A new year always brings changes and so it goes with health plans as well. Below is a list of the information we’ve received from the various carriers we work with:

Anthem Across the Board Changes as of January 1, 2021

  • No more balance billing from Out of Network providers when using In-Network facilities.*

Anthem Changes Effective with your Group Renewal in 2021

  • Small Group and Mid Market Employer Groups (1 – 99 employees) will no longer have Walgreen’s in their pharmacy network.  Groups with more than 100 employees that are classified as Large Group will have the option to choose this Pharmacy Network change.
    • Anthem members who recently used a Walgreen's pharmacy for their prescriptions will be sent a notice letting them know they need to find a new pharmacy. 
  • Mail Order will now be Opt-Out rather than an optional election.  If a member does not Opt-Out, they will only be able to receive their 90-day supplies via mail order.
  • Tier 4 Specialty Meds will now have a $300 30-day max
  • Diagnosis and Treatment for Autism will be covered.
  • Insulin cost is limited to $50 per 30-day supply or $150 per 90-day supply at an In-Network Pharmacy
  • Medically necessary formula and enteral nutrition products will be covered if prescribed by a physician and approved by the plan for treating Inherited Metabolic Disorder.

Please see attached:

Anthem 2021 Small Group Renewal Changes

Anthem 2021 Mid Market Renewal Changes

 

Optima Changes Effective with your Group Renewal in 2021

  • No more balance billing from Out of Network providers when using In-Network facilities.*
  • Vision Therapy is now covered for Acquired Convergence Insufficiency & Congenital Convergence Insufficiency. Up to 12 visits at the Specialist cost share and with a Pre-Auth.
  • Applied Behavior Analysis (ABA) will now be covered as a treatment for Autism with no limits on PT, OT, ST or other therapy.
  • Pre-Auth is no longer required for inter-hospital transfer of a newborn or mother if the infant is experiencing life-threatening emergency conditions.
  • Medically necessary formula and enteral nutrition products will be covered if prescribed by a physician and approved by the plan for treating Inherited Metabolic Disorder.
  • Specialty Drugs on Tier 4 will cost the same whether obtained retail or via mail order and be limited to a 31-day supply.
  • Insulin cost is now limited to $50 per 30-day supply

Please see attached:

Optima Small Group Changes

Optima Mid Market Changes

Optima Business Edge Changes

 

*The new VA state mandate on No Balance Billing Out of Network is limited to certain emergency services at a hospital or for certain non-emergency services during a scheduled procedure at an in-network hospital or another care facility.

Filed Under: Benefits Briefs