you through the changes and
demonstrate the new abilities to manage claim payments online.
*For self-insured groups, fees will be broken out as a separate line
item on your invoice.
5
POPULATION HEALTH MANAGEMENT
In order to build the optimal health management plan focused
on the unique health and wellness needs of your employees,
Highmark provides a highly customized population health
management approach. This solution positively impacts the
adherence and utilization patterns of your workforce by integrating
condition, case, utilization and lifestyle management programs.
Our utilization management programs help you and your
employees get proper care in the right setting, at the appropriate
cost, and with positive outcomes. That’s why our Medical
Management & Policy team reviews services, supplies and
medications before your benefits pay, to make sure they are
medically necessary and appropriate. This review process is
called authorization, prior approval or precertification.
AUTHORIZATION (PRIOR APPROVAL/
PRECERTIFICATION) REQUIREMENTS
Your 2016 plan will follow Highmark’s authorization requirements
for care. Most of our authorization requirements are already
aligned with those of Highmark. However, you will see new
authorization requirements for outpatient services and durable
medical equipment (DME) when your plan renews in 2016.
Services that need authorization are continually reviewed and
may change, so it’s important to check your Policy/Contract. As
always, if your employees use a network provider, the provider
will initiate the authorization request.
6
MEDICAL POLICY
Medical policy guides how your health plan’s covered benefits
are applied. Your 2016 plan will follow Highmark’s medical
policy. Current medicaI policy is already aligned with
Highmark’s for the most part, but you may notice a few
additions. For example:
• Highmark’s medical policy includes criteria to determine if
advanced imaging tests like MRI’s and CT scans are covered;
current medical policy does not address these services.
• Highmark’s medical policy addresses payment for an
assistant surgeon; current medicaI policy does not
address reimbursement.
As a reminder, not every Highmark medical policy will apply
to every group. Medical policy is written to cover general
situations. The benefits/coverage listed in your Policy/Contract
will always supersede medical policy. You and your employees
can access Highmark’s medical policy on highmarkbcbs.com,
under Additional Links.
SEAMLESS CARE MANAGEMENT PROGRAMS PROVIDE
A POSITIVE MEMBER EXPERIENCE
Starting with your plan’s 2016 renewal for coverage, services
that you and your employees previously received under Blue
Health Solutions, including Case and Health Management
programs will be offered under Highmark’s Case and Condition
management programs. Highmark provides an enhanced
selection of specialized condition programs. Just as with
the current program, teams of licensed clinical professionals
coordinate care and work with your employees to identify and
resolve gaps in care and help your employees use appropriate
providers and facilities, reduce avoidable hospital readmissions,
learn about disease conditions and improve self-management
skills. In addition, Highmark offers another clinical tool to help
support members’ health care decisions, Blues On CallSM
24-hour nurse line.
HEALTH PROMOTION PROGRAMS SUPPORT BEHAVIOR CHANGE
NEW PROGRAM ENHANCEMENTS WITH HIGHMARK
Highmark offers a robust variety of health and wellness programs
to keep your employees and their families on the road to better
health. These programs are similar to the Blue Health SolutionsSM
programs you are familiar with, but have different names and
include even more resources.
• Customized health management planning
specific to your employee population using
proprietary Ipad App, Health Architect.
Using our proprietary Health Architect® iPad app, our clinical
team will consult with you to assess and develop a plan that
addresses the clinical and lifestyle risks of your population.
Based on the assessment findings and your health management
goals, the clinical team will work with you to determine programs
that best support your strategy.
• WebMD capabilities:
Through a partnership with WebMD®, Highmark also offers a
variety of programs and resources to meet the unique needs
of each employee:
• The Wellness Profile (health risk assessment) is an
online survey for members that identifies health strengths
and weaknesses and provides recommendations for
health improvement.
• Member programs including lifestyle improvement classes,
smoking cessation programs and health management
programs for chronic and costly conditions such as asthma,
COPD, congestive heart failure, coronary artery disease,
depression, diabetes, high blood pressure and high cholesterol.
• Online tools are available to help members in making wise
health care choices. These include Health Trackers, Symptom
Checker, Personal Health Record and Health Education
& Information. In addition, My Health Assistant provides
self-guided programs so members can create their own
customized wellness program based on their health focus
and desired participation level.
• A Wellness Rewards incentive program is also available for
some plans. Check with your Highmark client manager for
more information.
In addition, Highmark brings you these valuable wellness
resources to help support and motivate your employees:
• Women who are pregnant can join Baby Blueprints®
(maternity and education program) for dedicated health
coach support and health education resources.
• Enhanced reporting capabilities and automated
program features
–– Wellness Profile
–– Self-guided programs (My Health Assistant)
–– Enhanced online health and wellness platform
–– Integrated data from Fitbit personal fitness
devices into online Health Trackers, Wellness
Rewards and Wellness Challenges.
• The Wellness Discount Program offers special savings
and discounts of up to 30 percent on non-covered wellness
products and services from leading national companies in
a wide range of categories.
• Some plans offer a Telemedicine Benefit for the ultimate
convenience in resolving minor medical issues.
Highmark also offers an online Consumer Communications
Toolkit as an effective means to help engage your employees
and help them make informed health care decisions through
videos, posters, flyers, plasma ads, articles and emails. This also
allows you to customize materials and resources on member
engagement, health topics, online resources, worksite wellness,
spending accounts, Health Care Reform and more.
FORGING A SOLID HEALTH MANAGEMENT PARTNERSHIP
Highmark’s integrated approach offers health care solutions
centered on your workforce’s unique needs through consultative
health management strategies:
• A fully-integrated care management program.
• A differentiated member experience with high-touch
coaching interventions.
• Cost-containment processes and innovative health
promotion programs.
7
TOOLS AND RESOURCES
COST & QUALITY COMPARISON TOOLS
Highmark offers a variety of online tools at highmarkbcbs.com
to empower your employees and give them information to
make smart decisions. Starting with your plan’s 2016 renewal
for coverage, your employees can compare providers’ quality of
care ratings and search for convenient locations with the Find
a Provider tool. They can write their own Patient Experience
Reviews of providers and read what others have to say as well.
It’s easy to search for medical procedures and services to compare
cost estimates with the Care Cost Estimator.* Highmark’s
Care Cost Estimator uses real time data and takes into account
how much you’ve met toward your deductible and what your
plan-specific cost-share is, so you get a more accurate estimate
of your out-of-pocket cost. The Claims and Spending tabs
allow members to budget funds by tracking spending activity
and claims activity for medical, prescription drug, dental, vision
and health spending accounts.
Highmark’s employer website at highmarkbcbs.com offers
even more tools and services to help you manage your plan.
A few months before your group’s renewal date for coverage
in 2016, your group’s contract signer will receive an email with
login information and instructions on how to access the
Highmark employer website. If we don’t have your email
address on file, you can reach out to your Highmark client
manager or account service representative to get access to the
Highmark employer website. Once you have access, you can
then delegate additional access as needed.
*This is not available for HMO and HMO Plus plans.
The employer website is grouped into five key sections:
EMPLOYER NEWSLETTER
Manage Enrollment—Add a newly hired employee to your
medical, vision and dental plans. View coverage, make changes
for, and terminate coverage for existing members.
Once your plan renews in 2016, you will receive a new electronic
newsletter from Highmark, called Group Bulletin, every two to
three months, with valuable benefit and care delivery news,
health and wellness resources and information on managing
costs. The Group Bulletin is also available on Highmark’s
employer website at highmarkbcbs.com.
EMPLOYER WEBSITE
Billing—Access your group’s payment history, view invoices
and make payments through this new online bill pay tool.
Assist Employees—Help your employees with their benefits
by ordering ID cards, viewing benefits booklets, reviewing their
spending account activity and finding a provider.
Account Profile—View your company’s accounts and contact
information, change your password and review your user
profile. If you have delegated administrators who are permitted
to receive information about employees, you will complete a
new authorization form with your Highmark client manager to
ensure the appropriate employees are given access through
Highmark. Contact your client manager closer to your plan’s
renewal in 2016.
Resources—Use this tab to find important resources like
member services contacts, website maintenance schedules,
educational videos, group newsletters and a consumer
communications toolkit to promote health and wellness
campaigns in your workplace.
8
MEMBER WEBSITE
Once your plan renews in 2016, you and your employees
will be able to access the Highmark website at
highmarkbcbs.com for online tools that make it
convenient and easy to get the most value from your
health care plans. Your employees will need to register
for the Highmark member website to get personalized
information about coverage and claims, search for a
provider, sign up for special programs and learn more
about staying healthy.
The member website has five key sections:
Coverage—Includes a summary of benefits, including
vision, health & wellness, member discounts, and
other health plan resources. Members can download
a benefits booklet and learn about how their
network works.
Claims—Review claims in real time, progress toward
deductibles, accounts and messages.
Spending—If members have a spending account,
they can submit new claims, track account activity,
view the balance, and manage their debit card,
all on one integrated website.
MEMBER MATERIALS
When your plan renews in 2016, you’ll notice a different look
and design to the materials your employees receive, such
as benefit booklets, Policies/Contracts, SBCs (Summary of
Benefit Changes). Your supply of open enrollment materials
may be mailed to you, rather than being delivered in person by
your Highmark client manager. These will continue to contain
valuable information and we encourage you and your employees
to review them.
MEMBER NEWSLETTER
Starting with your plan’s 2016 renewal for coverage, you and
your employees can sign up on the Highmark member website.
It’s important to sign up so they receive personalized emails
containing information tailored to specific needs and interests.
Your employees will also receive Looking Healthward member
newsletter, unless they opt out. They will have the option to receive
a monthly issue electronically or a printed issue twice a year.
Find a Doctor or Rx—With the Find a Provider tool,
members can compare providers’ quality ratings and
search for convenient locations, write their own
Patient Experience Reviews of providers and read
what others have to say as well.
Health & Wellness—Here members can search for
conditions, treatments and healthy living topics, use a
symptom checker and medical encyclopedia, as well
as a large variety of other wellness tools and resources.
Please remind your employees to keep their username
and password handy for the bcnepa.com Self-Service
website. Member Self-Service at bcnepa.com will
remain live for a full year after you renew into a 2016
Highmark health plan to allow your employees to look
back at their 2015 claim history.
9
PHARMACY BENEFITS
PHARMACY NETWORK
When your plan renews in 2016, your pharmacy benefit
manager will continue to be Express Scripts, Inc. (ESI).
However, your coverage will use Highmark’s Premier 2012
Network—it is being renamed National Network, January 1, 2016.
NOTE—Walgreens Retail Pharmacies are currently EXCLUDED
from this Highmark network, just as they are excluded from
our current pharmacy network.
Since there will be differences from your current pharmacy
network, please remind your employees to check if their
pharmacy is a network provider under their new Highmark plan.
They can check the member website at highmarkbcbs.com
under the Find a Doctor or Rx tab. Or, they can call Member
Service at the number on the back of their new Highmark ID
card, once they receive it. Please note this process is a change.
Currently, members call Express Scripts directly. However,
Highmark’s Member Service reps can answer general pharmacy
questions and will transfer calls to Express Scripts if needed.
PHARMACY FORMULARY
Also when your plan renews in 2016, your pharmacy formulary
will change:
• All large group plans and small group pre-ACA plans will
move into the Pre-Reform Comprehensive Incentive formulary.
• Small group ACA plans will move into the Post-Reform
Progressive Incentive formulary.
Please remind your employees to show their new Highmark ID
card to the pharmacist before they fill their first prescription
under their new coverage in 2016, so their claims are processed
timely and accurately.
PRIOR AUTHORIZATIONS
Most medications will have previous prior authorizations
transferred to your Highmark profile. However, some drugs
may have different criteria for coverage and the lengths of
authorizations may be different.
10
Other medications may now need a new prior authorization
before coverage is approved. These drugs will be noted on
Highmark’s formulary with the letters “PA.”
• Step therapy history will be transferred, if applicable.
In general, Highmark’s formularies have considerably less
drugs that need step therapy. These drugs will be noted on
Highmark’s formulary with the letters “PA” as well
• Regarding quantity level limits, Highmark has its own
quantity limits—some drugs and some limits may be the
same; some may be different. These drugs are noted on the
Highmark formulary with the letters “QL”
You can check how your drugs are covered on Highmark’s
formulary websites at highmarkbcbs.com. Click on the Find
a Doctor or Rx tab at the top of the page.
HOME DELIVERY
Currently, most pharmacy plans have the Select Home Delivery
program. Highmark will roll out a similar program starting
January 1, 2016, upon your plan’s 2016 renewal for coverage,
called Active Choice. It works the same way as our current
Select Home Delivery program. If your employees already
called ESI with their decision regarding Select Home Delivery,
the authorization will transfer to the Active Choice program,
so your employees do not need to call ESI again. ESI will send
letters with more information to impacted members.
SPECIALTY DRUGS/PHARMACY
Highmark has its own specialty drug listing. Many specialty
drugs will be the same as those under your current plan,
but some can be different. Specialty drugs are indicated on
Highmark’s formulary websites with the letters “SP.” Once your
plan renews, your employees have to get these drugs from
Walgreens Specialty Pharmacy®, which is Highmark’s specialty
pharmacy. (Please do not confuse this with Walgreens retail
pharmacy, which is NOT a participating pharmacy.) Highmark
will send letters with more details to impacted members.
PHARMACY COPAYS
DRUG COVERAGE CHANGES
There may be copay differences for certain medications
depending on the tier classification on Highmark’s formulary.
Medications may cost more or less depending on your
Highmark plan and drug formulary.
There are a number of products currently covered under your
pharmacy benefit that will not be covered by Highmark’s
pharmacy benefit, but will instead be covered by Highmark’s
medical benefit. These are products that are not commonly
used, such as enzyme therapies or hemophiliac factor products.
Highmark will send a letter to impacted members notifying
them of the change.
The general copay structure for prescription drugs will be updated:
• Tier $0 will be replaced with a $3 copay for any prescription
drugs in this category. However, there will be more prescription
drugs in this $3 category. Please keep in mind though, not all
Tier $0 drugs will be on the $3 copay list.
• All home delivery copays will be two times the retail copay
amounts. For example, if your benefit design has a $20 copay
for a 30-day retail supply, your employees can pay $40 for a
90-day home delivery supply.
• Some groups may currently have Specialty Tiers for drugs
designated as specialty medications. Note, these drugs may
be different than the medications that have to be obtained
from Walgreens Specialty Pharmacy.
• Drugs may fall into different tiers based on formulary
differences. This means members may pay more or less for
drugs they are taking now.
Most vaccines will also be covered under Highmark’s medical
benefit. This means members won’t be able to obtain vaccines
at most retail pharmacies any longer. Rather, they need to get
vaccines at their doctor’s office.
Self-insured clients with pharmacy benefits will likely experience
improved pharmacy discounts with the move to the Highmark
platform. Self-insured clients will also have the option of
changing their plan formulary at any time during the year.
Your Highmark client manager will be able to offer more
information on specific differences closer to your plan’s
renewal in 2016.
• Most pharmacy plans will have a generic policy in place;
either hard, soft or no penalty. Talk to your Highmark client
manager for more information on your plan’s generic policy
or check your Contract/Policy.
EXAMPLE OF FORMULARY DIFFERENCES
DRUG
TREATMENT
BCNEPA’S FORMULARY
HIGHMARK’S COMPREHENSIVE
INCENTIVE FORMULARY
Vyvanse
ADHD
Tier 3
Tier 2
Benicar
Hypertension
Tier 3
Tier 2
Epiduo
Acne
Tier 2
Tier 3
Voltaren gel
Pain related to osteoporosis
Tier 2
Tier 3
Oxycontin
Chronic pain
Tier 2
Tier 3
Contour test strips
Diabetes
Tier 2
Tier 3
This table represents only some of the formulary differences for commonly used drugs and supplies. It is not a complete list and may change at any time.
11
GENERAL BENEFIT CHANGES
OUT-OF-POCKET MAXIMUM
For BlueCare HMO and HMO Plus plans that renew in 2016,
the out-of-pocket (OOP) maximum amount for medical and
prescription drug services will be combined. Currently, the OOP
maximum amount applies to medical and prescription drug
services separately.
BENEFIT ACCUMULATORS (DEDUCTIBLES, COINSURANCE,
OUT-OF-POCKET MAXIMUM AND VISIT LIMITS)
If your group has a benefit period that is “benefit year”
(refer to the Renewal sheet in your renewal package), your
accumulators will reset and start over when your 2016 plan
year renews, as usual. However, if your group has a benefit
period that is “calendar year” and renews other than January 1,
the accumulators will not start over at that time. Instead,
the accumulators will reset at the beginning of the next
calendar year. For example, if your plan renews July 1, 2016,
and has a “calendar year” benefit plan, your accumulators
will carry over through December 31, 2016.
PREVENTIVE SCHEDULE
When your plan renews in 2016, if you choose either the
PPOBlue, PPOBlue Qualified High Deductible Health plan,
EPOBlue or ClassicBlue plan, your coverage will use Highmark’s
preventive package, which is very similar to your current
preventive schedule. Differences include:
• Prostate screenings are not considered a preventive service,
so member cost-sharing will apply.
• Nutritional therapy is only covered with a diagnosis
of obesity.
If you are not renewing into one of these plans, your coverage
will continue to use your current Blue Cross of Northeastern
Pennsylvania preventive schedule.
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Highmark is a registered mark of Highmark Inc.
Blue Cross Blue Shield and the Cross and Shield symbols are registered service
marks of the Blue Cross Blue Shield Association.
Express Scripts is a registered trademark of Express Scripts Holding Company.
Express Scripts, Inc. is an independent company that administers pharmacy
services, not affiliated with the Blue Cross Blue Shield Association.
Walgreens Specialty Pharmacy is a registered trademark of Walgreen Company.
Walgreens Specialty Pharmacy is an independent company that administers
pharmacy services, not affiliated with the Blue Cross Blue Shield Association.
Baby Blueprints is a registered mark of the Blue Cross Blue Shield Association.
Blues On Call is a service mark of the Blue Cross Blue Shield Association.
Blue Edge Dental is a service mark of the Blue Cross Blue Shield Association.
WebMD Health Services is a registered trademark of WebMD, LLC., an independent
and separate company that supports Highmark Blue Cross and/or Blue Shield
online wellness services. WebMD Health Services is solely responsible for its
programs and services, which are not a substitute for professional medical advice,
diagnosis or treatment. WebMD Health Services does not endorse any specific
product, service or treatment. Please consult your physician or other qualified
health care provider before beginning a new exercise or dietary program, or if
you have any medical concerns or questions.
Please note that self-funded group benefits may be different from the benefits
and services described here.
Highmark Blue Cross Blue Shield provides FSAs, HRAs and HSAs that are administered
by Health Equity, Inc., an independent personal health care financial services
company not affiliated with the Blue Cross Blue Shield Association.
Bank of America is an independent company that is the custodian of Highmark
health spending accounts (HSA). Highmark does not offer banking, investment
or financial services. HSA funds are maintained in accounts under the custody
of Bank of America, a separate company that does not offer Blue Cross and/or
Blue Shield products or services.
The information in this brochure is for plans offered through First Priority Life
Insurance Company® or First Priority Health®, which are licensed affiliates of
Highmark Blue Cross Blue Shield.
Highmark Blue Cross Blue Shield, First Priority Life Insurance Company and First
Priority Health are independent licensees of the Blue Cross Blue Shield Association.
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